Health Inequalities amongst Refugees and Migrant Workers in the Midst of the COVID-19 Pandemic: a Report of Two Cases

Malaysia hosts a significant number of refugees, asylum-seekers and migrant workers. Healthcare access for these individuals has always proved a challenge: language barriers, financial constraints and mobility restrictions are some of the frequently cited hurdles. The COVID-19 pandemic has exacerbated these existing inequalities, with migrants and refugees bearing the brunt of chronic systemic injustices. Providing equitable healthcare access for all, regardless of their citizenship and social status remains an ethical challenge for healthcare providers, particularly within the framework of a resource-limited healthcare system. Inclusive healthcare and socio-economic policies are necessary to ensure every individual’s equal opportunity to attain good health. The collective experiences of refugees and migrants in the pursuit of healthcare, as highlighted by the two cases described, showcases the importance of equity in healthcare access and the detrimental implications of non-inclusive healthcare and socio-economic policies.

Et Al.: New Voices in Arts Management

Et Al. imagines kaleidoscopic possibilities for the stewardship of culture and land as decolonizing practices. Culture and the arts can enhance society by strengthening our connections to each other and to the earth. This arts management book was born during a racial reckoning and accelerated by a global pandemic. What exactly is the business of no-business-as-usual? The ethical challenge for arts management is far more complex than asking how to get things done; we must also ask who gets to do things, where, and with what resources? Our task is to generate cultures that refuse to annihilate themselves or each other, much less the planet. Et Al. contributes to the conversation about arts and cultural management by providing rare, behind-the-scenes insights on justice-centered arts management praxis — ideas tied to action. The book makes space for people to publicly reflect, write, and share insights about their own ideas and ways of working. Its polyphonic voices speak to pragmatic strategies for arts management across cultures, genres, and spaces. Its stories are told from the perspective of individuals and families, micro businesses, artist collectives, and civic institutions. As a digital publication, the platform lends itself to multi-media knowledge objects; the experiences documented within it include ethnographies, qualitative social research, personal and communal manifestos, dialogues between peers, visual essays, videos, and audio tracks. This open source, multimedia book is structured into six streams which are numbered for their exponential powers: Stream¹ : Center is Everywhere; Stream² : Gathering Community; Stream³ : Honoring Histories; Stream⁴ : Shifting Research; Stream⁵ : Forging Paths; Stream⁶ : Generative Practice. The book discusses imaginative ways of generating cultural equity in praxis, and is an invitation for further imagination, conversation, and connection. Et Al. presents an interactive landscape for readers, thinkers, and creators to engage with multimedia and intergenerational essays by Amy Shimshon-Santo, Genevieve Kaplan, Gerlie Collado, Abraham Ferrer, Julie House, Britt Campbell, Delia Xóchitl Chávez, Sean Cheng, Yvonne Farrow, Allen Kwabena Frimpong, Kayla Jackson, Erika Karina Jiménez Flores, Cobi Krieger, Loreto Lopez, Cynthia Martínez Benavides, Christy McCarthy, Janice Ngan, Cailin Nolte, Michaela Paulette Shirley, Robin Sukhadia, Katrina Sullivan, and Tatiana Vahan.

Intensive care nurses’ experiences of Covid-19 care: A practical and ethical challenge – a qualitative descriptive design

The Covid-19 pandemic has generated new experiences of intensive care. It has entailed new working methods, treatment strategies, and ethical dilemmas. The aim of this study was to describe intensive care nurses’ experiences of Covid-19 care and its ethical challenges. Data collection consisted of 11 individual semi-structured interviews and a qualitative content analysis was used. The COREQ checklist was followed. Three main themes emerged: to meet Covid-19 patients’ needs for specifically tailored intensive care; to have a changed approach to the excluded relatives is unethical, but defensible; and to strive to protect ethical values needs to be considered as good enough. In conclusion, ICU nurses shouldered a heavy burden in taking responsibility for the safety of these patients, continuously learning about new treatment strategies. Caring for Covid-19 patients was to strive to make the best of the situation.

