Research Area: Public Health Ethics

Looming Blood Shortage Raises Ethical Questions about Allocation

FOR COMPREHENSIVE COVID-19 ETHICS AND POLICY RESOURCES, VISIT OUR DEDICATED WEBPAGE, BIOETHICS.JHU.EDU/CORONAVIRUS.

 

While much attention is currently focused on how hospitals will allocate ventilators when the expected surge of COVID-19 cases outstrips supply, Jeffrey Kahn, Andreas C. Dracopoulos director of the Berman Institute, highlighted another looming medical issue caused by the outbreak – a severe disruption in the nation’s blood supply.

In a March 27 New York Daily News commentary, Kahn wrote that the American Red Cross and other suppliers of blood should be prepared for an ongoing 25% cut to their regular supply.

Read the full article.

Kahn highlights a number of factors that “make blood and its allocation somewhat different than the allocation of ICU beds or ventilators:”

  • The perishability of blood and reliance on volunteer donors to meet needs;
  • Disruption to the “usual ability to move blood to where it’s most needed … since supplies are suppressed nationwide;”
  • The variability of patient needs in amount of blood required for treatment.

“Utilitarian logic is clear that we should save as many as possible, and the numbers overwhelmingly favor saying no to the cases requiring massive transfusion,” writes Kahn.

“If only ethics were so simple. We need to think about who is most likely to be affected by refusing or reducing the numbers in Mass Transfusion Protocol cases, where the critical supply threshold should be for invoking restrictions, how that supply might look tomorrow as compared to today, who should decide about whether to say yes or no to high volume cases, and whether and under what conditions it is acceptable to start on a massive transfusion case but stop when a certain limit of units is reached.”

However, as Kahn points out, unlike many other situations arising from COVID-19, in this instance “there is something many of us can do that is as easy as it is precious: Give blood! This is up to each one of us as individuals. The step you take today can prevent medical professionals from making terribly wrenching choices tomorrow.”

JHU Faculty Express Urgent Concern about Covid-19 Spread in Prison

FOR COMPREHENSIVE COVID-19 ETHICS AND POLICY RESOURCES, VISIT OUR DEDICATED WEBPAGE, BIOETHICS.JHU.EDU/CORONAVIRUS.

 

More than 200 Johns Hopkins faculty in public health, bioethics, medicine, and nursing signed a letter delivered to Governor Larry Hogan today, expressing their urgent concern about the spread of COVID-19 in Maryland’s prisons, jails, and juvenile detention centers and calling on the state to protect the health of its incarcerated population and make “efforts to reduce the state prison population as well.”

Read the full letter.

The Dean of the School of Nursing, the Director of the Berman Institute of Bioethics, and a Vice Dean and seven department chairs from the Bloomberg School of Public Health were among the signatories. Organized by Len Rubenstein, core faculty of the Berman Institute of Bioethics and the Center for Humanitarian Health at Johns Hopkins, the letter said:

“This pandemic is shedding a bright light on the extent of the connection between all members of society: jails, prisons and other detention facilities are not separate, but are fully integrated with our community. As public health experts, we believe these steps are essential to support the health of incarcerated individuals, who are some of the most vulnerable people in our society; the vital personnel who work in prisons and jail; and all people in the state of Maryland.  Our compassion for and treatment of these populations impact us all.”

The letter also urged Gov. Hogan to take 10 steps, including:

  • Require correctional facility administrators to make their plans for prevention and management of COVID-19 in their institutions publicly available;
  • Ensure the availability of sufficient soap and hand sanitizer for incarcerated individuals without charge;
  • Consider pre-trial detention only in genuine cases of security concerns. Prioritize for release persons held for non-payment of fees and fines, or because of insufficient funds to pay bail, or parole or probation violations;
  • Expedite consideration of all older incarcerated individuals and those with chronic conditions predisposing to severe COVID-19 disease (heart disease, lung disease, diabetes, immune-compromise) for parole or other form of release from prison;
  • Arrange for COVID-19 testing of incarcerated individuals and correctional facility workers who become ill;
  • Cease any collection of fees or co-pays or medical care.

The letter represents the views of it signatories, and does not necessarily reflect the views of The Johns Hopkins University.

An Approach for Rationing Care During the Pandemic

 

Amid growing fears that the United States could face a shortage of ventilators for coronavirus patients, state officials, bioethicists and hospitals are conferring with state health officials to hammer out their policies to determine which coronavirus patients would get ventilators if they run short — essentially deciding whose lives to save first.

In Maryland, these discussions include how to factor in age, pre-existing health conditions, overall life expectancy and other criteria to determine which patients would have priority if there are not enough ventilators. These talks have been informed by a 2009 Berman Institute study into the allocation of scarce medical resources.

