Health Care Ethics in Covid-19 Crisis

 

Updates:

2 April 2020 (Thursday)

 

Manchester Evening News Reports: 

Coronavirus patients could have their treatment withdrawn and offered to others who are more likely to survive, new guidance for doctors has warned.

The British Medical Association’s (BMA) latest ethics advice said health professionals could be forced to make “grave decisions” should hospitals become overwhelmed with patients

https://www.manchestereveningnews.co.uk/news/uk-news/doctors-coronavirus-treatment-withdrawn-survive-18026241

 

Ventilators maybe withdrawn to treat more serious patients

 

Mirro.co.uk (Rationing Scarce Resources)

Coronavirus patients could have their treatment withdrawn and given to others who are more likely to survive, new guidance for doctors has warned.

The British Medical Association’s (BMA) stark new ethics advice says health professionals could be forced to make “grave decisions” should hospitals become overwhelmed with patients.

The document warns that decisions around rationing scarce resources, such as ventilators, could determine whether large numbers of patients will receive life-saving treatment or not.

 

 

Covid19 has not only brought us in to a health crisis but also it brings many legal issues. The following are some of my views. These are not legal advices. If you need any legal advice, you may contact a lawyer. I do not practice law.

Alike the other professions, the legal care profession is subject many statutory standards. If a corona virus patient is being brought to a hospital, medical practitioners should give medical treatment. It is as simple as this. However, what if there are 20 patients brought or came however only five beds are left in the hospital? How will the doctor decide who he will attend first? What if there is only one ventilator?

Doctors and medical practitioners are taught how to treat people in these situations. It is medical ethics. In the above given scenario, the doctor has to make a quick research as to who he will give priority. These incidents may lead to medical negligence claim in the future, after this pandemic is over, against the National Health Services of the countries, hospitals or policy makers.

It only requires the doctors to make decisions objectively. I could remember one of the philosophical doctrine established by Geremy Bentham called “Utilitarianism”. When I apply utilitarianism, I would say it is the same on the principle that the doctors should apply here. The doctors weigh the worst over good: most critical patient over the other. A person who cannot breathe and a person who is showing mild symptoms of the virus will be differed.

The medical practitioner will attend the most vulnerable person. It will relieve doctors from any liability.

Moreover, during health care crisis this may not be followed as it is stated in the law. The doctors are expecting and are treating a significant number of patients. The doctors are exposed to a high risk in treating patients. When the pandemic is being spreading, the societal interests are priority.

As we can see many countries has declared a national emergency on health, the fundamental rights of the people are limited.

Stay-Home slogans are imposed on mandatory or as an individual responsibility.

Consent to treatment

In pandemics or epidemics, the state has authority to treat patients who are sick. It is not a choice of patients to undergo medical treatment. However, if a disease is not transmittable, the patient has choice of making decisions. It is called the patient autonomy.

Countries have made laws giving the power to the Health Agencies to initiate treatment. Let’s see for example, an elderly person who has wished to undergo euthanasia, may found positive of covid19, it may be possible that he may refuse the treatment. However, in pandemics the state lies with the utmost authority of health care. The interest of the whole society will overcome the patient’s autonomy. Thus, it relieves the medical practitioners from any liability.

Can the medical practitioners give trial drugs to the patients? I will write on that topic this week.

Stay Safe- Say Home!

 

 

 

Media a farce? A question on balancing Morality and Law

Few days ago, I came across a news headline stating “4 Arizona Women Convicted for Leaving Water for Migrants” in Times. It was an eye-catching heading. Surprisingly the details of article gave another preview that the four women were convicted for entering a national wild life refuge without a permit. Also, a part of the claim states “entering and leaving personal property or possession”- possibly referring “leaving water”.

Firstly, the catchy headline made us to believe the four aid workers were convicted for leaving water for migrants. However, the existing fact was not as it was described. This is a method among many other where the media make us read their content.

Often times, we argue that media is the fourth estate or in other terms the fourth power of the state. All other powers, other than media, are subject scrutiny. However, media has been an untouchable blame-maker in the society. Debatable!

