Publich Health Policy

This study evaluates the operational efficiency of accredited private healthcare facilities in Italy, a sector increasingly complementing the public National Health Service. Unlike previous studies that aggregate public and private providers, this research focuses exclusively on private facilities, providing a consistent and detailed evaluation of their performance. Utilizing game-theoretic cross-efficiency Data Envelopment Analysis (DEA) combined with Classification and Regression Tree (CART) analysis, this study identifies endogenous and exogenous efficiency drivers. Results indicate that private facilities operate at high efficiency levels (mean cross-efficiency = 0.923), with smaller facilities outperforming larger ones, though resources remain underutilized. Inactive ward and bed non-occupancy rates emerge as key inefficiency factors. Regional analysis highlights minimal disparities between the north-center and south, but significant local variations persist, shaped by governance, funding allocation, and institutional frameworks. This study also identifies an "efficiency paradox", as in deficit regions, private expenditure correlates with higher efficiency, whereas in surplus regions, greater spending does not necessarily improve performance. These findings provide actionable insights for healthcare managers and policymakers, emphasizing the need to maximize capacity utilization, optimize staffing, and structure public-private partnerships strategically. Methodologically, integrating game cross-efficiency DEA with CART strengthens accuracy, offering a robust tool for benchmarking and improving private healthcare performance.

According to the Global Research on Antimicrobial Resistance, the Philippines has an average antibiotic use of 5.3 DDDs per 1,000 people, with pediatric antibiotic use constituting approximately 56.2%. Although lower than in neighboring countries, this level of use still poses a significant threat to the healthcare system. The widespread availability of antibiotics has been a major contributing factor to the rise of antibiotic resistance (ABR) in the Philippines. Historically, antibiotics could be purchased without a prescription from local pharmacies. This study examined the prevalence of consumers attempting to purchase antibiotics without a prescription in Carmona, Cavite. Utilizing quantitative descriptive and correlational research methodologies, the study employed convenience sampling due to the limited number of community pharmacies and their tendency to cluster in specific areas. A structured survey questionnaire was used to gather data and analyze correlations between variables. Findings indicate that the majority of consumers in Carmona, Cavite, frequently attempt to obtain antibiotics without a prescription, with a preference for penicillin-class antibiotics. The reasons for these purchases vary, including self-medication for minor illnesses, treatment for pets and poultry, and topical wound care. The results underscore the importance of community education and engagement on the risks of ABR. The study suggests that local government educational programs can enhance consumer awareness of the need for prescriptions. The findings indicate that awareness of prescription requirements moderately affects the frequency of attempting to buy antibiotics without a prescription. However, no significant association was found between the reasons for obtaining medicine without a prescription and the type or class of medicine purchased.

Objectives: Each new wave of the COVID-19 pandemic invites the possible obligation to prioritize individuals' access to vital resources, and thereby leads to unresolved and important bioethical concerns. Governments have to make decisions to protect access to the health system with equity. The prioritization criteria during a pandemic are both a clinical and legal-administrative decision with ethical repercussion. We aim to analyse the prioritization protocols used in Spain during the pandemic which, in many cases, have not been updated.Method: We carried out a narrative review of 27 protocols of prioritization proposed by healthcare ethics committees, scientific societies and institutions in Spain for this study. The review evaluated shared aspects and unique differences and proffered a bioethical reflection.Results: The research questions explored patient prioritization, the criteria applied and the relative weight assigned to each criterion. There was a need to use several in...

Early on, geriatricians in Israel viewed with increasing alarm the spread of coronavirus disease 2019 (COVID‐19). It was clear that this viral disease exhibited a clear predilection for and danger to older persons. Informal contacts began with senior officials from the country's Ministry of Health, the Israel Medical Association, and the country's largest health fund; this was done to plan an approach to the possible coming storm. A group was formed, comprising three senior geriatricians, a former dean, a palliative care specialist, and a lawyer/ethicist. The members made every effort to ensure that their recommendations would be practical while at the same time taking into account the tenets of medical ethics. The committee's main task was to think through a workable approach because intensive care unit/ventilator resources may be far outstripped by those requiring such care. Recommendations included the approach to older persons both in the community and in long‐term c...