Models of COVID-19 vaccine prioritisation: a systematic literature search and narrative review

Background How best to prioritise COVID-19 vaccination within and between countries has been a public health and an ethical challenge for decision-makers globally. We reviewed epidemiological and economic modelling evidence on population priority groups to minimise COVID-19 mortality, transmission, and morbidity outcomes. Methods We searched the National Institute of Health iSearch COVID-19 Portfolio (a database of peer-reviewed and pre-print articles), Econlit, the Centre for Economic Policy Research, and the National Bureau of Economic Research for mathematical modelling studies evaluating the impact of prioritising COVID-19 vaccination to population target groups. The first search was conducted on March 3, 2021, and an updated search on the LMIC literature was conducted from March 3, 2021, to September 24, 2021. We narratively synthesised the main study conclusions on prioritisation and the conditions under which the conclusions changed. Results The initial search identified 1820 studies and 36 studies met the inclusion criteria. The updated search on LMIC literature identified 7 more studies. 43 studies in total were narratively synthesised. 74% of studies described outcomes in high-income countries (single and multi-country). We found that for countries seeking to minimise deaths, prioritising vaccination of senior adults was the optimal strategy and for countries seeking to minimise cases the young were prioritised. There were several exceptions to the main conclusion, notably that reductions in deaths could be increased if groups at high risk of both transmission and death could be further identified. Findings were also sensitive to the level of vaccine coverage. Conclusion The evidence supports WHO SAGE recommendations on COVID-19 vaccine prioritisation. There is, however, an evidence gap on optimal prioritisation for low- and middle-income countries, studies that included an economic evaluation, and studies that explore prioritisation strategies if the aim is to reduce overall health burden including morbidity.

Consciousness as a multidimensional phenomenon: implications for the assessment of disorders of consciousness

Disorders of consciousness (DoCs) pose a significant clinical and ethical challenge because they allow for complex forms of conscious experience in patients where intentional behaviour and communication are highly limited or non-existent. There is a pressing need for brain-based assessments that can precisely and accurately characterize the conscious state of individual DoC patients. There has been an ongoing research effort to develop neural measures of consciousness. However, these measures are challenging to validate not only due to our lack of ground truth about consciousness in many DoC patients but also because there is an open ontological question about consciousness. There is a growing, well-supported view that consciousness is a multidimensional phenomenon that cannot be fully described in terms of the theoretical construct of hierarchical, easily ordered conscious levels. The multidimensional view of consciousness challenges the utility of levels-based neural measures in the context of DoC assessment. To examine how these measures may map onto consciousness as a multidimensional phenomenon, this article will investigate a range of studies where they have been applied in states other than DoC and where more is known about conscious experience. This comparative evidence suggests that measures of conscious level are more sensitive to some dimensions of consciousness than others and cannot be assumed to provide a straightforward hierarchical characterization of conscious states. Elevated levels of brain complexity, for example, are associated with conscious states characterized by a high degree of sensory richness and minimal attentional constraints, but are suboptimal for goal-directed behaviour and external responsiveness. Overall, this comparative analysis indicates that there are currently limitations to the use of these measures as tools to evaluate consciousness as a multidimensional phenomenon and that the relationship between these neural signatures and phenomenology requires closer scrutiny.