Secondly, the balance of morality and legality is a great debatable topic in the legal fraternity. When we apply it here, we can argue that entering the wild life without permit is a crime where giving water for a needy is legal and morally right. However, in the scenario, the aid workers had to breach a law in order to provide water. Is there any imminent threat to the lives of the people if the water is not being distributed? Undoubtedly, water is essential.

There are two stages to scrutinize this standard: in the parliament, when making the law and by judiciary, when interpreting the law. In the former authority, the laws of parliament should reflect morality and justice. It is one of the profound standards that laws that are to be governed the state of affairs of its people should be morally right.

If a parliament makes an unjust law, the legitimacy shall be questioned. Attempt to challenge the legality of such laws often arises with a breach of such law where a judge, who have no power to make or repeal law but to uphold law, would not have much choices but to enforce the law of the parliament or will of the majority of the people. Even if the judges are empowered to strike down such laws a society where there is no consensus on good morality, the judges cannot determine legality and morality of laws.

Morality differs society by society.

 

 

Half and Half: Footstep in Sand

According to Rumi Love is to fly to a secret destiny by steps without our feet.

I just thought of sharing this photo of mine on a white and sandy beach and the famous poem on this week’s subject.

And here we go with the famous poem on footstep, the Foot Step in Sand.

Footstep in Sand

One night I dreamed a dream.
I was walking along the beach with my Lord.
Across the dark sky flashed scenes from my life.
For each scene, I noticed two sets of footprints in the sand, one belonging to me and one to my Lord.
When the last scene of my life shot before me I looked back at the footprints in the sand.
There was only one set of footprints.
I realized that this was at the lowest and saddest times of my life.
This always bothered me and I questioned the Lord about my dilemma.
“Lord, You told me when I decided to follow You, You would walk and talk with me all the way.
But I’m aware that during the most troublesome times of my life there is only one set of footprints.
I just don’t understand why, when I need You most, You leave me.”
He whispered, “My precious child, I love you and will never leave you, never, ever, during your trials and testings.
When you saw only one set of footprints, It was then that I carried you.”
-Margaret Fishback Powers- 

In response to The Daily Post’s weekly photo challenge: “Half and Half.”

Lock: The Ultimate Limit

Lock provides protection and emphasis limitations

Every Day life we see lots of locks and latches emphasising us the limitation our life; where can we go, where should stop proceeding further.

We could say that it’s a command by the authority that it doesn’t wish anyone further through it without prior permission. According to John Austin, the famous philosopher, if you break a command prescribed to you by an authority, you will be penalised.

Everyday life we have limitations. We do not have permit to access to lands and properties that belong to others. We do not have authority to open luggage that belongs to others. We do not have authority to use a motorbike or a vehicle that belongs to others, even if the the key is in the keyhole. We do not have authority to use other’s mobile phones.

The limitations imposed are to protect property, life, reputation, and rights of others and the society.

In response to The Daily Post’s writing prompt: “Symbol.”

My Muse: Sunrise

Sunrise at Raalhugandu, the famous surf point in Male’, the capital of Maldives, is one of the best place to watch beauty of the world.

A New Dawn: Even the Dark Disappears

Even the dark disappears….

Formulating and Implementing a Strategy

Being strategic means connecting intentions to outcomes

• A five-step cycle to achieve strategic thinking:
  1. Begin with intention
  2. Engage in problem diagnosis to determine destination
  3. Devise a guiding policy to determine approach
  4. Create a set of actions
  5. Observe outcomes and compare to intention
• Challenges to being strategic include:

• Confusing understanding with reality
• Swayed by organizational habits, norms, practices, and culture
• Distracted by other things and failing to execute
• Forgetting to reflect on evidence and improve understanding of environment

• To be strategic, one must regularly practice and become aware of these challenges
• Indicators of being strategic:

• Awareness of the five-step cycle and challenges
• Purposeful navigation of the cycle in conducting business
• Regular practice to improve capacity for strategic thinking

Strategy Work:

• Doing strategy work can mean being a designated strategist or just part of a leader’s or manager’s job
• Stereotypes of a strategist include: wizard in an ivory tower, magician traveling between teams, or a consultant
• Strategy work involves:
  • Understanding context
  • Understanding problems and challenges
  • Understanding goals and objectives
  • Understanding constraints
  • Evaluating potential options
  • Deciding on the best approach
  • Communicating strategy and gaining buy-in
• Continuously monitoring progress and adjusting strategy.