The COVID-19 pandemic provides the opportunity to re-think health policies and health systems approaches by the adoption of a biopsychosocial perspective, thus acting on environmental factors so as to increase facilitators and diminish barriers. Specifically, vulnerable people should not face discrimination because of their vulnerability in the allocation of care or life-sustaining treatments. Adoption of biopsychosocial model helps to identify key elements where to act to diminish effects of the pandemics. The pandemic showed us that barriers in health care organization affect mostly those that are vulnerable and can suffer discrimination not because of severity of diseases but just because of their vulnerability, be this age or disability and this can be avoided by biopsychosocial planning in health and social policies. It is possible to avoid the banality of evil, intended as lack of thinking on what we do when we do, by using the emergence of the emergency of COVID-19 as a Troja...

ACAP Toolkit in Cameroon is one of the three components of the Adolescent Health Well-being Package (AHWP) which constitute the outputs of the Advocating for Change for Adolescents Project (ACAP) in Cameroon. The other AHWP outputs are the DESERVE Manual for teaching Comprehensive Sexuality Education and a toolkit for the collection and analysis of disaggregated date on adolescent health and well-being.

ACAP Toolkit in Cameroon is an informative, pedagogic and policy document:
1. It presents the concept of adolescent well-being.
2. It presents the situation of adolescent well-being in Cameroon. We recently added the results and advocacy actions of the 1point8 billion campaign in Cameroon which culminated in the Cameroon Forum for Adolescents (please see page 35-37 English version).
3. It is a pedagogic manual for young people to meaningfully engage in actions to improve their health and well-being. It also guides stakeholders to appreciate and practice meaningful adolescent and youth engagement and ultimately include the adolescent well-being in their actions.
4. It provides a compendium of policy commitments made by the government of Cameroon that touch on adolescents while identifying gaps that need to be closed.
5. It synthesizes evidence on the effects of the COVID-19 on the well-being of adolescents with a call to action for crises preparedness to avert their effects on adolescents’ well-being.

The five chapters of this toolkit and the addendum are each interspersed with examples on local actions to respond to community problems, and practical exercises to enable you to work on the field. Each of the chapters is informative, pedagogic and policy-oriented at the same time. The following are the chapter perspectives:
• Chapter 1 focuses on the concept of adolescent well-being and analyses adolescent health and well-being in Cameroon;
• Chapter 2 concentrates on researching national policies, strategies, plans, programmes and visions that justify the problem to be solved;
• Chapter 3 explains how to use commitments like treaties, programmes and plans to improve adolescent health and well -being;
• Chapter 4 highlights the steps used to draw an advocacy roadmap;
• Chapter 5 focuses on monitoring and evaluating projects to promote adolescent health and well-being.
• The COVID-19 Addendum presents a global and national overview of COVID-19 and its impact on the health and well [1]being of adolescents in Cameroon, with a call to action for improved adolescent health and well-being during such crisis.

The Government of Cameroon endorsed this work on 1 November 2021 in Yaoundé, through the Ministry of Youth Affairs and Civic Education, with a foreword by the Minister.

A public health emergency, as the COVID-19 pandemic, may lead to shortages of potentially life-saving treatments. In this situation, it is necessary, justifiable and proportionate to have decision tools in place to enable healthcare professionals to triage and prioritise access to those resources. An ethically sound framework should consider the principles of beneficence and fair allocation. Scientific Societies across Europe were concerned with this problem early in the pandemic and published guidelines to support their professionals and institutions. This article aims to compare triage policies from medical bodies across Europe, to characterise the process of triage and the ethical values, principles and theories that were proposed in different countries during the first outbreak of COVID-19.

Objectives: Each new wave of the COVID-19 pandemic invites the possible obligation to prioritize individuals' access to vital resources, and thereby leads to unresolved and important bioethical concerns. Governments have to make decisions to protect access to the health system with equity. The prioritization criteria during a pandemic are both a clinical and legal-administrative decision with ethical repercussion. We aim to analyse the prioritization protocols used in Spain during the pandemic which, in many cases, have not been updated.Method: We carried out a narrative review of 27 protocols of prioritization proposed by healthcare ethics committees, scientific societies and institutions in Spain for this study. The review evaluated shared aspects and unique differences and proffered a bioethical reflection.Results: The research questions explored patient prioritization, the criteria applied and the relative weight assigned to each criterion. There was a need to use several in...

This study is designed to review health sector of Sindh by the analysis of different subsectors and major programs of the Health Department of Government of Sindh. This paper examines the Mother and Child Healthcare, Immunization, Malaria Control Program, Child Nutrition, Child Feeding Practices and Childhood Mortalities as subsectors and conducts performance appraisal on the 3rd goal of SDG. The prevalence of different indicators for relevant sectors at two different time points (i.e. 2014-15 and 2018-19) have been used to analyze the performance and trend of sub-sectors. Average Performance Index (API) is computed for each sector and the progress of each sector is tracked by trend of two points. Sindh service delivery variables are looking better but there are specific issues in mother and child care such as prevalence of child weight at birth is declining alarmingly owing to lack of nutritional monitoring. The culture of performing C-sections has significantly increased which badly affect mother's health. In the light of above evaluation of different sectors, policy recommendations are made for the improvement of overall health system.

