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COVID-19 Case Studies
- How do we allocate finite resources in medical emergencies? (Utilitarianism, QALY, trade-offs) Italian doctors face tough choices during corona virus outbreak: Link
2. Peter Singer: Should we value all human lives equally? This question arose in an acute form in March, when the novel coronavirus overwhelmed Italy’s health care system. Envisaging a situation in which there would not be enough ventilators for all patients needing one, a working group of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care reluctantly supported rationing by age, while also taking into account frailty and the severity of any other health problems. The group’s aim was to support those with the greatest chance of survival and likely to have the most years of life ahead of them. Link
3. Fair Allocation of Scarce Medical Resources in the Time of Covid-19 (NEJM): The rapidly growing imbalance between supply and demand for medical resources in many countries presents an inherently normative question: How can medical resources be allocated fairly during a Covid-19 pandemic? Link
4. QALY and Healthcare Economics: Economic and human cost of general quarantine vs economic and human cost of no quarantine: Link
5. In emergencies should we allow untested drugs to be used? Dr. Kalil, who has decades of experience grappling with questions about the use — and misuse — of experimental drugs, has rarely been more frustrated. He has seen what happens when desperation drives treatment decisions. “Many drugs we believed were fantastic ended up killing people,” he said in an interview. “It is so hard to keep explaining that.” Link
6. Articles from Harvard on Covid, resource allocation, and disability: Link
7. Kennedy Institute of Ethics: Special Edition on Pandemic Ethics (Open Access): Link
8. Healthcare Justice: Rationing ventilators might be a necessary response in the new Covid-19 world. Many hospitals decide who gets them by selecting patients most likely to benefit. Experts agree this is the best way of saving most lives. The approach, the model guidance, may sound fair. But baked into it are biases that disadvantage groups who, even without a Covid-19 infection, experience worse health because of historical and structural reasons, especially black people.
Consider this case. Three patients are waiting to be admitted to an intensive care unit that has one remaining bed. All have equally severe Covid-19 symptoms. John is an otherwise healthy, white 40-year-old man. Rosa is a 45-year-old African-American woman with underlying health issues. Linda is a white 56-year-old woman with Down syndrome. Who should be admitted? NYT
9. Overview of the Process of Vaccine Development with some discussion of ethics of vaccine challenge trials:
Barouch: For certain pathogens, it has been considered ethical to perform human-challenge studies but typically only for pathogens for which there is a highly effective treatment. For example, for malaria there is a very widely and effectively used human-challenge model in which vaccines or other interventions can be tested. Human volunteers can be inoculated with malaria and then, if they develop the disease, can be treated rapidly so that they don’t actually get sick.
Mukherjee: Why can’t we do this for Covid-19?
Barouch: The dilemma for Covid-19 is that there currently is no curative therapy. So, if a volunteer in a potential human-challenge study gets severely ill, there may not be a way to cure that person. In fact, far from it: The drugs in our armamentarium are not perfect, and so we would have no guarantee that we could “rescue” a person who got severely ill.
Weiss: I’m not an ethicist, but my gut feeling is that challenge trials are too dangerous. Young people can get quite sick and die from Covid-19. NYT
10. Accelerated vaccine trials for coronavirus: Vaccine challenge trial. What would you do if you were on the IRB? Why? Would you join the trial? Link
11. Article that argues for coronavirus vaccine challenge trials: Link
12. Peter Singer and Richard Chappell on the ethics of accelerated vaccine trials (Washington Post): Link
13. Argument against human vaccine challenge trials for Covid-19: Link
14. Argument against human vaccine challenge trials for Covid-19: Hastings Center
15. Who Is Responsible If A University Reopens And A Student Dies From Covid-19? The divergence of opinions expressed by universities indicates the complexity of assessing the risk Covid-19 presents on campuses. Because the situation is unprecedented, it’s hard to predict the liability a university may face should it allow students to return and there be an outbreak or, worse, deaths. Link
16. Is it ethical to reopen universities for face to face learning? Collection of Editorials in Chronicle of Higher Ed.
17. The ethics of pricing an eventual coronavirus vaccine: [Drug manufacturers] have justified high prices by comparing them to the costs they would prevent. Expensive hepatitis C drugs, they say, avoid the need for a $1 million liver transplant. No matter that the comparison being made is to the highly inflated costs of treating disease in American hospitals. Such logic would be disastrous if it were applied to a successful Covid vaccine. Covid-19 has shut down countless businesses, creating record-high unemployment. And the medical consequences of severe Covid-19 mean weeks of highly expensive intensive care. NYT
18. Ethics of Financial Incentives in Human Challenge Trials: “I argue that advertised incentives as a recruitment strategy undermine the the benefit of recruiting individuals to participate out of altruism. Given the high poverty index rate, the government and medical scientists could, in effect, be taking advantage of the vulnerability of those who are socially and economically impoverished, treating them as mere means to some scientific end.” Voices in Bioethics
