The author asserts that coercion to vaccinate is ethically analogous to mandatory seatbelts or the use of physical force to remove a dangerous substance from a child. This is a false analogy. Wearing seatbelts while driving or removing a dangerous toy from a child does not alter anyone’s individual constitution, but vaccines do, permanently, and with largely unknown long-term consequences. Vaccination is an intimate, deeply invasive and permanent medical procedure, not just a behavioural preference. The same flawed comparison could be used to support mandatory abortion or coercive organ harvesting if these procedures were deemed in the interest of public health: a repugnant conclusion.

Regarding seriousness of Covid-19 as a public health issue, the author ignores the fact that Covid-19 deaths are recorded in a non-standard way which precludes meaningful assessment of the true public health impact of this disease in comparison to other respiratory infections. Acording to the WHO https://www.who.int/classifications/icd/Guidelines_Cause_of_Death_COVID-... guidelines, “A death due to COVID-19 is defined for surveillance purposes as a death resulting from a clinically compatible illness [...] COVID-19 should be recorded on the medical certificate of cause of death for ALL decedents where the disease caused, or is assumed to have caused, or contributed to death.” The Office of National Statistics UK, for example, counts all mentions of Covid-19 on death certificates as Covid-19 deaths, irrespective of whether Covid-19 is the underlying cause of death (see Note 5 in the ONS Spreadsheet). https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri... Due to this definition ambiguity, it is unclear how many people died from infection with SARS-CoV-19 as the underlying cause. On the other hand, judging by the excess deaths in UK due to respiratory illness, it is doubtful whether anyone would notice that there is a pandemic if not for the associated media campaign and the unprecedented, draconian counter-measures. The fact that Covid-19 is characterised as a serious global threat based on potentially misleading mortality statistics automatically disqualifies any ethical justification of coercive measures to vaccinate against Covid-19, due to potential disagreement about the alleged normative facts. On the other hand, I do agree with the author that mandatory seatbelts to prevent Covid-19 would be ethically permissible, although probably ineffective.

On the grounds that the elderly are more likely than the non-elderly to become severely unwell, require intensive, scarce and expensive and thereby put the NHS at risk of being overwhelmed, if they catch COVID-19, Savulescu and Cameron make two dubious claims. Firstly, they say that a selective, legally compulsory, lockdown of the elderly to stem a resurgence of the pandemic could be morally justifiable. Secondly, they say that such a selective lockdown would be just. They write: ‘Ethically, selective isolation is permissible. It is not unjust discrimination. It is analogous to only screening women for breast cancer: selecting those at a higher probability of suffering from a disease.’1
I shall focus here on a response to the latter claim. To justify a particular allocation of benefits or burdens as a just allocation is different from justifying a particular allocation – whether or not it is just – in terms of its morally desirable consequences. I do not believe that a lockdown of the elderly would be morally justified by its consequences but, whether or not it would so be, it would be unjust discrimination.
ARISTOTLE ON DISTRIBUTIVE JUSTICE AND WOMEN
Under the heading of ‘THE IDEAL OF EQUALITY AND THE CONCEPT OF UNJUST DISCRIMINATION.’, Savulescu and Cameron write:
‘Aristotle described the principle of equality as treating like cases alike, unless there is a morally relevant difference. For example, if men are allowed to vote, and women are not, the only difference is sex. Sex cannot of itself make a difference to the capacity or performance of voting—it involves a mere chromosomal or anatomical difference. Unless one could point to an inherent property that tracked with sex that affected ability to vote, then this violates Aristotle’s principle and is unjust discrimination.’2
Distributive justice, for Aristotle seems to be about treating like people rather than like cases alike. The focus, too, is on the distribution of burdens and benefits between different people of the same category or status rather than on the just treatment of people of different categories or statuses. Chroust and Osborn say of ‘Aristotle’s Conception of Justice’:
‘Justice and Equality, which for the purpose of comparison always presupposes a duality, requires, therefore, at least four different factors: namely, two conflicting claims and two claiming persons.6 should these two persons be of unequal rank they cannot be treated alike," for the principle of Equality demands that only equals be treated equally." In this sense Equality is always proportionate equality - that is to say, it is a form of Justice which allots burdens according to the individual's ability to carry them and accords sup- port in amounts which vary with the needs of the individuals - and is called "distributive Justice." ’3
Fundamental to Aristotle’s and, I would suggest, any tenable theory of distributive justice is the notion that when x is justly given to A but not to B, A (in some sense or other) merits or deserves to receive it more than or rather than B. This merit or desert consists in the nature of and relationship between A, B and x. For instance, Aristotle would contend that scarce flutes should be given to those who can play flutes rather than to those who cannot and to the best flute players rather than to the less talented ones if there are not enough flutes to provide to provide all citizens with one.
To the best of my knowledge, he did not ever say that flutes should be given to all the members of the category or categories of citizens which had the highest proportion of good flute players. Proxies for just criteria do not seem to feature in his scheme nor do they have an obvious logical place in any tenable theory of distributive justice. For instance, it would hardly be just or fair, no matter how efficient and expedient it might be if a lecturer gave grades to the essays of students on the basis of the social categories to which they belonged on the grounds that students in particular social categories tend to get particular grades.
One might readily assume that the example that Savulescu and Cameron give of discrimination on the basis of sex is Aristotle’s own one or, at the very least, one he would obviously agree with. This is not the case.
According to Stefan Gosepath, writing in the Stanford Encyclopedia of Philosophy:
‘When two persons have equal status in at least one normatively relevant respect, they must be treated equally with regard to this respect. This is the generally accepted formal equality principle that Aristotle formulated in reference to Plato: “treat like cases as like” (Aristotle, Nicomachean Ethics, V.3. 1131a10-b15; Politics, III.9.1280 a8-15, III. 12. 1282b18-23). Of course the crucial question is which respects are normatively relevant and which are not.’4