This research aims to examine access to medical treatment during the COVID-19 pandemic for people living with disabilities. During the COVID-19 pandemic, the practical and ethical problems of allocating limited medical resources such as intensive care unit beds and ventilators became critical. Although different countries have proposed different guidelines to manage this emergency, these proposed criteria do not sufficiently consider people living with disabilities. People living with disabilities are therefore at a higher risk of exclusion from medical treatments as physicians tend to assume they have poor quality of life, whereas access to medical treatment should be based on several parameters, including clinical data and prognosis. However, the COVID-19 pandemic shifts the medical paradigm from person-centred medicine to community-centred medicine, challenging the main ethical theories. We reviewed the main guidelines and recommendations for resources allocation and examined the...

In January 2020, the Chinese authorities identified a new virus of the Coronaviridae family as the cause of several cases of pneumonia of unknown aetiology. The outbreak was initially confined to Wuhan City, but then spread outside Chinese borders. On 31 January 2020, the first case was declared in Spain. On 11 March 2020, The World Health Organisation (WHO) declared the coronavirus outbreak a pandemic. On 16 March 2020, there were 139 countries affected. In this situation, the Scientific Societies SEMICYUC and SEEIUC, have decided to draw up this Contingency Plan to guide the response of the intensive care services. The objectives of this plan are to estimate the magnitude of the problem and identify the necessary human and material resources. This is to provide the Spanish Intensive Medicine Services with a tool to programme optimal response strategies.

COVID 19 represent the pandemic of the century. It challenged all of us to look at the way we live, work, practice and interact with one another. This paper looks at the ethical issues and dilemmas COVID 19 posed. It looks at the difference between the day to day practice versus working under exceptional crisis situations. Common ethical principles are discussed candidly by the author, who is a full time frontline Emergency Physician and also a Member of Parliament in Singapore. Ethical principles of beneficence, justice, equity and virtue ethics are discussed with examples, as well as the three factors which are critical in managing a pandemic: leadership, values and balancing individual rights versus collective duties and responsibilities in society.

Background: Throughout the Pandemic caused by COVID-19, health professionals have faced the ght against this disease in the front line, even without effective treatment, this uncertainty led to the presentation of various ethical crises in health services to be analyzed. Methods: An exploratory, cross-sectional investigation was developed, for which a self-application instrument was designed, in the online interview modality, aimed at doctors and university professors involved with bioethics with the purpose of analyzing ethical aspects in care of COVID-19 patients. Results: 100 interviews were collected for the convenience of their work location, 67% worked in hospitals, 11% in clinics, and 22% in universities teaching the bioethics course. Problematic situations related to high exposure to risks of health professionals, infrastructure gap, ICU beds, and hospital beds were identi ed as problematic situations. The main con icts and ethical dilemmas were related to decisionmaking for the allocation of resources, lack of culture of self-care for the health of the population, the risk of contagion from the doctor, therapies not supported by clinical trials, and patient-physician prioritization. Conclusions: It was evidenced that university doctors and teachers identi ed various problematic situations, con icts and ethical dilemmas in the care of COVID-19 patients, which compromise ethical values of maximization of bene ts, equity, in addition to ethical principles such as bene cence, justice, reciprocity, solidarity, integrity, respect, vulnerability, dignity, damaging their human and legal rights.

We report here an emerging dispute in Italy concerning triage criteria for critically ill covid-19 patients, and how best to support doctors having to make difficult decisions in a context of insufficient life saving resources. The dispute we present is particularly significant as it juxtaposes two opposite views of who should make triage decisions, and how doctors should best be supported. There are both empirical and normative questions at stake here. The empirical questions pertain to the available level of evidence that healthcare professionals would rather not be left alone with their ‘clinical judgments’ to make triage decisions, and to the accounts of distributive justice that doctors and healthcare professionals rely on, when making triage decisions. The normative questions pertain to how this empirical evidence should inform guidelines on how prioritisation decisions are made in a context of emergency, and who gets to have the authority to do so. This debate goes beyond the...

