Extracorporeal membrane oxygenation (ECMO) is typically viewed as a time-limited intervention—a bridge to recovery or transplant—not a destination therapy. However, some patients with decision-making capacity request continued ECMO support despite a poor prognosis for recovery and lack of viability as a transplant candidate. In response, critical care teams have asked for guidance regarding the ethical permissibility of unilateral withdrawal over the objections of a capacitated patient. In this article, we evaluate several ethical arguments that have been made in favor of (...) withdrawal, including distributive justice, quality of life, patients’ rights, professional integrity, and the Equivalence Thesis. We find that existing justifications for unilateral withdrawal of ECMO support in capacitated patients are problematic, which leads us to conclude that either: (1) additional ethical arguments are necessary to defend this approach or (2) the claim that it is not appropriate to use ECMO as a destination therapy should be questioned. (shrink)

This article discusses the triage response to the COVID-19 delta variant surge of 2021. One issue that distinguishes the delta wave from earlier surges is that by the time it became the predominant strain in the USA in July 2021, safe and effective vaccines against COVID-19 had been available for all US adults for several months. We consider whether healthcare professionals and triage committees would have been justified in prioritising patients with COVID-19 who are vaccinated above those who are unvaccinated (...) in first-order or second-order triage. Given that lack of evidence for a correlation between short-term survival and vaccination, we argue that using vaccination status during first-order triage would be inconsistent with accepted triage standards. We then turn to notions of procedural fairness, equity and desert to argue that that there is also a lack of justification for using vaccination status in second-order triage. In planning for future surges, we recommend that medical institutions base their triage decisions on principles meant to save the most lives, minimise inequity and protect the public’s trust, which for the time being would not be served by the inclusion of vaccination status. (shrink)

In their target article, Fox & Duke provide evidence that consult volumes vary based on ethics staffing, leading to their conclusion that ethics consultation is an example of supply-sensitiv...

Health has an important role in the achievement of a good quality of life. Many public policies intended to enhance individual and population health. Amartya Sen’s Capability Approach (CA) offers a framework to assess well-being, as well as interventions seeking to increase it. There are, however, important practical challenges that must be faced before applying CA to concrete situations, such as health. One of these challenges is defining whether it is functioning or a capability that is the feature to be (...) assessed. Moreover, some aspects of freedom that are relevant for CA are frequently neglected, such as agency. These aspects must be considered when performing a health assessment using the CA as a framework. A health assessment using the CA as a framework should include indicators based on the achieved dimension (health functioning), resources and conversion factors (health capability), and freedom to achieve (agency). (shrink)

Controversy exists over how to ethically distribute health care resources and which factors should determine access to health care services. Although the US has traditionally used a market-based private insurance model that does not ensure universal coverage, the Patient Protection and Affordable Care Act in the United States aims to increase equitable access to health care by increasing the accessibility, affordability, and quality of health care services. This article evaluates the impact of the ACA on equitable mental health care delivery (...) according to access factors that can hinder or facilitate the delivery of mental health services based on need. The ACA has successfully expanded coverage to millions of Americans and promoted coordination and access to mental health care; however, financial and non-financial access barriers to mental health care and access disparities remain. Reform efforts should not undervalue the gains that the ACA has made but should attempt to balance considerations of cost and increasing free-market mechanisms with decreasing remaining health care disparities. (shrink)