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首页> 外文期刊>Annals of Internal Medicine >Who Should Receive Life Support During a Public Health Emergency? Using Ethical Principles to Improve Allocation Decisions
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Who Should Receive Life Support During a Public Health Emergency? Using Ethical Principles to Improve Allocation Decisions

机译：谁应该在公共卫生突发事件中获得生命支持？使用道德原则改善分配决策

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A public health emergency, such as an influenza pandemic, will lead to shortages of mechanical ventilators, critical care beds, and other potentially life-saving treatments. Difficult decisions about who will and will not receive these scarce resources will have to be made. Existing recommendations reflect a narrow utilitarian perspective, in which allocation decisions are based primarily on patients' chances of survival to hospital discharge. Certain patient groups, such as the elderly and those with functional impairment, are denied access to potentially life-saving treatments on the basis of additional allocation criteria. We analyze the ethical principles that could guide allocation and propose an allocation strategy that incorporates and balances multiple morally relevant considerations, including saving the most lives, maximizing the number of “life-years” saved, and prioritizing patients who have had the least chance to live through life's stages. We also argue that these principles are relevant to all patients and therefore should be applied to all patients, rather than selectively to the elderly, those with functional impairment, and those with certain chronic conditions. We discuss strategies to engage the public in setting the priorities that will guide allocation of scarce life-sustaining treatments during a public health emergency. nnThe threat of pandemic influenza has produced large-scale federal, state, and local efforts to prepare for a public health disaster. Modeling studies suggest that a public health disaster similar in magnitude to the 1918 influenza pandemic would require 400% of current U.S. intensive care unit beds and 200% of all mechanical ventilators (1, 2). Even a smaller epidemic could be grave, because U.S. intensive care units typically run at greater than 90% occupancy and have little surge capacity (3). nnThe U.S. Department of Health and Human Services acknowledges the possibility of ventilator and critical care shortages during a public health emergency but has been silent on what principles should guide allocation decisions (4, 5). In response, several groups have recently published guidelines for allocating ventilators and other life support during a public health emergency (6–9). Each guideline recommends categorically excluding large groups of patients from life support and allocating life-sustaining treatments on the basis of patients' chances of survival to hospital discharge. These efforts to achieve a transparent process of allocation are an important first step to minimize the chance of arbitrary or biased decisions during a crisis. However, we believe that these guidelines omit morally relevant considerations that should be incorporated into allocation strategies. nnTo date, there has not been broad engagement of professionals and the public on what ethical principles should guide these difficult allocation decisions. Such debate is needed because a successful public health response will require public trust and cooperation with restrictive measures, such as the use of police powers, social distancing, and quarantine (10). Moreover, advance discussion is essential because in-depth deliberations will not be feasible during a public health crisis. nnTo foster debate, we place these issues in the context of a clinical scenario during a hypothetical influenza pandemic, analyze the ethical principles that could guide allocation, propose an allocation strategy that balances multiple morally relevant considerations, and provide recommendations for meaningful public engagement in priority setting. Although we focus our discussion on the example of scarcity of mechanical ventilators during an influenza pandemic, the ethical considerations are similar for other types of public health emergencies during which there may be a scarcity of resources, such as critical care beds, health care personnel, and renal replacement therapy.
机译：突发公共卫生事件，例如流感大流行，将导致缺乏机械呼吸机，重症监护床和其他可能挽救生命的治疗方法。必须做出关于谁将接受哪些稀缺资源的艰难决定。现有建议反映了狭义的功利主义观点，其中分配决策主要基于患者出院生存的机会。根据其他分配标准，某些患者组（例如老年人和功能受损的患者）将无法获得可能挽救生命的治疗。我们分析了可以指导分配的伦理原则，并提出了一种分配策略，该策略应纳入并平衡多种与道德相关的考虑因素，包括挽救最多生命，最大程度地节省“生命年”，以及优先考虑那些机会最少的患者。经历人生的各个阶段。我们还认为，这些原则与所有患者都相关，因此应适用于所有患者，而不是选择性地适用于老年人，功能障碍者和某些慢性病患者。我们讨论使公众参与的战略，以确定在公共卫生突发事件中分配稀缺的维持生命的治疗方法的优先事项。 nn大流行性流感的威胁已引起联邦，州和地方的大规模努力，为公共卫生灾难做准备。模型研究表明，一场与1918年流感大流行相似的公共卫生灾难将需要目前400％的美国重症监护病床和200％的所有机械呼吸机（1、2）。甚至较小的流行病也可能是严重的，因为美国重症监护室的入住率通常超过90％，而急诊能力却很小（3）。 nn美国卫生与公共服务部承认在公共卫生紧急情况下可能出现呼吸机和重症监护不足的情况，但未对应指导分配决策的原则保持沉默（4，5）。作为回应，最近有几个小组发布了在公共卫生紧急情况下分配呼吸机和其他生活支持的指南（6-9）。每个指南都建议将大批患者排除在生命支持之外，并根据患者生存到医院出院的机会分配维持生命的治疗方法。这些努力实现透明分配过程的努力是重要的第一步，可以最大程度地减少危机期间任意或有偏见的决策的机会。但是，我们认为，这些准则忽略了与道德相关的考虑，应将其纳入分配策略中。 nn迄今为止，专业人士和公众尚未就什么道德原则应指导这些困难的分配决定进行广泛参与。之所以需要进行这样的辩论，是因为成功的公共卫生对策将需要公众的信任和合作，并采取限制性措施，例如使用警察权力，社会隔离和检疫（10）。此外，提前讨论至关重要，因为在公共卫生危机期间进行深入讨论是不可行的。为了促进辩论，我们将这些问题放在假设的流感大流行期间的临床情况中进行分析，分析可指导分配的伦理原则，提出平衡多个道德相关考虑因素的分配策略，并为有意义的公众参与提供优先级的建议设置。尽管我们将讨论的重点放在流感大流行期间缺乏机械呼吸机的例子，但是对于其他类型的公共卫生紧急情况，其伦理考虑也类似，在这些紧急情况下，可能会缺乏资源，例如重症监护病床，卫生保健人员，和肾脏替代疗法。

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