This paper proposes communities of practice (CoP) as a process to build moral resilience in healthcare settings. We introduce the starting point of moral distress that arises from ethical challenges when actions of the healthcare professional are constrained. We examine how situations such as the current COVID-19 pandemic can exponentially increase moral distress in healthcare professionals. Then, we explore how moral resilience can help cope with moral distress. We propose the term collective moral resilience to capture the shared capacity arising from mutual engagement and dialogue in group settings, towards responding to individual moral distress and towards building an ethical practice environment. Finally, we look at CoPs in healthcare and explore how these group experiences can be used to build collective moral resilience.

The following article presents the relevant and unprecedented bioethical and biolaw issues posed by the SARS-COV-2 pandemic and summarizes the initiatives adopted by the Italian Society of Anesthesia and Resuscitation (SIAARTI) as well as by the Veneto Region ICU Network. Since the initial phase of the pandemic, in March 2020, there has been a strong appeal from both SIAARTI and the Veneto Region ICU Network to consider “the appropriate intensive treatment.” During the pandemic, the principle of proportionality must be applied, in compliance with the main principle in bioethics. This encompasses the concept of clinical appropriateness, based on the efficacy of the treatment in specific case and context, as well as the concept of ethical appropriateness, which refers to ethical and juridical principles of acceptance of health care. The “appropriate treatment” must never interfere with the withdrawal of patients, who are not eligible for intensive treatments since they would not benef...

This research aims to examine access to medical treatment during the COVID-19 pandemic for people living with disabilities. During the COVID-19 pandemic, the practical and ethical problems of allocating limited medical resources such as intensive care unit beds and ventilators became critical. Although different countries have proposed different guidelines to manage this emergency, these proposed criteria do not sufficiently consider people living with disabilities. People living with disabilities are therefore at a higher risk of exclusion from medical treatments as physicians tend to assume they have poor quality of life, whereas access to medical treatment should be based on several parameters, including clinical data and prognosis. However, the COVID-19 pandemic shifts the medical paradigm from person-centred medicine to community-centred medicine, challenging the main ethical theories. We reviewed the main guidelines and recommendations for resources allocation and examined their position toward persons with disabilities. Based on our findings, we propose criteria for not discriminating against people with disabilities in allocating resources. The shift from person-centred to community-centred medicine offers opportunities but also risks sacrificing the most vulnerable people. The principle of reasonable accommodation must always be considered to guarantee the rights of persons with disabilities.

Many healthcare goods, such as surgical instruments, textiles and gloves, are manufactured in unregulated factories and sweatshops where, amongst other labour rights violations, workers are subject to considerable occupational health risks. In this paper we undertake an ethical analysis of the supply of sweatshop-produced surgical goods to healthcare providers, with a specific focus on the National Health Service of the United Kingdom. We contend that while labour abuses and occupational health deficiencies are morally unacceptable in the production of any commodity, an additional wrong is incurred when the health of certain populations is secured in ways that endanger the health and well-being of people working and living elsewhere. While some measures have been taken to better regulate the supply chain to healthcare providers in the UK, further action is needed to ensure that surgical goods are sourced from suppliers who protect the labour and occupational health rights of their workers.

Due to COVID-19’s strain on health systems across the globe, triage protocols determine how to allocate scarce medical resources with the worthy goal of maximising the number of lives saved. However, due to racial biases and long-standing health inequities, the common method of ranking patients based on impersonal numeric representations of their morbidity is associated with disproportionately pronounced racial disparities. In response, policymakers have issued statements of solidarity. However, translating support into responsive COVID-19 policy is rife with complexity. Triage does not easily lend itself to race-based exceptions. Reordering triage queues based on an individual patient’s racial affiliation has been considered but may be divisive and difficult to implement. And while COVID-19 hospital policies may be presented as rigidly focused on saving the most lives, many make exceptions for those deemed worthy by policymakers such as front-line healthcare workers, older physicia...

In this paper, we analyse the most important documents establishing the criteria for the treatment and exclusion of COVID-19 patients, especially in regard to the giving of respiratory support, in Italy and Spain. These documents reflect a tension that stems from limited healthcare resources which are insufficient to save lives that, under normal conditions, could have been saved, or at least could have received the best possible treatment. First, we analyse the healthcare systems of these two countries before the spread of the virus, both of which have seen decreases in the number of intensive care beds and have been marked by financial cuts during the last ten years. It is a fact that a greater number of people, especially those over 70 years of age, have been left without respiratory support treatment, and therefore, there have been a greater number of deaths. It is also a fact that there has been a higher infection rate among healthcare professionals due to the delay in the management of protective measures and the inability to provide adequate care for those in nursing homes, as recognised by WHO. In the context of this health emergency, healthcare professionals have suffered a real 'moral distress' because, knowing first-hand the causes of the limitation of resources, they have had to put triage protocols into practice. Finally, we set forth a series of concrete ethical proposals with which to face the successive waves of COVID-19 infection, as well as other future pandemics.

