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The Government's advisory body on Bioethics enters the public debate on the prioritization of patients when resources are scarce with a report that questions what the society of intensive care physicians (the Semicyc) has pointed out in its triage guide and asks the Government to create a commission with representatives of medical societies, professional associations and bioethics committees to "work on unique prioritization criteria at the national level".

The document admits that, although in a context of scarce resources, the adoption of an allocation criterion based on the resilience of the patient can be justified, "the extension of a utilitarian mentality or, worse still, contrary prejudices towards elderly or disabled people . " For this reason, the term "social utility", which appears in some of the published recommendations, "seems to us extremely ambiguous and ethically debatable, because every human being by the mere fact of being so is socially useful, given the very ontological value of dignity, "they say.

In this sense, they describe as "radically unfair" that the people whose health is most threatened by a contagion of coronavirus were, in turn, the most affected by this crisis. So "concepts such as social utility or the like do not respond to the bioethical principles that must support decision-making in the healthcare field."

They recall that the World Health Organization in 2016 published its Recommendations for the management of ethical issues in epidemics , where it points out that the ethical principles that should guide resource allocation decisions in these exceptional situations are that of utility and equity. And they explain that "while the utility principle requires the allocation of resources to maximize benefits and minimize burdens, the principle of equity requires the fair distribution of benefits and burdens. In some cases, an equitable distribution of benefits and Burdens may be considered fair, but in others, it may be fairer to give preference to groups in a poorer situation , such as the least wealthy, the sick or the vulnerable. It is not always possible to fully achieve both utility and equity "

Faced with this dilemma, the Committee opts for weighing equity. He says: "The criterion of equity has a specific meaning in the context of access to health care and, therefore, it seems that it is the best suited to a case such as the one at hand. Prioritizing groups more vulnerable is shown prima facie as an adequate criterion. It has been concluded in this respect that justice supposes an equitable distribution of available resources ".

Regarding the concept of social utility, experts insist that "while it may be ethical to prioritize people who are essential to handle an outbreak, it is not appropriate to prioritize people based on considerations of social value unrelated to carrying out critical services necessary for society. " Thus, they find it justified to give preference to health personnel in access to available resources , with two arguments: "Because the best way to protect the health of each and every one is to protect the health of professionals and because the principle of justice requires prioritizing to those who for the benefit of third parties have exposed their health more intensely. " In addition, they leave the door open to include in this priority treatment "other professionals of particular importance in the treatment of the pandemic."

Regarding people with disabilities, the Committee finds arguments both in the UN Convention on the Rights of Persons with Disabilities and in our legal system to affirm that "the disability of the sick person can never be a reason by itself that prioritizes the care of those without disabilities. " For this reason, they consider that some of the concepts included in the Semicyuc triage guide in the ICU " are not compatible with the UN Convention ." "Above all, those that refer to issues such as disability-free survival over isolated survival or the one that recommends that: any patient with cognitive impairment, dementia or other degenerative diseases, would not be subsidiary to invasive mechanical ventilation."

They make it clear that neither the age nor the order of arrival to request assistance can be used as priority criteria. With one exception, in the first case, attention to minors: "The principle of the best interests of the minor requires giving priority to assistance to children and adolescents." So "the age criterion can only be used to prioritize, but not to deny or limit health care and the use of certain life support measures."

Limit a fundamental right

Deciding who is the first to receive health care in a situation like the present one is a very serious question, since it is "about limiting the right to health protection of some individuals due to the scarcity of resources." For this reason, the Committee considers that the decision corresponds "solely and exclusively to the public authority, the only constitutional authority to limit and suspend rights". In short, the experts emphasize, "we are making reference to limiting or suspending the constitutional right to health protection enshrined in Article 43 of our Magna Carta."

For this reason, the Committee recalls that scientific societies "are fundamental actors in providing the public authority with the knowledge necessary to establish national prioritization criteria, but in no way constitute the appropriate entities to establish such prioritization."

The group of experts in Bioethics proposes that "scientific societies, professional associations, national and autonomous bioethics committees" be urgently "made available to the competent public authority, the Government and the Ministry of Health itself, to work on certain criteria unique prioritization at the national level . " Because they consider that at present there have been many selection criteria that are counterproductive, because "it can be so stressful for the health professional not to have any generalized and uniform criteria to help them make decisions, such as being constrained to general criteria that it may be considered unfair or unethical in the specific case. It is, therefore, about striking a balance between a general rule and the individual decision that must be taken with each patient ".

Finally, experts remember that all patients are in demand for health care, not just those with the Covid-19 virus. "Decisions must be made from the perspective of the interest of all patients and not only those with coronavirus," and draw attention to the "enormous negative impact that the suspension of certain therapies these people need is having on some people with disabilities. to advance their quality of life and personal development , and whose interruption for a more or less long period can mean a serious setback for them. "

With this report, the Bioethics Committee of Spain responds to the request that the Ministry of Social Law and Agenda 2030 made to this advisory body of the Government, on March 23. The question raised by the Ministry was about the ethical implications that the recommendations published by the Bioethics Working Group of the Spanish Society of Intensive, Critical Medicine and Coronary Units (Semicyuc) may have for people with disabilities, under the title of Ethical recommendations for decision-making in the exceptional crisis situation of the covid-19 pandemic in intensive care units .

The virus at the heart of the Committee

At the beginning of its document, the Committee explains that several of its members have passed Covid-19 and that others are still convalescing. The focus of the contagion of the disease among experts occurred at the meeting held on March 4. A report on the coronavirus pandemic was approved at that meeting , but was not made public . The reason? "We dismissed this possibility for two reasons. First, because we considered that the state of the question did not yet pose specific problems of bioethical relevance. And, secondly, because we understood that at that time all the protagonism belonged to the public authority and, in specifically, to the Government, and that messages that, being well-intentioned, caused more confusion than usefulness, should be avoided. Prudence made us choose not to speak out. "

However, time is pressing and during these days recommendations from different medical societies, healthcare ethics committees and the Central Commission of Deontology of the Collegiate Medical Organization have been published. For this reason, the Committee insists in its report on the need to unify criteria coinciding with what has already been stated by the WTO.

Do not forget: Health professionals are essential

Because this will happen, but it should not be forgotten, the Committee breaks a spear in favor of health professionals to whom it dedicates one of the 12 points in its report. "It is important to remember that whenever an event occurs with a serious impact on health, it is common for citizens to praise the work of health and support professionals, but it is also true that said effort usually falls shortly afterwards, not adopting economic, material and personal measures to provide true dignity to professions that, as we are once again proving, play such an essential role in sustaining the lives of individuals and societies. We are convinced that, on this occasion This will not be the case and health professionals will receive the recognition they deserve in due course, "they conclude.

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