Defining ethical challenge(s) in healthcare research: a rapid review

Background Despite its ubiquity in academic research, the phrase ‘ethical challenge(s)’ appears to lack an agreed definition. A lack of a definition risks introducing confusion or avoidable bias. Conceptual clarity is a key component of research, both theoretical and empirical. Using a rapid review methodology, we sought to review definitions of ‘ethical challenge(s)’ and closely related terms as used in current healthcare research literature. Methods Rapid review to identify peer-reviewed reports examining ‘ethical challenge(s)’ in any context, extracting data on definitions of ‘ethical challenge(s)’ in use, and synonymous use of closely related terms in the general manuscript text. Data were analysed using content analysis. Four databases (MEDLINE, Philosopher’s Index, EMBASE, CINAHL) were searched from April 2016 to April 2021. Results 393 records were screened, with 72 studies eligible and included: 53 empirical studies, 17 structured reviews and 2 review protocols. 12/72 (17%) contained an explicit definition of ‘ethical challenge(s), two of which were shared, resulting in 11 unique definitions. Within these 11 definitions, four approaches were identified: definition through concepts; reference to moral conflict, moral uncertainty or difficult choices; definition by participants; and challenges linked to emotional or moral distress. Each definition contained one or more of these approaches, but none contained all four. 68/72 (94%) included studies used terms closely related to synonymously refer to ‘ethical challenge(s)’ within their manuscript text, with 32 different terms identified and between one and eight different terms mentioned per study. Conclusions Only 12/72 studies contained an explicit definition of ‘ethical challenge(s)’, with significant variety in scope and complexity. This variation risks confusion and biasing data analysis and results, reducing confidence in research findings. Further work on establishing acceptable definitional content is needed to inform future bioethics research.

論傳統＂義＂德在抗擊重大疫情中的現實意義——基於博弈論的分析

LANGUAGE NOTE | Document text in Chinese; abstract also in English. 在中國發生重大的公共衛生危機——新型冠狀肺炎病毒爆發的背景下，防疫工作不可避免地面臨一些個人與他人或社會的利益衝突。妥善解決這些衝突需要道德的支撐。當前重大疫情下普通人表現出的助人為樂、捨己為人的義舉，或繼承自傳統美德，或至少與傳統“義”德相符合。傳統的“義”德注重公利，在抗擊重大疫情過程中能夠發揮重要作用。這種現實作用能夠被博弈論中的純策略博弈和信任博弈分析所證明。抗擊重大疫情需要整個社會的團結協作，個人需講求“公義”、 “信義”，明白義利的統一性，必要地讓渡“私利”，將防疫的“公利”最大化，方能打贏抗疫戰，從而更廣泛地保護個人“私利”。 In the context of the outbreak of covid-19 pandemic and its impact on public health, the conflicts of interests between individuals and between an individual and society have become an ethical challenge. The traditional Chinese concept of “righteousness” (yi) calls for the need for public good, whereas “benefit” (li) is often associated with private interests, as shown in the Confucian-Mohist debate. In this paper, I show that there is another reading of the concept of “righteousness” that does not necessarily exclude the idea of individual interest and benefit. In addition, I use “game theory” to illustrate the unity of public righteousness and private benefit.

Neonatologists’ decision-making for resuscitation and non-resuscitation of extremely preterm infants: ethical principles, challenges, and strategies—a qualitative study

Background Deciding whether to resuscitate extremely preterm infants (EPIs) is clinically and ethically problematic. The aim of the study was to understand neonatologists’ clinical–ethical decision-making for resuscitation of EPIs. Methods We conducted a qualitative study in Belgium, following a constructivist account of the Grounded Theory. We conducted 20 in-depth, face-to-face, semi-structured interviews with neonatologists. Data analysis followed the qualitative analysis guide of Leuven. Results The main principles guiding participants’ decision-making were EPIs’ best interest and respect for parents’ autonomy. Participants agreed that justice as resource allocation should not be considered in resuscitation decision-making. The main ethical challenge for participants was dealing with the conflict between EPIs’ best interest and respect for parents’ autonomy. This conflict was most prominent when parents and clinicians disagreed about births within the gray zone (24–25 weeks). Participants’ coping strategies included setting limits on extent of EPI care provided and rigidly following established guidelines. However, these strategies were not always feasible or successful. Although rare, these situations often led to long-lasting moral distress. Conclusions Participants’ clinical–ethical reasoning for resuscitation of EPIs can be mainly characterized as an attempt to balance EPIs’ best interest and respect for parents’ autonomy. This approach could explain why neonatologists considered conflicts between these principles as their main ethical challenge and why lack of resolution increases the risk of moral distress. Therefore, more research is needed to better understand moral distress in EPI resuscitation decisions. Clinical Trial Registration: The study received ethical approval from the ethics committee of UZ/KU Leuven (S62867). Confidentiality of personal information and anonymity was guaranteed in accordance with the General Data Protection Regulation of 25 May 2018.