WHO states five ethical principles for the care of patients with COVID-19: Equal moral respect, duty of care, non-abandonment, protection of the community, and confidentiality. Healthcare professionals might have to make difficult decisions such as selecting patients and withholding or withdrawing mechanical ventilation of critically ill patients. In such difficult situations, a well-prepared action plan which considers ethical principles and prioritizes both public health and the safety of healthcare professionals, can help them. In this case, the development of an effective pandemic action plan, together with a triage plan based on emergency and disaster medicine is necessary. The only parameter of selection in this plan must be the correct application of triage, which respects every human life and depends on the criteria of clinical suitability. In this context, the fundamental ethical principles and human rights must be considered when allocating resources and prioritizing patients. Additionally, all protective measures for healthcare professionals must be taken, including all necessary equipment being adequately provided. If healthcare professionals become infected or face a life-threatening risk, then their obligations will be limited. Therefore, it is necessary to realize these limitations which may arise while providing appropriate health services.

This paper puts forward a wish list of requirements for formal fairness in the specific context of triage in emergency departments (EDs) and maps the empirical and conceptual research questions that need to be addressed in this context in the near future. The pandemic has brought to the fore the necessity for public debate about how to allocate resources fairly in a situation of great shortage. However, issues of fairness arise also outside of pandemics: decisions about how to allocate resources are structurally unavoidable in healthcare systems, as value judgements underlie every allocative decision, although they are not always easily identifiable. In this paper, we set out to bridge this gap in the context of EDs. In the first part, we propose five formal requirements specifically applied for ED triage to be considered fair and legitimate: publicity, accessibility, relevance, standardisability and accountability. In the second part of the paper, we map the conceptual and empirical ethics questions that will need to be investigated to assess whether healthcare systems guarantee a formally just ED triage. In conclusion, we argue that there is a vast research landscape in need of an in-depth conceptual and empirical investigation in the context of ED triage in ordinary times. Addressing both types of questions in this context is vital for promoting a fair and legitimate ED triage and for fostering reflection on formal fairness allocative issues beyond triage.

Occasionally, doctors and health providers have to choose whom they save from death and this is an extremely hard decision to take. Here, I work on what I deem to be a crucial caveat: scarcity of resources should never be used as an alibi for bad, and sometimes wicked, public policies. In other words, if scarcity is somewhat produced or at least induced, it should never serve as a pretext to put the blame or the responsibility on medical doctors, nurses and other people who are at the front of the war against COVID-19. During the COVID-19 pandemic, an ethical question was often raised: if resources are scarce (and they often have been), whom should you prioritize? Should we protect first of all those who are young and can then have a long life before them? Or should we rather prioritize those who have rendered important services to health, or broadly to mankind, and could, therefore, bring other good results to society? This discussion is of course important, but it leaves aside som...

The following article presents the relevant and unprecedented bioethical and biolaw issues posed by the SARS-COV-2 pandemic and summarizes the initiatives adopted by the Italian Society of Anesthesia and Resuscitation (SIAARTI) as well as by the Veneto Region ICU Network. Since the initial phase of the pandemic, in March 2020, there has been a strong appeal from both SIAARTI and the Veneto Region ICU Network to consider “the appropriate intensive treatment.” During the pandemic, the principle of proportionality must be applied, in compliance with the main principle in bioethics. This encompasses the concept of clinical appropriateness, based on the efficacy of the treatment in specific case and context, as well as the concept of ethical appropriateness, which refers to ethical and juridical principles of acceptance of health care. The “appropriate treatment” must never interfere with the withdrawal of patients, who are not eligible for intensive treatments since they would not benef...

Background In early 2020, the Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) published clinical ethics recommendations for the allocation of intensive care during COVID-19 pandemic emergency. Later the Italian National Institute of Health (ISS) invited SIAARTI and the Italian Society of Legal and Insurance Medicine to prepare a draft document for the definition of triage criteria for intensive care during the emergency, to be implemented in case of complete saturation of care resources. Methods Following formal methods, including two Delphi rounds, a multidisciplinary group with expertise in intensive care, legal medicine and law developed 12 statements addressing: (1) principles and responsibilities; (2) triage; (3) previously expressed wishes; (4) reassessment and shifting to palliative care; (5) collegiality and transparency of decisions. The draft of the statements, with their explanatory comments, underwent a public consultation opened to Ita...

