DRUGS

This op-ed by Crutchfield, Gibb, and Redinger tackles issues of distributing remdesivir, an antiviral drug that shows promise in reducing COVID-19 recovery time. Using Michigan as an example, the authors argue that fair allocation of the drug requires prioritizing distribution to communities that are bearing a disproportionate burden of the pandemic. While there are a variety of ethically justifiable approaches to resource allocation, the authors explain that when there are significant existing disparities in the burden of illness, it is unjust to allocate in a manner that fails to benefit those who are worst off. This is also consistent with the overarching goal of scarce resource allocation to save the most lives. Additionally, the authors note various additional benefits to prioritizing the hardest-hit communities, including repairing community trust, which may encourage healthy behaviors and compliance with public health interventions.

NURSING HOMES

Testing nursing home staff: This NY Times article describes the hurdles impeding comprehensive COVID-19 testing for nursing home staff. Disputes over whether the testing will be paid for by the nursing home, the state, or the employee’s health insurer have hindered compliance with mandates and recommendations, and continuing supply shortages and lack of coordination have further constrained availability. Nursing homes can bill insurers (primarily Medicare and Medicaid) for testing residents, but they cannot bill for testing employees. Adding to the challenge, nursing home staff are among the lowest paid workers in health care and often do not have insurance coverage themselves.

Nursing homes have received federal stimulus funding for COVID-19-related expenses, but they have sought further help to cover testing from federal and state governments. Nursing home staff are among the most important targets for testing due to their frequent exposure to residents who are among those at highest risk from the virus. Federal agencies have offered conflicting advice on how frequently nursing home staff should be tested, and states, which are the primary regulators of nursing homes, have taken vastly different approaches. Some states have mandated frequent testing for nursing home staff, with costs to be borne by the nursing homes if insurance does not cover the costs. Some insurers have refused coverage, and nursing homes argue that they cannot afford the cost of frequent testing for all staff.

Liability protections: This Conversation article by Sklar and Terry discusses state efforts to protect health care providers, including nursing homes, from liability from lawsuits over their actions and inactions related to COVID-19. The protections are intended to aid providers who have to make difficult decisions in an environment where resources (like PPE and testing kits) are scarce, but the authors argue that the protections nursing homes are seeking are overly broad and leave few options for holding the facilities accountable for failing their residents. Regulatory oversight of nursing homes has declined despite widespread and well-documented problems in staffing and infection control, and many U.S. nursing homes failed to implement basic protocols to counter COVID-19, contributing to nursing homes being the site of (at least) 45% of deaths in the country.

TRIAGE AND ALLOCATION

Social justice and triage: This editorial by Stone argues that triage decisions in situations of resource scarcity should not incorporate life-years saved beyond brief post-hospitalization survival. Persistent societal inequities have created chronic disadvantages for some populations (particularly racial and ethnic minorities) that are often reflected in reduced expected life-years at the population level. The author argues that principles of justice require avoiding policies that increase or exacerbate those inequities and that this necessitates rejecting consideration of subsequent life-years saved as a triage criterion.

Ventilator priority for health care workers: This essay by Chen, Marshall, and Shepherd argues that scarce resource allocation plans for ventilators that prioritize health care workers are the wrong approach with regard to COVID-19. Ethical justifications for prioritizing health care workers for scarce resources usually center on one of two principles: the essential role these workers play in continued effective response or reciprocity for workers’ willingness to be exposed to high risks. The authors argue that neither justification is sufficient in the case of ventilators during COVID-19 response because health care workers are unlikely to be able to quickly return to front line care roles following treatment and are not unique in accepting higher risk in essential jobs.

Ethical Challenge Overview: This article by McGuire et al. provides a comprehensive overview of ethical challenges related to COVID-19 from the perspective of an Association of Bioethics Program Directors task force. Key issues addressed include resource allocation, defining benefit, informed consent, special needs of pediatric patients, community engagement, and mitigation of discrimination and the effects of structural inequities. The authors catalog and analyze a range of specific health care system and social issues with the aim of providing lessons for facilities, health care professionals, public health authorities, and the bioethics community.