Kopar Piroska K, Kramer Jessica B, Brown Douglas E, Bochicchio Grant V
All authors: Department of Surgery, Washington University, Saint Louis, MO.
Crit Care Explor. 2021 Jan 22;3(1):e0326. doi: 10.1097/CCE.0000000000000326. eCollection 2021 Jan.
A cornerstone of our healthcare system's response to the coronavirus disease 2019 pandemic is widespread testing to facilitate both isolation and early treatment. When patients refuse to undergo coronavirus disease testing, they compromise not only just their own health but also the health of those around them. The primary objective of our review is to identify the most ethical way a given healthcare system may respond to a patient's refusal to undergo coronavirus disease 2019 testing.
We apply a systematic approach to a true clinical case scenario to evaluate the ethical merits of four plausible responses to a patient's refusal to undergo coronavirus disease testing. Although our clinical case is anecdotal, it is representative of our experience at our University Tertiary Care Center.
Each plausible response in the case is rigorously analyzed by examining relevant stakeholders, facts, norms, and ethical weight both with respect to individuals' rights and to the interests of public health. We use the "So Far No Objections" method as the ethical approach of choice because it has been widely used in the Ethics Modules of the Surgical Council on Resident Education Curriculum of the American College of Surgeons.
Two ethically viable options may be tailored to individual circumstances depending on the severity of the patient's condition. Although unstable patients must be assumed to be coronavirus disease positive and treated accordingly even in the absence of a test, stable patients who refuse testing may rightfully be asked to seek care elsewhere.
Although patient autonomy is a fundamental principle of our society's medical ethic, during a pandemic we must, in the interest of vulnerable and critically ill patients, draw certain limits to obliging the preferences of noncritically ill patients with decisional capacity.
我们的医疗保健系统应对2019年冠状病毒病大流行的一个基石是广泛检测，以促进隔离和早期治疗。当患者拒绝接受冠状病毒病检测时，他们不仅损害自己的健康，还会损害周围人的健康。我们此次综述的主要目标是确定特定医疗保健系统应对患者拒绝接受2019年冠状病毒病检测的最符合伦理的方式。
我们采用系统方法处理一个真实的临床病例场景，以评估对患者拒绝接受冠状病毒病检测的四种合理应对措施的伦理价值。虽然我们的临床病例是轶事性的，但它代表了我们在大学三级护理中心的经验。
通过检查相关利益相关者、事实、规范以及关于个人权利和公共卫生利益的伦理权重，对病例中的每种合理应对措施进行严格分析。我们使用“迄今为止无异议”方法作为首选的伦理方法，因为它已在美国外科医师学会住院医师教育课程外科委员会的伦理模块中广泛使用。
根据患者病情的严重程度，可针对具体情况量身定制两种符合伦理的可行选择。虽然即使在没有检测的情况下，不稳定的患者也必须被假定为冠状病毒病阳性并相应地进行治疗，但拒绝检测的稳定患者可以被合理地要求到其他地方寻求治疗。
虽然患者自主权是我们社会医学伦理的一项基本原则，但在大流行期间，为了弱势和重症患者的利益，我们必须对满足有决策能力的非重症患者的偏好设定一定限制。