Occasionally, doctors and health providers have to choose whom they save from death and this is an extremely hard decision to take. Here, I work on what I deem to be a crucial caveat: scarcity of resources should never be used as an alibi for bad, and sometimes wicked, public policies. In other words, if scarcity is somewhat produced or at least induced, it should never serve as a pretext to put the blame or the responsibility on medical doctors, nurses and other people who are at the front of the war against COVID-19. During the COVID-19 pandemic, an ethical question was often raised: if resources are scarce (and they often have been), whom should you prioritize? Should we protect first of all those who are young and can then have a long life before them? Or should we rather prioritize those who have rendered important services to health, or broadly to mankind, and could, therefore, bring other good results to society? This discussion is of course important, but it leaves aside som...

For medical schools, the COVID-19 pandemic necessitated examination and curricular restructuring as well as significant changes to clinical attachments. With the available evidence suggesting that medical students’ mental health status is already poorer than that of the general population, with academic stress being a chief predictor, such changes are likely to have a significant effect on these students. This online, cross-sectional study aimed to determine the impact of COVID-19 on perceived stress levels of medical students, investigate possible contributing and alleviating factors, and produce recommendations for medical schools to implement during future healthcare emergencies. The majority (54.5%) of respondents reported levels of stress ranging from moderate to extreme. Higher levels of stress were significantly associated with female gender (p=0.039) and international status (p=0.031). A significant association was also noted between reported stress and the transition to onl...

The COVID-19 pandemic has prompted unprecedented global disruption. For medical schools, this has manifested as examination and curricular restructuring as well as significant changes to clinical attachments. With the available evidence suggesting that medical students’ mental health status is already poorer than that of the general population, with academic stress being a chief predictor, such changes are likely to have a significant effect on these students. In addition, there is an assumption that these students are an available resource in terms of volunteerism during a crisis. This conjecture should be questioned; however, as those engaging in such work without sufficient preparation are susceptible to moral trauma and adverse health outcomes. This, in conjunction with the likelihood of future pandemics, highlights the need for ‘pandemic preparedness’ to be embedded in the medical curriculum.

A patient's age serves as a very useful guide to physicians in deciding what disease manifestations to anticipate, what treatment to offer for certain conditions, and how to prepare for possible emergencies. In the context of the COVID-19 pandemic, determining treatment options on the basis of a patient's chronological age can easily give rise to unjustified discrimination. This is of particular significance in situations where the allocation of scarce critical care resources could have a direct impact on who will live and who will die. This paper examines the fairness of recommendations contained in resource allocation guidelines in the Philippines that have implications for the way elderly patients could be treated or excluded from some forms of critical care treatment in the context of the ongoing Corona virus emergency.

This paper proposes communities of practice (CoP) as a process to build moral resilience in healthcare settings. We introduce the starting point of moral distress that arises from ethical challenges when actions of the healthcare professional are constrained. We examine how situations such as the current COVID-19 pandemic can exponentially increase moral distress in healthcare professionals. Then, we explore how moral resilience can help cope with moral distress. We propose the term collective moral resilience to capture the shared capacity arising from mutual engagement and dialogue in group settings, towards responding to individual moral distress and towards building an ethical practice environment. Finally, we look at CoPs in healthcare and explore how these group experiences can be used to build collective moral resilience.

Covid-19 is causing a catastrophic sanitary problem worldwide. Many countries find themselves in the midst of this sanitary problem, while others will soon be facing the same fate. The Covid-19 pandemic public health goal should not only be to protect the life of a few patients, but also to save the lives of as many patients as possible (Berlinger et al., 2020). If it were possible to save everyone, the duty would be straightforward and simply thatto save everyone. However, as we reach the peak of the pandemic, this may not be possible. That is why, utilizing all the means available (SEMICYUC, 2020), the duty is to save the life of as many patients as possible (Emanuel et al., 2020). There are many ethical dilemmas that have come out of the Covid-19 pandemic. The discussion about what the ethical parameters for medical decision-making should be is still open for consideration. Specifically, a few clinical strategies that consider the intrinsic dignity of the human person requires further elucidation. The aim of this paper, during Covid-19 pandemic's peak, is to consider whether it is appropriate to limit therapeutic efforts, knowing that the staying time in intense care units (ICUs) for patients with Covid-19 is significantly longer and that mortality rates are higher especially for those who do not demonstrate signs of improvement.