Read More by Dimitri Glazkov

Covid19 Legal Consequences Blog

Kosovo Constitutional court decides the lockdown measures are unconstitutional 

Exit News

The Constitutional Court of Kosovo has ruled against the Kurti government’s decision to restrict movement of people to contain the spread of coronavirus.

The court ruled that the decision does not comply with the constitution and that “the restriction of rights and freedoms can only be done through laws passed in the Assembly”.

The court decision came after President Thaçi’s request to review the constitutionality of the government decision.

On March 23, the government decided to “prohibit the circulation of citizens and private vehicles […] from 10:00 am – 4:00 pm and from 8:00 pm – 6:00 pm except for medical needs, production, supply and sale of essential goods […] and for services and activities related to pandemic management.”

The decision prompted reactions against from President Hashim Thaçi, coalition ally Democratic League of Kosovo and opposition parties, all of which said it violated the Constitution.

The government relied on Art.41.2 of the Law on Preventing and Fighting Infectious Diseases, which states that it can restrict circulation “in regions that have been infected or are directly threaten”.

However, President Thaçi took the matter to the Constitutional Court, after urging citizens and institutions not to comply with government measures. The government slammed Thaçi’s call for public disobedience, and the Vetevendosje party of outgoing Prime Minister Albin Kurti took the matter to the Constitutional Court.

Thaçi argued that restrictions could only be imposed under a state of emergency, which should be approved in parliament.

The Kosovo government had declared a “state of public health emergency” a week before the decision for restrictions. However, President Thaçi requested the parliament to impose a “state of emergency”, which would also give him more power to manage the situation.

The request triggered a crisis. Prime Minister Albi Kurti opposed Thaçi’s request but coalition ally LDK supported it. Kurti fired his Minister of Interior from the LDK, and the latter brought a motion of no confidence against him in parliament. As a result, Kurti’s government was ousted.

Kosovo has reported one victim and 108 people infected with coronavirus to date.

https://exit.al/en/2020/03/31/constitutional-court-rules-against-kosovo-governments-restrictive-coronavirus-measures/

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Bosnia Court Rules Against Movement Curbs on Minors, Seniors

Nedim Dervisbegovic

Sarajevo

BIRN

April 22, 202016:12

Constitutional Court gives the country’s Federation entity five days to review movement restrictions that it says lacked ‘proportionality’ and violated important human rights.

A woman wearing a face mask in Sarajevo, Bosnia and Herzegovina, 2020. Photo: EPA-EFE/FEHIM DEMIR

Bosnia’s Constitutional Court, the top court in the country, ruled on Wednesday that banning minors and people over 65 from leaving their homes because of the coronavirus pandemic breaches their right to freedom of movement.

The court said it had rejected the request in the appeal to abolish the order and stopped short of outright annulling the measure in the Federation of Bosnia and Herzegovina, the larger of the country’s two entities.

Instead, the court said it had sent an instruction to the entity government and Civil Protection headquarters, giving them five days to “adjust the order [dating] from March 27, 2020 [in line] with the standards of the Constitution of Bosnia and Herzegovina and Protocol number 4 of the European Convention [on human rights]”.

The measure was already amended early in April to allow minors to be transported in a car and allow pensioners to leave their homes for up to four hours on weekdays in the first week of the month to collect pensions and buy medicines and essentials.

Explaining its ruling, the court said the movement curbs did not fulfill the principle of “proportionality” in connection with the European Convention because the authorities had not made clear why they estimated certain age groups had a larger risk of being infected or of transmitting the infection.

