Sociedades científicas publicam guidelines éticas, face a pandemia COVID-19 – Itália e Espanha

O Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) publicou guidelines dos critérios que devem ser seguidos em circunstâncias extraordinárias.

Decisioni eticamente fondate per il trattamento dei pazienti affetti da insufficienza respiratoria grave secondaria a infezione da COVID-19

Il Documento in questione – Decisioni eticamente fondate per il trattamento dei pazienti affetti da insufficienza respiratoria grave secondaria a infezione da Covid-19 – riprende, conferma e divulga le nostre Raccomandazioni di etica clinica per l’ammissione a trattamenti intensivi e per la loro sospensione, in condizioni eccezionali di squilibrio tra necessità e risorse disponibili.

 The document begins by likening the moral choices Italian doctors may face to the forms of wartime triage that are required in the field of “catastrophe medicine.” Instead of providing intensive care to all patients who need it, the authors suggest, it may become necessary to follow “the most widely shared criteria regarding distributive justice and the appropriate allocation of limited health resources.” The principle they settle upon is utilitarian. “Informed by the principle of maximizing benefits for the largest number,” they suggest that “the allocation criteria need to guarantee that those patients with the highest chance of therapeutic success will retain access to intensive care.” The authors, who are medical doctors, then deduce a set of concrete recommendations for how to manage these impossible choices, including this: “It may become necessary to establish an age limit for access to intensive care.” Those who are too old to have a high likelihood of recovery, or who have too low a number of “life-years” left even if they should survive, would be left to die. This sounds cruel, but the alternative, the document argues, is no better. “In case of a total saturation of resources, maintaining the criterion of ‘first come, first served’ would amount to a decision to exclude late-arriving patients from access to intensive care.” In addition to age, doctors and nurses are also advised to take a patient’s overall state of health into account: “The presence of comorbidities needs to be carefully evaluated.” This is in part because early studies of the virus seem to suggest that patients with serious preexisting health conditions are significantly more likely to die. But it is also because patients in a worse state of overall health could require a greater share of scarce resources to survive: “What might be a relatively short treatment course in healthier people could be longer and more resource-consuming in the case of older or more fragile patients.” (The Atlantic)

Em Espanha, a Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) publicou recomendações

RECOMENDACIONES ÉTICAS PARA LA TOMADE DECISIONES EN LA SITUACIÓN EXCEPCIONAL DE CRISIS POR PANDEMIA COVID-19 EN LAS UNIDADES DECUIDADOS INTENSIVOS.(SEMICYUC)

Los objetivos principales de estas recomendaciones, en conclusión, son: 1-Apoyar a los profesionales en la toma de decisiones difíciles, facilitando criterios colegiados que permitan compartir la responsabilidad en situaciones que implican una gran carga emocional. 2-. Explicitar unos criterios de idoneidad de asignación de recursosen una situación de excepcionalidad y escasez.

Ante situaciones de crisis como la que vive España con la enfermedad Covid-19 y en un contexto de recursos limitados, las personas con más posibilidades de sobrevivir deben tener prioridad para ser ingresadas en las unidades de cuidados intensivos (UCI). «Admitir un ingreso puede implicar denegar otro a otra persona que puede beneficiarse más, de forma que hay que evitar el criterio primero en llegar, primero en ingresar».

Así reza literalmente el documento de recomendaciones UCI y Covid-19 que ha elaborado el Grupo de Trabajo de Bioética de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (Semicyuc) y cuyo contenido han consensuado con la Sociedad Española de Medicina Interna (SEMI). En suma, las sociedades médicas que representan a internistas e intensivistas, dos de los especialistas que están en primera línea de combate en la lucha contra la infección.

La limitación de recursos en una situación de pandemia como la actual obliga, según intensivistas e internistas, a «consensuar una serie de criterios técnicos y éticos comunes», y el primero que plantean es que el ingreso en UCI se base en «maximizar el beneficio común. Ante pacientes críticos con patologías críticas diferentes de la infección por Covid-19, se debe valorar ingresar prioritariamente al que más se beneficie». (El Mundo)

“Guidance for managing ethical issues in infectious disease outbreaks” [OMS, 2016]

oms-2016
World Health Organization 2016
Forewords:
“Infectious disease outbreaks are periods of great uncertainty. Events unfold, resources and capacities that are often limited are stretched yet further, and decisions for a public health response must be made quickly, even though the evidence for decision-making may be scant. In such a situation, public health officials, policy-makers, funders, researchers, field epidemiologists, first responders, national ethics boards, health-care workers, and public health practitioners need a moral compass to guide them in their decision-making. Bioethics puts people at the heart of the problem, emphasizes the principles that should guide health systems, and provides the moral rationale for making choices, particularly in a crisis.”
Introduction:
“This guidance grew out of concern at the World Health Organization (WHO) about ethical issues raised by the Ebola outbreak in West Africa in 2014–2016. The WHO Global Health Ethics Unit’s response to Ebola began in August 2014, immediately after it was declared a “public health emergency of international concern” pursuant to the International Health Regulations (2005). That declaration led to the formation of an Ethics Panel, and later an Ethics Working Group, which was charged with developing ethics guidance on issues and concerns as they arose in the course of the epidemic. It became increasingly apparent that the ethical issues raised by Ebola mirrored concerns that had arisen in other global infectious disease outbreaks, including severe acute respiratory syndrome (SARS), pandemic influenza, and multidrug-resistant tuberculosis. However, while WHO has issued ethical guidance on some of these outbreaks, prior guidance has only focused on the specific pathogen in isolation. The purpose of this document is to look beyond issues specific to particular epidemic pathogens and instead focus on the cross-cutting ethical

issues that apply to infectious disease outbreaks generally. In addition to setting forth general principles, it examines how these principles can be adapted to different epidemiological and social circumstances.”
Relevant ethical principles
Ethics involves judgements about “the way we ought to live our lives, including our actions, intentions, and our habitual behaviour.” The process of ethical analysis involves identifying relevant principles, applying them to a particular situation, and making judgements about how to weigh competing principles when it is not possible to satisfy them all. This guidance document draws on a variety of ethical principles, which are grouped below into seven general categories. These categories are presented merely for the convenience of the reader; other ways of grouping them are equally legitimate.”
Justice
Beneficence
 Utility

Respect for persons
 Liberty
Reciprocity
Solidarity

Table of Contents

Guidelines
1. Obligations of governments and the international community

2. Involving the local community

3. Situations of particular vulnerability
4. Allocating scarce resources

5. Public health surveillance

6. Restrictions on freedom of movement

7. Obligations related to medical interventions for the diagnosis, treatment, and prevention of infectious disease

8. Research during infectious disease outbreaks

9. Emergency use of unproven interventions outside of research

10. Rapid data sharing
11. Long-term storage of biological specimens collected during infectious disease outbreaks

12. Addressing sex- and gender-based differences

13. Frontline response workers’ rights and obligations

14. Ethical issues in deploying foreign humanitarian aid workers