Early on, geriatricians in Israel viewed with increasing alarm the spread of coronavirus disease 2019 (COVID-19). It was clear that this viral disease exhibited a clear predilection for and danger to older persons. Informal contacts began with senior officials from the country's Ministry of Health, the Israel Medical Association, and the country's largest health fund; this was done to plan an approach to the possible coming storm. A group was formed, comprising three senior geriatricians, a former dean, a palliative care specialist, and a lawyer/ethicist. The members made every effort to ensure that their recommendations would be practical while at the same time taking into account the tenets of medical ethics. The committee's main task was to think through a workable approach because intensive care unit/ventilator resources may be far outstripped by those requiring such care. Recommendations included the approach to older persons both in the community and in long-term care institutions, a triage instrument, and palliative care. Patient autonomy was emphasized, with a strong recommendation for people of all ages to update their advance directives or, if they did not have any, to quickly draw them up. Considering the value of distributive justice, with respect to triage, a "soft utilitarian" approach was advocated with the main criteria being function and comorbidity. Although chronological age was rejected as a sole criterion, in the case of an overwhelming crisis, "biological age" would enter into the triage considerations, but only in the case of distinguishing between people with equal nonage-related deficits. The guideline emphasized that no matter what, in the spirit of beneficence, anyone who fell ill must receive active palliative care throughout the course of a COVD-19 infection but especially at the end of life. Furthermore, in the spirit of nonmaleficence, the frail, very old, and severely demented would be actively protected from dying on ventilation.

The intensive care unit (ICU) is a vital and expensive location when the medical equipment and their maintenance are taken into account. 1 It has gained more importance nowadays. Under normal clinical conditions, all patients have been reached life-supporting care with their free will after being informed or with their pre-submitted testament, unless they refuse the medical support. 2,3 An ultimate goal of

The COVID-19 pandemic provides the opportunity to re-think health policies and health systems approaches by the adoption of a biopsychosocial perspective, thus acting on environmental factors so as to increase facilitators and diminish barriers. Specifically, vulnerable people should not face discrimination because of their vulnerability in the allocation of care or life-sustaining treatments. Adoption of biopsychosocial model helps to identify key elements where to act to diminish effects of the pandemics. The pandemic showed us that barriers in health care organization affect mostly those that are vulnerable and can suffer discrimination not because of severity of diseases but just because of their vulnerability, be this age or disability and this can be avoided by biopsychosocial planning in health and social policies. It is possible to avoid the banality of evil, intended as lack of thinking on what we do when we do, by using the emergence of the emergency of COVID-19 as a Troja...

Introduction: Almost a year and a half after its appearance, Covid-19 continues to make painful triage choices necessary in granting access intensive care. Objective: the article aims to illustrate the difference between the utilitarian-collectivist approach and the deontologic approach, which inspired the guidelines drawn up in Italy in 2021 by SIAARTI in collaboration with SIMLA. Materials and methods: the article draws upon international scientific sources and documents from ethics committees and scientific societies on triage for Covid-19 patients in intensive care. Results: only medical parameters should be evaluated to establish the prognosis through which to identify the patients to be treated as a priority. If non-medical standards are taken into account, such as patient age, discrimination is likely to arise, and the patient’s interest is somehow subordinated to that of the community. Discussion: it is not part of the doctor’s duty to exclude patients from intensive care in...

In the face of a possible health saturation due to the pandemic caused by the SARS-CoV2 coronavirus, the present paper wants to contribute with some guidelines in order to provide ethical orientation to prioritize patients and maximize the benefits for the majority of the population. This paper aims to generate an acceptable, consistent, and reasonable ethical framework to support the difficult work that health professionals will have in emergency rooms and intensive care units. The criteria and reflections in this paper aim to respect not only ethical-medical principles that focus their efforts on a particular patient, but especially on a broader public health ethics based on the principle of justice. Prioritization is therefore oriented in a utilitarian framework that seeks to save the largest number of lives, of life-years and considering the life stage, without neglecting the people's dignity. In this sense, it is not only a matter of considering epidemiological criteria, but also of establishing socially acceptable ethical criteria. This proposal is a collective effort to

In 2016, following pandemic influenza threats and the 2014–2016 Ebola virus disease outbreaks, the WHO developed a guidance document for managing ethical issues in infectious disease outbreaks. In this article, we analyse some ethical issues that have had a predominant role in decision making in response to the current COVID-19 pandemic but were absent or not addressed in the same ways in the 2016 guidance document. A pandemic results in a health crisis and social and political crises both nationally and globally. The ethical implications of these global effects should be properly identified so that appropriate actions can be taken globally and not just in national isolation. Our analysis, which is a starting point to test the broader relevance of the 2016 WHO document that remains the only available guidance document applicable globally, concludes that the WHO guidance should be updated to provide reasoned and thoughtful comprehensive ethics advice for the sound management of the c...