“Furthermore, the possibility of introducing lighter measures … was not considered; they [the measures] are not strictly limited in time, and neither was an obligation established to regularly review them to ensure that they lasted only as long as was necessary”, it added.

The Presiding Judge, Zlatko Knezevic, told BIRN last week that the court had received several appeals since the Civil Protection body imposed the measure in response to the COVID-10 outbreak.

Over the years, various authorities in Bosnia have routinely ignored Constitutional Court rulings, although the number of completely unenforced rulings has dropped in recent years. Up until three years ago, more than 80 Court rulings had not been implemented.

Medical Negligence in Covid19

Photos of Michal Jarmoluk

Medical negligence has been a wide area of discussion in this pandemic. As the number of cases has surpassed two million and fatalities reached nearly 200,000, the world is at stake. Most of the economic activities are on halt, the medical practitioners and caretakers are extremely occupied. Everyone is at risk. The virus has no limit.

In this troublesome time, doctors are making a tough decision; rationing care and making other patient-related decisions.

Imagine the following situations;

1. Alice is showing symptoms of covid19. He contacted the emergency services, where an ambulance took him to the hospital. The paramedics took Alice to the emergency service area. Dr. Paul occupy with Patient-B. The paramedics informed Dr. Paul about the new patient. The new patient has severe breathing difficulties, thus needs a ventilator. Few minutes before Alice, Paul inserted the ventilator tubes to the Patient-B. Patient B- presumably cannot cope with the disease. Patient-B also has other health issues and is 90 years old.
2. Anna is a nurse at the government hospital. While she was driving to her apartment, she saw a person laying on the road. Anna has no PPE in her car. She has only her mask. She knew if she gives CPR the person will survive. She has no sanitizer to wash her hands with. She called the ambulance. It took 12 minutes to arrive, where the person already passed away. An onlooker would understand that had Anna attended the person, the person would survive.

These are few examples  of medical negligence claims.

Medical practitioners owe a duty of care to the patients. Also, the duty is absolute in most of the circumstances.  It is for this reason that the universities teach ethics to medical students.

Check for free photos of Gordon Johnson 

Duty of Care- Law of Tort 

The English courts recognized remedy for breach of obligation almost a century ago. The courts since then have been developing the law. In the old case of Donoghue v Stevenson (1932) AC 562, the beer-snail case established the very first rule of duty of care in the Common Law.

In the case of Donoghue v Stevenson, the judges established how negligence will be established in common law. Summarily the following requirements are essential.

1. Duty of care;
2. Breach of Duty; and
3. Damages.

How to apply negligence in tort to medical negligence

1. Duty of care (Medical practitioners owe a duty to all patients-the duty is absolute)
2. Breach of Duty (If there is a wrong medication prescribed or a careless diagnosis or if a patient left unattended)
3. Damages (The patient must have suffered a loss. A loss is sufficing if the patient has to spend money, suffer physically and mentally, loss of earnings. Moreover, damage and the breach should not be remote.)

The governor of New York issued an executive order exempting the medical practitioners from liability-gross negligence is still effective.

New York has been an epicenter of the pandemic in the United States. The States has failed to provide PPEs for the medical staff, and sufficient medical equipment to hospitals. Thus, the State may also have to face negligence claims in another context.

These events anticipate several medical negligence claims. But only when the pandemic is over.

The standard of care in this pandemic is not as it was in the normal days. Medical staff are directly exposed to the virus. States failed to provide sufficient PPEs. Medical equipment is in scars. Thus, the state has no other way but to exempt medical practitioners from ordinary medical negligence claims. This decision will guarantee the frontline-workers of exemption on medical negligence claims. And this decision will encourage the medical practitioner to fight against the virus with little regard to the likely negligence claims.

This special prevention will avail front liners-flu fighters to the extent of this pandemic.

