Ethical Issues in the COVID Era: Doing the Right Thing Depends on Location, Resources, and Disease Burden
Ethical Issues in the COVID Era: Doing the Right Thing Depends on Location, Resources, and Disease Burden
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DOI：
10.1097/tp.0000000000003291
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发表时间：
2020-07-01
期刊：
影响因子：
6.2
通讯作者：
Allen, Richard
中科院分区：
文献类型：
--
作者：
Stock, Peter G.;Wall, Anji;Allen, Richard
移植界非常熟悉围绕稀缺资源分配的伦理问题，但COVID-19大流行使移植的道德困境升级，远远超出了简单地分配有限的捐赠器官。不幸的是，Emanuel等人1在其最近的NEJM文章中预言了在COVID-19大流行期间指导医疗决策的伦理原则以及相关的资源消耗。在高传播地区，医院和重症监护资源正变得严重有限，影响了关于谁应该接受移植的决定，并影响了捐赠器官的可用性。2 COVID-19传播给捐赠者和接受者的风险进一步改变了这种风险考虑。COVID-19之前的器官分配方案复杂、透明且具有器官特异性，其本身不足以决定在这种情况下谁应该接受移植，特别是在资源有限的地区。在这种大流行期间，对移植的复杂伦理考虑必然会因国家、地区和文化而存在很大差异，并且会随着时间的推移而变化，并受到COVID-19疾病负担和发展轨迹的影响。但是，不伤害、仁慈、分配正义和尊重自主权等广泛原则必须继续指导这些艰难的决定。例如，无恶意可能要求活体捐献者手术在受影响严重的地区进行，因为捐献者存在感染COVID-19的潜在风险。事实上，同样的担忧也适用于移植受者，他们的免疫抑制可能会增加移植后感染的风险。相反，益处可能表明，成功的肾移植除了其他益处外，还可以防止进一步透析中心就诊的需要，从而可能降低医院内COVID-19传播的风险。相比之下，从分配正义的角度来看，项目可能需要减少某些移植活动，这仅仅是由于压倒性的大流行病负担造成的资源限制。最后，自主性要求项目向移植患者传达COVID-19感染的已知和未知风险，以及我们各自制定的政策，使他们能够就自己的护理做出明智的决定。
The transplant community is well-versed in ethical issues surrounding the allocation of scarce resources, but the COVID-19 pandemic has escalated moral dilemmas of transplantation far beyond simply allocation of limited donor organs. Emanuel et al 1 were unfortunately prophetic in their recent NEJM article addressing the ethical principles guiding medical decisions during the COVID-19 pandemic and the associated depletion of resources. Hospital and intensive care resources are becoming severely limited in high-transmission areas, influencing decisions about who should be transplanted and affecting the availability of donated organs. 2 The risk of COVID-19 transmission to donors and recipients further alters such risk considerations. Pre–COVID-19 organ allocation schemes, which are complex, transparent, and organ-specific, are by themselves insufficient to determine who should be transplanted under such conditions, particularly in resource-constrained areas.Complex ethical considerations for transplantation during such a pandemic will inherently vary greatly by country, region, and culture—and be dynamic over time, and affected by both COVID-19 disease burden and trajectory. But the broad principles of nonmaleficence, beneficence, distributive justice, and respect for autonomy must continue to guide these difficult decisions. Nonmaleficence, for example, may dictate that living donor operations be held in heavily affected areas because of the potential risk of COVID-19 infection in donors. Indeed the same concern applies to transplant recipients, whose immunosuppression may put them at increased risk of infection posttransplant. Conversely, beneficence might suggest that successful kidney transplantation could, in addition to its other benefits, prevent the need for further dialysis center visits, potentially reducing the risk of nosocomial COVID-19 transmission. From a distributive justice perspective, by contrast, programs may need to curtail certain transplant activity simply as a result of resource constraints imposed by an overwhelming pandemic disease burden. Finally, autonomy dictates that programs communicate both the known and unknown risks of COVID-19 infection—and the policies we are each enacting as a result—to their transplant patients allowing them to make informed decisions about their care.