Berman Institute faculty Ruth Faden and Alan Regenberg, along with JHU collaborators Lee Daugherty Biddison and Eric Toner shared insights from their project in the March 12 Washington Post commentary, “U.S. hospitals may have to ration care during the pandemic. Here’s one approach.”

“After the 2009 H1N1 pandemic, in a calm between emergencies, we and other collaborators engaged the Maryland public in a discussion of ventilator rationing during a pandemic. Over the course of 18 months, we hosted 15 day-long forums across the state with over 300 participants (both laypeople and health-care professionals) to encourage in-depth conversations about the brutal challenges that rationing presents — and about the community values that should guide allocation. …”

“It is appropriate and accurate to reassure the public that most people who contract Covid-19 will recover fully on their own. At the same time, the public needs to be prepared for the possibility of more dire scenarios. Participants in our study were adamant that politicians, and health officials, be transparent and honest about the prospect of and plans for the rationing of ventilators and other equipment. In health emergencies, experts often ask the public to heed the advice of public health professionals; in the case of planning for situations involving scarcity, it is equally important that the experts heed the advice of the public.”

Overview: Ethical Concerns in Responding to Coronavirus

For comprehensive Covid-19 Ethics and Policy Resources, visit our dedicated webpage, bioethics.jhu.edu/coronavirus.

The ongoing coronavirus outbreak vividly demonstrates the important role of bioethicists in leading the charge for equitable and effective public health policies.

“Through years of experience and scholarship, and tested through multiple threatened and actual epidemics, there now exists a rough consensus about the ethical principles that should guide responses to this latest threat,” said Jeffrey Kahn, Andreas C. Dracopoulos Director of the Berman Institute of Bioethics. “Bioethicists from the Berman Institute have been leaders in shaping this framework.”

The Berman Institute is working to disseminate these ideas through social media, appearances in traditional news media, and through other means, as widely as possible on an ever-expanding range of issues, including:

Human Research
“For reasons of safety, efficacy, and ethics, it’s usually better to test vaccines on animals before humans. You have to have good reason to say, ‘We need to go straight to humans or go to humans at this particular point.'”

“Kahn worries about people signing up to be in the trial because they think the vaccine could give them immunity before it becomes available to everyone else. In reality, this kind of early trial is just to make sure that the vaccine is not toxic and does indeed provoke some kind of immune response in people. Participants are very unlikely to be fully immunized to the virus over the course of their participation.”

Travel Restrictions
“A critical principle in outbreak response is that governments should implement the least restrictive measure that can still achieve the public health objective. The goal is to balance the freedom of individuals against the restrictions on freedom required to achieve legitimate protections of the public’s health, with public and transparent justification of policy decisions. Quarantine is considered a measure of last resort given the severe restrictions it imposes on individual liberty.”

Inequitable Impact of School Closings
“As in all public health emergencies, poor children and poor families will suffer the most. An ethically defensible policy of school closures needs not only to meet the bar of public health necessity. Government agencies and community organizations in education, nutrition assistance and housing, as well as public health, must also be planning to take active measures to mitigate the disproportionate burden that will fall on our most vulnerable children.”

Dr. Faden’s prescient Education Week piece helped prompt discussion among K-12 educators nationwide. Officials in numerous states have sought USDA waivers that will enable them to continue providing free meals during school closures.

Allocation of Scarce Resources
“It is appropriate and accurate to reassure the public that most people who contract Covid-19 will recover fully on their own. At the same time, the public needs to be prepared for the possibility of more dire scenarios. Participants in our study were adamant that politicians, and health officials, be transparent and honest about the prospect of and plans for the rationing of ventilators and other equipment. In health emergencies, experts often ask the public to heed the advice of public health professionals; in the case of planning for situations involving scarcity, it is equally important that the experts heed the advice of the public.”

Inequitable Impact of Social Distancing
“The implications of some of these public health measures are so wildly different for people who are differently situated in the United States that the social distancing [decision] is not our only decision. It’s our first one, and then there’s a very different set of ethical dominos that follow from that.”

Kass listed a number of ethical considerations she’s concerned about, like making sure there’s adequate income replacement for workers unable to earn a living, making sure grocery stores stay open and accessible, and even making sure people have access to the creature comforts that make social distancing bearable.

Inequity of Work Requirements During Pandemic
“Income replacement for people whose employment has been curtailed by the government isn’t just an economic issue, it’s an ethical one. Likewise, we need to consider what to do for workers in jobs where sufficient protection from infection cannot be provided. While we have expectations of certain healthcare professionals, like doctors and nurses, who have taken oaths to continue working even when it puts them at personal risk, the same isn’t true for hospital support staff or grocery store checkers. We can’t simply expect those workers to continue facing risks that others can avoid.”