A Judge in the court, at his discretion, will not weigh the standard as it was before. Still, if medical practitioners make errors which are grossly negligent, reckless, willful, or criminal nature, there is no prevention.

Is it justifiable?

It is. They can use utilitarianism in decision making where they should consider the consequences of their action. Which decision leads most people happy? The decision-maker should consider the recipient of the decision, and how they would be benefited; and, compare the other decision and consequence. Jeremy Bentham and John Stuart Mill developed is theory.

In the above example, Dr. Paul will be exempted from liability even if he disconnects the ventilator and connects it to Alice. Because Patent-B is unlikely to survive.

 

 

 

RUBÀIYÀT of Omar Khayyam

I just started reading this beautiful book.

———————————————————————————————

Dreaming when Dawn’s Left-leaning Hand was in the Sky,

I heard a Voice within the Tavern cry,

“Awake, my little ones, and fill the cup

“Before Life’s liquor in its Cup be dry”

———————————————————————————————

Yes, get the best you can before it is the dusk.

Home-exiled due to Covid 19

The world is now facing a bin calamity-covid-19. Even it was started two months ago in Wuhan, China, it has now started spreading all over the world. The virus has put us down. Most of the countries are on lockdown. It forced us to stay at home. Factories are closed. It has halted transportation. Boarders are closed.

I thought of writing a few words on this difficult time for my followers- even they are very few, and for everyone else who are out there.

Home lock down in my country, in Maldives, is a self-disciplined action. The state is encouraging us to stay at home. To date, only 13 are confirmed case of covid-19. Among them, now, five are recovered. There are no fatalities in Maldives. Moreover, there are 496 persons in 22 quarantine facilities. These 496 persons are not showing symptoms of the virus; however, they are isolated because the government has decided that everyone arriving to Maldives will be quarantined for 14 days.

 

Today’s latest updates:

New cases (last 24 hours): 0
Total confirmed cases: 13
Total recovered cases: 05
Total in quarantine facilities: 496
Total in isolation facilities: 22

— HPA Maldives (@HPA_MV) March 23, 2020

https://platform.twitter.com/widgets.js

There are several frontline workers doing a tremendous job for all of us. In all the countries, these frontline workers are not hesitant to face the threat-bravo.

I have been away from blogging for more than a year. As Robin Sharma said, the best time has gone. The second-best time is today. On this basis, I believe the best time is always ahead.

We are stranded at homes. What are the things we can do? For me, of cause, the best idea is to restart blogging.

Reading

I was told many years ago that “reading gives you wings”-not redbull of cause. What should you read? To start, I would say, read few news articles every day. Keep on reading for few days. Read few articles on the same topic. For example, I have been reading news on Covid-19 for all these days. I read the same story being reported on different newspapers. It will teach how to explore and think differently on the same topic.

Home-Workouts

Spend at least 20-30 minutes on stretching. There are good videos, you just need to follow. It will be difficult to start. However, just give some strength and start, you will not regret it.

Some Links:

Abs work our- Try, atleast 300 calories will burn

CrossFit | Workouts

Finally, I would say, it is this best time that we can spend a lot of time with our families.

Everyone please stay safe! Wash hands and avoid crowds. Do not leave home for no reason, but for fundamental needs.

Prisoner: A Great Movie

Last Friday I watched a movie called Prisoner. Prisoner is about how a father of an abducted daughter tries to find the culprits. Upon freeing a suspect the father kidnapped him, and tortures to find the truth about the abducted daughter.

The characters are mainly the detective and the father where the film is depend on how they unveil the truth on the abduction.

The detective was very patience and not emotional. But, he was very much influenced by his senior. I often think that detectives should not be forced or shall they be influenced when they investigate such kind of cases. Nevertheless, they should be directed on the right paths. It would be the investigator who will think about the case every now and then. The seniors will need only the result. They would not mind on how the results are attained.

A friend of mine, who watched the movie with me, asked if whether the father was morally right in kidnapping and torturing the person to obtain the truth. We  had a good debate over the topic.