The COVID-19 pandemic provides the opportunity to re-think health policies and health systems approaches by the adoption of a biopsychosocial perspective, thus acting on environmental factors so as to increase facilitators and diminish barriers. Specifically, vulnerable people should not face discrimination because of their vulnerability in the allocation of care or life-sustaining treatments. Adoption of biopsychosocial model helps to identify key elements where to act to diminish effects of the pandemics. The pandemic showed us that barriers in health care organization affect mostly those that are vulnerable and can suffer discrimination not because of severity of diseases but just because of their vulnerability, be this age or disability and this can be avoided by biopsychosocial planning in health and social policies. It is possible to avoid the banality of evil, intended as lack of thinking on what we do when we do, by using the emergence of the emergency of COVID-19 as a Troja...

In the face of a possible health saturation due to the pandemic caused by the SARS-CoV2 coronavirus, the present paper wants to contribute with some guidelines in order to provide ethical orientation to prioritize patients and maximize the benefits for the majority of the population. This paper aims to generate an acceptable, consistent, and reasonable ethical framework to support the difficult work that health professionals will have in emergency rooms and intensive care units. The criteria and reflections in this paper aim to respect not only ethical-medical principles that focus their efforts on a particular patient, but especially on a broader public health ethics based on the principle of justice. Prioritization is therefore oriented in a utilitarian framework that seeks to save the largest number of lives, of life-years and considering the life stage, without neglecting the people's dignity. In this sense, it is not only a matter of considering epidemiological criteria, but also of establishing socially acceptable ethical criteria. This proposal is a collective effort to

A patient's age serves as a very useful guide to physicians in deciding what disease manifestations to anticipate, what treatment to offer for certain conditions, and how to prepare for possible emergencies. In the context of the COVID-19 pandemic, determining treatment options on the basis of a patient's chronological age can easily give rise to unjustified discrimination. This is of particular significance in situations where the allocation of scarce critical care resources could have a direct impact on who will live and who will die. This paper examines the fairness of recommendations contained in resource allocation guidelines in the Philippines that have implications for the way elderly patients could be treated or excluded from some forms of critical care treatment in the context of the ongoing Corona virus emergency.

The COVID-19 pandemic provides the opportunity to re-think health policies and health systems approaches by the adoption of a biopsychosocial perspective, thus acting on environmental factors so as to increase facilitators and diminish barriers. Specifically, vulnerable people should not face discrimination because of their vulnerability in the allocation of care or life-sustaining treatments. Adoption of biopsychosocial model helps to identify key elements where to act to diminish effects of the pandemics. The pandemic showed us that barriers in health care organization affect mostly those that are vulnerable and can suffer discrimination not because of severity of diseases but just because of their vulnerability, be this age or disability and this can be avoided by biopsychosocial planning in health and social policies. It is possible to avoid the banality of evil, intended as lack of thinking on what we do when we do, by using the emergence of the emergency of COVID-19 as a Troja...

We report here an emerging dispute in Italy concerning triage criteria for critically ill covid-19 patients, and how best to support doctors having to make difficult decisions in a context of insufficient life saving resources. The dispute we present is particularly significant as it juxtaposes two opposite views of who should make triage decisions, and how doctors should best be supported. There are both empirical and normative questions at stake here. The empirical questions pertain to the available level of evidence that healthcare professionals would rather not be left alone with their ‘clinical judgments’ to make triage decisions, and to the accounts of distributive justice that doctors and healthcare professionals rely on, when making triage decisions. The normative questions pertain to how this empirical evidence should inform guidelines on how prioritisation decisions are made in a context of emergency, and who gets to have the authority to do so. This debate goes beyond the...

Whenever the government makes medical resource allocation choices, there will be opportunity costs associated with those choices: some patients will have treatment and live longer, while a different group of patients will die prematurely. Because of this, we have to make sure that the benefits we get from investing in treatment A are large enough to justify the benefits forgone from not investing in the next best alternative, treatment B. There has been an increase in spending and reallocation of resources during the COVID-19 pandemic that may have been warranted given the urgency of the situation. However, these actions do not bypass the opportunity cost principle although they can appear to in the short term, since spending increases cannot continue indefinitely and there are patient groups who lose out when resources are redirected to pandemic services. Therefore, policy-makers must consider who bears the cost of the displaced healthcare resources. Failure to do so runs a risk of...