Volume 19, Issue 6, June 2019, Page 30-31.

The Centers for Medicare & Medicaid Services has initiated bundled payments for hip and knee total joint replacement in an effort to decrease healthcare costs and increase quality of care. The ethical implications of this program have not been studied. This article considers the ethics of patient selection to improve outcomes; specifically, screening patients by body mass index to determine eligibility for total joint replacement. I argue that this type of screening is not ethically defensible, and that the bundled payment (...) program as structured is likely to lead to unfair restrictions on who receives total joint replacements. (shrink)

The COVID-19 pandemic has increased demand for physicians, leading to widespread redeployment of specialty physicians to care for patients with COVID-19. These redeployments highlight an important question: How do physicians balance competing obligations to their own health, their own patients, and society during a public health crisis? How can physicians, specifically subspecialists, navigate this tension? In this article, we analyse a clinical scenario in which an orthopaedic sports surgeon is redeployed to care for patients with COVID-19. This case raises questions (...) about physicians’ obligations to their own patients compared with society at large, the relative value of specialty physicians during a global pandemic, and the ethical permissibility of compulsory redeployment. Using the orthopaedic surgery specialty as a model, we build a redeployment framework for surgical specialists that is both ethical and equitable. We argue that although orthopaedic surgeons have a moral obligation to participate in physician redeployment schemes, the scope of this obligation is limited and contingent on the following conditions: (1) the number of local COVID-19 cases is high; (2) obligations to their own patients or orthopaedic patients requiring urgent or emergency care have been fulfilled; (3) their value as physicians exceeds their value as specialists because of the pandemic climate; (4) voluntary redeployments are exhausted before compulsory redeployments are implemented; and (5) redeployment would not put the physicians at unreasonable risk of harm. (shrink)

Background The allocation of scarce deceased donor kidneys is a complex process. Transplant providers are increasingly relying on constructs such as frailty and cognitive function to guide kidney transplant (KT) candidate selection. Patient views of the ethical issues surrounding the use of such constructs are unclear. We sought to assess KT candidates’ attitudes and beliefs about the use of frailty and cognitive function to guide waitlist selection.Methods KT candidates were randomly recruited from an ongoing single-center cohort study of frailty and (...) cognitive function. Semi-structured interviews were conducted, and thematic analysis was performed. Inductively derived themes were mapped onto bioethics principles.Results Twenty interviews were conducted (65% contact rate, 100% participation rate) (60% male; 70% White). With respect to the use of frailty and cognitive function in waitlisting decisions, four themes emerged in which participants: (1) valued maximizing a scarce resource (utility); (2) prioritized equal access to all patients (equity); (3) appreciated a proportional approach to the use of equity and utility (precautionary utility); and (4) sought to weigh utility- and equity-based concerns regarding social support. While some participants believed frailty and cognitive function were useful constructs to maximize utility, others believed their use would jeopardize equity. Patients were uncomfortable with using single factors such as frailty or cognitive impairment to deny someone access to transplantation; participants instead encouraged using the constructs to identify opportunities for intervention to improve frailty and cognitive function prior to KT.Conclusions KT candidates’ values mirrored the current allocation strategy, seeking to balance equity and utility in a just manner, albeit with conflicting viewpoints on the appropriate use of frailty and cognitive impairment in waitlisting decisions. (shrink)