19. Who should get priority in the Covid-19 vaccine?
20. Should we prioritize the elderly, or other vulnerable groups, or the younger, or essential workers, or some other group? In the second phase, as production increases, there may be more vaccine than people willing to take it. The question then is: how should vaccine uptake be ethically be increased? For example, should vaccines be made mandatory, or nudged, or incentivised? We won’t consider this phase here but one of us has recently written about it. Practical Ethics Alberto Giubilini, Julian Savulescu, Dominic Wilkinson
21. Who should get priority? Those who spread (i.e., the young) or those at highest risk? The Conversation
22. Philosopher Makes List of 7 Mistakes in the Pandemic: Note to self. I disagree with 1 and 2 in some respects. Richard Chappell
23. Technical paper on the trade-offs between lives and GDP: There is, however, a surprising feature: in some scenarios, laissez-faire is the optimal solution for all values of life below a certain threshold, while immediately above the threshold a sizeable restriction policy is optimal. This determines that at the threshold itself two different optimal policies coexist (due to the non convexity of C for large c). This situation, which we see appearing for various policy classes, is indicative of the variety of optimal responses depending on the value attributed to statistical life; it also clarifies some of the differences in the proposed policies (among which laissez-faire has been initially advocated by some governments). Although such discontinuity in the optimal policy takes place presumably only at isolated values of the value of life, we argue that a social planner particularly responsive to the population diverse views might be inclined to act according to a value of life near the critical one. In addition, discontinuity of controls around the critical value can have relevant social consequences in terms on how to evaluate potential alternatives to a given containment policy. Link
24. Who should get the vaccine first? Essential workers vs the Elderly: NYT
25. Who should get the vaccine first? Those who spread it (the young) or those who are most vulnerable? Link
Non-COVID-19 Medical Ethics Cases
Research Ethics
- Healthy volunteer dies in asthma study: 24 year old Ellen Roche was a healthy volunteer who had nothing to gain by taking part in the study. Her death has revived debate about the adequacy of oversight of medical research that followed the death of 18 year old Jesse Gelsinger who volunteered for a gene therapy experiment. Issues: Inducement, moral and institutional responsibility, informed consent, negligence. Case study in detail
- In emergencies should we allow untested drugs to be used? Dr. Kalil, who has decades of experience grappling with questions about the use — and misuse — of experimental drugs, has rarely been more frustrated. He has seen what happens when desperation drives treatment decisions. “Many drugs we believed were fantastic ended up killing people,” he said in an interview. “It is so hard to keep explaining that.” Link
- Can we give untested drugs without consent? While the “overwhelming majority of them are awake and alert and can actually have a conversation,” Armstrong said some suffer from middle stages of dementia. In some cases, he did not discuss prescribing the tablets with anyone at all before doing so. He said it is common for physicians to prescribe new medications to patients without explicit consent from the patient or family members. “It’s not required,” he said. Link
Privacy and Patient Confidentiality
- Collection of Case Studies on Patient Confidentiality for Nursing: https://www.cno.org/globalassets/4-learnaboutstandardsandguidelines/prac/learn/webcasts/privacy-and-confidentiality-casestudies.pdf
- Collection of Case Studies on Patient Privacy/Confidentiality: http://champlainethics.ca/case-studies-privacy-confidentiality/
Genetic Testing
- Abby is a 33-year old, married Roman Catholic woman who has received successful treatment for melanoma. While at the cancer center, she gave her consent to use her tissue samples in a research protocol in which researchers scrutinized chromosomes most frequently involved in rearrangements of melanoma cells. While visually inspecting Abby’s tissue sample, a researcher discovered a translocation or mutation between two other chromosomes. The mutated chromosomes were not among those the researcher had specific authorization to examine, in accord with the informed consent form Abby had signed.
According to the researcher’s description of the situation, the aberration is not directly responsible for the initiation of melanoma. Whether the aberration is a factor in promoting tumor growth or tumor metastasis remains a question. However, with such a genetic abnormality, Abby, if she became pregnant, has a 50% chance of spontaneous miscarriage, a 25% chance of delivering a severely deformed child, and a 25% chance of a healthy child. Moreover, her viable offspring risk carrying the same abnormality.
Unsure whether to tell Abby about these findings, the researcher contacts Abby’s primary oncologist (who has a longstanding relationship with her) as well as the Ethics Consultation Service.
Large Collections of Bioethics Ethics Case Studies
Wrestling with Philosophy 