The ethical allocation of scarce medical resources has received significant attention, yet a key question remains unaddressed: how should scarce, divisible resources be allocated? We present a case from the COVID-19 pandemic in which scarce resources were divided among patients rather than allocated to some patients over others. We assess how widely accepted allocation principles could be applied to this case, and we show how these principles provide insufficient guidance. We then propose alternatives that may help guide decision-making in such (...) cases, and we evaluate the possibility of treating patients equally by dividing resources equally. Resource scarcity is not limited to pandemic situations, and many healthcare resources are divisible. This question—how to allocate these divisible resources—deserves greater attention from bioethics. (shrink)

The opioid crisis has greatly increased the number of patients who are illegally injecting drugs while hospitalized for other conditions. Physicians face a difficult decision in these circumstances: when is it appropriate to involuntarily discharge or “fire” a patient with opioid use disorder for their continued nonmedical use of opioids? This commentary analyzes physicians’ responsibilities to their patients and argues that physicians should fire non-adherent patients only when every other option has been exhausted and the expected benefits of firing the (...) patient outweigh the expected harms. (shrink)

Organ procurement organization (OPO) staff play an essential role in the facilitation of organ donation as they guide family members and loved ones of dying patients through the donation process. Throughout the donation process, OPO staff must assume the role of a dual advocate, considering both the interests of the donor (which often include the wishes of the donor’s family) and the interests of potential recipient(s). The benefits of this role are well established; however, minimal literature exists on the ways (...) this role can cause moral distress in OPO staff, who frequently face scenarios in which adhering to the wishes of a donor family may compromise donation potential but failing to honor donor family requests may result in further emotional burden for the family. Given the frequency with which these ethically complex situations exist during donation, OPO staff are at heightened risk for experiencing moral distress and burnout, yet they are seldom acknowledged in the existing moral distress literature. As a result, it is unclear whether the current practices available to mitigate moral distress are beneficial for this population. (shrink)

The assumption in current U.S. mainstream medicine is that birthing requires hospitalization. In fact, while the American College of Obstetricians and Gynecologists supports the right of every birthing person to make a medically informed decision about their delivery, they do not recommend home birth owing to data indicating greater neonatal morbidity and mortality. In this article, we examine the evidence surrounding home birth in the United States and its current limitations, as well as the ethical considerations around birth setting.

Background: Little is known about U.S. healthcare provider views and practices regarding evidence, counseling, and shared decision-making about in-hospital versus out-of-hospital birth settings. Methods: We conducted 19 in-depth, semistructured, qualitative interviews of eight obstetricians, eight midwives, and three pediatricians from across the United States. Interviews explored healthcare providers’ interpretation of the current evidence and their personal and professional experiences with childbirth within the existing medical, ethical, and legal context in the United States. Results: Themes emerged concerning risks and benefits, decision-making, (...) and patient-provider power dynamics. Collectively, the narratives illuminated fundamental ideological tensions between in- and out-of-hospital providers arising from divergent assignment of value to described risks and benefits. The majority of physicians focused on U.S.-specific data demonstrating increased neonatal morbidity and mortality associated with delayed access to hospital-based interventions, thereby justifying hospital birth as the standard of care. By contrast, midwives emphasized data demonstrating fewer interventions and superior maternal and neonatal outcomes in high-income European countries, where out-of-hospital birth is more common for low-risk birthing people. A key gap in counseling was revealed, as no interviewees offered anticipatory counseling regarding birth setting options. Providers directly and indirectly illustrated the propensity for asymmetric power relations between birth providers and pregnant people, especially in hospital settings. Conclusions: The narratives highlight the common goal of optimizing maternal and neonatal outcomes despite tensions arising from divergent prioritization of specific maternal and neonatal risks. Our findings suggest opportunities to foster collaboration and optimize outcomes via mutual respect and improved integration of care. (shrink)

There is societal consensus that cancer clinical trial participation is unjust because some sociodemographic groups have been systematically underrepresented. Despite this, neither a definition nor an ethical explication for the justice norm of equity has been clearly articulated in this setting, leading to confusion over its application and goals. Herein we define equity as acknowledging sociodemographic circumstances and apportioning resource and opportunity allocation to eliminate disparities in outcomes, and we explore the issues and tensions this norm generates through practical examples. (...) We assess how equality-based enrollment structures in clinical cancer research have perpetuated historical disparities and what equity-based alternatives are necessary to achieve representativeness and an expansive conception of participatory justice in clinical cancer research. This framework addresses the breadth from normative to applied by defining the justice norm of equity and translating it into practical strategies for addressing participation disparities in clinical cancer research. (shrink)

This introduction to The Journal of Clinical Ethics highlights and expands four articles within this issue that propose somewhat new and radical innovations to help and further the interests of patients and families worst off. One article urges us to enable historically marginalized groups to participate more than they have in research; a second urges us to allocate limited resources that can be divided, such as vaccines and even ventilators, in a different way; a third urges us to help families (...) find greater meaning when their loved ones are dying; and a fourth urges us to treat patients who illegally use drugs as caringly as is possible, though there may be limits to what providers can do. This piece also addresses the importance of providers bonding with patients, recognizing that some providers may be better at eliciting patients’ trust than others, and thus the importance of connecting these patients with these providers since this may be the sole way these patients can optimally respond and do well. Finally, providers taking time away from their patients to oppose and reduce social stigma is considered. (shrink)

To examine the ethical duty to patients and families in the setting of the resuscitation bay, we address a case with a focus on providing optimal care and communication to family members. We present a case of nonsurvivable traumatic injury in a minor, focusing on how allowing family more time at the bedside impacts the quality of death and what duty exists to maintain an emotionally optimal environment for family grieving and acceptance. Our analysis proposes tenets for patient and family-centric (...) care that, in alignment with trauma-informed care principles, optimize the long-term well-being of the family, namely valuing family desires and sensitivity to location. (shrink)