He believes that if the father had done so, the detective will not be able to find the truth. And the procedures of police and criminal proceedings will be unbalanced.

Those procedures were established to maintain the innocence of the people. Most of the constitutions are made up or most of the countries do believe that no person shall be arrested or detained for any alleged offence unless there are substantial evidence to believe that he may have committed the crime. Police shall not be mandated nor shall be given the power to detain anyone on their discretion.

On the other hand, no one shall be subject any harm or torture. Police shall not use force nor any way to “utter confession” from the accused.

I believe that evidence shall be collected legally, and no one shall be subject to torture for even in any heinous crimes. Sometimes, the accused may not be the wrongdoer, but he may confess during the interrogation due to inflicting severe pain and suffering.

This was an unpublished post of September 2014. 

Wake Up Early- Go Run

My New 3o-Day-Challenge

I am a distance runner-yes, my furthest run is 13 KM in 1 hour 26 minutes. But it was in 2016.

I started running in 2013 when the doctor prescribed me drugs to lower my bad cholesterol level. However, I did not take the meds for more than one week, instead I headed to the running track.

I was very fearful on cholesterol level and the possible sequences. Therefore, I took some home remedies (Ayurveda). It consisted of Apple Cider Vinegar, Onion, Garlic, some Ginger and galangal extracts, and roots of Akarakara. A Maldivian Ayurvedic Medical Practitioner prescribed it for me. And it worked. The total cholesterol level dropped from 270 to 230 within 60 days without any meds.

Along with it, I used to go for jogging every morning. I did not maintain a special diet but I abandoned eating deep fried foods. It was easy.

Also, I went to gym too. But my gym buddies were not regular. Therefore, I had to quit going gym after the expiry of the first month subscription. It was like $50 dollars per month with no instructor.

Later, I went on jogging on myself. I did not rely on anyone to tag on. It is an advice: never rely on anyone on jogging. Even if you are to tag some one, set a time and start on the agreed time, never wait for your friends to come.

I read few articles on running. I focussed on how to avoid injuries. At first I could not complete more than three Kilometres. Within a month, I could finish five Kilometres in 45 mins.

Running with music is at your choice. Most of the times I wear headsets. I only listen to the cheering and run data of NikePlus which are set to give on each Kilometre intervals. Sometimes I hear people passing calling me. I do not turn my face, I pretend that I did not hear it.

Throughout these years I did not had a planned run guide. I had long breaks. Sometimes two months sometimes four months. As a result I was 91 Kg in August 2018. But it is reduced to 88 now.

Now, I decided as a new year resolution to pursue on a running schedule. I would go jogging 5 days a week and swimming on 1 day and rest on the next day. So as usual I wake up early in the morning around 5 a.m. I do my early morning prayers and I go jogging. This is my 30-Day -challenge.

 

Hassan and Amir Agha- The Kite Runners

My bookshelf contains more text books and non-fictions than fictions. Most of the fictions I buy will be untouched for months. Among them, the collection of Khaled Hosseini has been left untouched for couples of months. I bought his collection from a visit to India on December 2016. However, until this year I haven’t opened the collection.

Many friends talk about Khaled Hosseini and his first story about the Phastuns and Hazars, The Kite Runner. The theme of the story may not be this- I do not want be a spoiler.

I have read almost 75 of the 300 page book. What I know about the book is it is a fiction. His imagination to different stories of life is fascinating. I know imagination has no boundaries. And imagination is free. I am inspired by his method of story telling.

As I said before, I am not going to tell about the story, but through out the pages many thoughts were swirling in my head.

Each an every part of the world the human race or a part of the society has been enslaved the other. The Apartheid System in South Africa, the Holocaust, the Sunnis and Shia fight, the superiority of Brahmins in India, the fight between West and East Pakistan, the crimes against humanity committed by the Serbian Forces, the ethnic cleansing of Rohingya, the Tamil-Sinhala fight and may more to count.

What was wrong with the human races. Just this fiction has taken my thoughts on all over the world.

Looking forward on what was remaining on the heart breaking story.