Equity in Vaccine Development
“Historically, the interests of pregnant women have not been adequately included in global responses to outbreaks and epidemics. As the world rushes to develop new vaccines against Covid-19, we must ensure that, this time, pregnant women and their babies will not be left behind. Developing a coronavirus vaccine that they are unable to use would be not only a tragedy but a grave injustice.

The article was included as required reading for the 38th Annual Congressional Leadership Conference of the American College of Obstetricians and Gynecologists, as physicians came to Washington from across the country to meet legislators and help shape public policy. Faden and Krubiner’s co-author of the STAT and Boston Globe article and collaborator in the PREVENT project, Ruth Karron of the Johns Hopkins Vaccine Initiative, was quoted in a March 3 New York Times article, “What Pregnant Women Should Know About Coronavirus.”

Patient Privacy and Contact Tracing
“Doctors don’t out people. Whether it’s HIV, syphilis, coronavirus or anything else, people simply won’t show up to their doctor if they feel they might be outed for a condition.”

Impact on Incarcerated Individuals
Detention and correctional spaces are the “perfect environment for the spread of COVID-19. So when we talk about social distancing, it’s almost impossible in prisons unless you have complete lockdown – basically, put everybody in solitary confinement.”

The Berman Institute continue to offer insights and expertise to aid in the response to the monumental challenges posed by the outbreak.

Related Berman Institute Resources

Failure to Respect Needs of Vulnerable Groups Will Undermine Response

For comprehensive Covid-19 Ethics and Policy Resources, visit our dedicated webpage, bioethics.jhu.edu/coronavirus.

 

 

Berman Institute faculty member Zackary Berger, MD, PhD, has published a new paper in The BMJ, “Covid-19: Control Measures Must Be Equitable and Inclusive,” stating that failure to respect the needs of vulnerable groups will seriously undermine response efforts. His paper says:

“Containment, mitigation, and suppression plans must be as inclusive as possible or risk undermining response efforts. A commitment to inclusion means responding to covid-19 in a way that is sensitive to our most vulnerable communities, including homeless people, those without adequate insurance or employment, communities of colour, indigenous communities, immigrant communities, people with disabilities, and certain frontline healthcare workers and emergency responders.

“Trust begins with communication, and communicating information during outbreaks is challenging, especially as our knowledge of a disease evolves. Inclusive messaging should be tailored and available in a variety of languages, including sign languages. Honest, transparent communication is vital; confusing or contradictory health messaging engenders mistrust and leads people to seek information from unreliable alternative sources. Underserved communities are rightly distrustful of public health institutions: communities of colour and people with disabilities have historically been undertreated or abused through the medical system, and undocumented immigrants fear punitive measures should they present at a clinic or hospital.”

The paper calls for free testing of all patients. Berger also states that during influenza outbreaks, paid sick leave policies could lower influenza infection rates by up to 40% and calls for healthcare institutions to set “the standard by guaranteeing paid sick leave for all employees. Governments should reimburse sick leave expenses for the healthcare enterprises counted on to respond to covid-19 and implement similar programmes to support casual, small business, and gig economy workforces.”

The BMJ (mostly referred to as the British Medical Journal) is one of the world’s top four most cited general medical journals.  Dr. Berger is an internist, clinical epidemiologist, and bioethicist whose clinical, educational, and research work is located at the intersection of shared decision making, patient-centered care and evidence-based medicine. How to make sense of a sharing patient-physician relationship in the context of social and political inequities is a central question underlying much of our health system’s imperfections. Dr. Berger is using interdisciplinary techniques to explore possible answers, especially among vulnerable and victimized populations.

Commentary: Coronavirus Could Result in School Closings in the U.S.

We must make sure these closings meet the needs of low-income children.

Ruth R. Faden, The Baltimore Sun. Feb 27, 2020.

It is official. The Centers for Disease Control and Prevention has alerted the American public that it is only a matter of time before we will see community transmission of coronavirus in the U.S. The CDC asked Americans to start preparing now for the major disruptions of daily life that are likely to occur.

Dr. Nancy Messonnier, the CDC’s director of the National Center for Immunization and Respiratory Diseases, specifically called out the possibility of school closings. And with good reason.

All schools in China are closed indefinitely, affecting 200 million school-aged children, as well as schools in Hong Kong. There are also significant school closures in Japan, South Korea, Mongolia, Vietnam and Iran (including in Tehran, the capital). Thus far, Italy has closed schools in the Lombardy region, including Milan, and as a result of local decisions some schools in Turin and Venice are closed as well. …

…Read More