Not all people should be treated equally, according to Aristotle, but only those of equal status. He does not seem to regard men and women to be persons of equal status. The following are among his famous quotes about women:5
Aristotle, Politics: "[T]he male, unless constituted in some respect contrary to nature, is by nature more expert at leading than the female, and the elder and complete than the younger and incomplete."
Aristotle, Politics: "[T]he relation of male to female is by nature a relation of superior to inferior and ruler to ruled."
Aristotle, Politics: "The slave is wholly lacking the deliberative element; the female has it but it lacks authority; the child has it but it is incomplete."

In The Internet Encyclopedia of Philosophy, Wayne P. Pomerleau writes

‘Given natural human inequality, it is allegedly inappropriate that all should rule or share in ruling. Aristotle holds that some are marked as superior and fit to rule from birth, while others are inferior and marked from birth to be ruled by others. This supposedly applies not only to ethnic groups, but also to the genders, and he unequivocally asserts that males are “naturally superior” and females “naturally inferior,” the former being fit to rule and the latter to be ruled. The claim is that it is naturally better for women themselves that they be ruled by men, as it is better for “natural slaves” that they should be ruled by those who are “naturally free.” 6

BREAST SCREENING FOR CANCER AND UNJUST DISCRIMINATION

Savulescu and Cameron write:
‘Discrimination is not always unjust. If there is a morally relevant difference, it may be acceptable. The government invests millions in screening women for breast cancer, but not men, even though breast cancer does occur in men. The reason for this is that breast cancer is much more likely in women. So, you will save more lives with the limited resource the government has available for prevention and treatment of breast cancer if you (justly) discriminate between men and women in this way.
This is not sexist because there is a morally relevant difference sufficient to justify different treatment: the probability of developing breast cancer. However, if there were a better, more accurate proxy for breast cancer risk besides sex, say some genetic mutation, then to continue to discriminate on the basis of sex would be unjust, all else being equal.’7
It is certainly true that discrimination is not always unjust. However, it is not true that all discrimination that can be morally justified is not unjust. Discrimination requires not merely a moral justification but a moral justification of a particular sort in order to render discrimination just.
Justice pertains to the treatment of people rather than cases. For instance, to use an example of my own choosing, lecturers who are acting in their capacity as private citizens, are not morally obliged to treat other private citizens impartially when, say, they are inviting guests to a dinner party. They might, without acting unjustly, discriminate between them on the basis of their personal preferences and prejudices. However, when they are acting qua lecturers and, for instance, marking the essays of their students, they are morally obliged to do so impartially and to give the same marks to essays that are equally good and proportionately more or less marks to those that are proportionately better or worse.

Acting justly does not merely mean treating their students the same unless there is a moral justification for treating them differently. It means treating them differently only when the difference in treatment is morally justified by a corresponding and proportionate difference pertaining to the merits of the essays that are submitted by them. In other words, the allocation of different treatment, of, say, benefits and burdens, is just or unjust regardless of the consequences of that particular allocation. The virtue of distributive justice does not lie in the consequences of any particular distribution of burdens and benefits but in its appropriateness.

There is a difference between morally justifying an action or policy and morally justifying it as a just one. Justice is not the only moral virtue. For instance, taxation is necessary to finance the operations of the state. If, somehow, it is not possible to formulate and implement a just and fair system of taxation, it might be morally justifiable to collect the necessary taxes unjustly and unfairly. Similarly, in the dire extreme emergencies that wars and, possibly, pandemics, can create, unjust and unfair actions and policies might, arguably, be morally justifiable.
There is, of course, a difference between successful and unsuccessful attempted justifications. To offer a moral justification for an action or policy is not the same as actually morally justifying it.
Just as lecturers in their role as lecturers have a moral duty to treat their students as students impartially, and their students have a corresponding moral right to receive such impartial treatment, the state, its agencies and agents have a similar moral duty to treat all citizens impartially and they each have a moral right to receive such impartial treatment and equal due consideration. What such impartiality consists of is often debatable and typically non determinate. In many cases, for instance, with regard to general policy decisions such as whether and where to build particular roads and bridges or, say, whether or not to adopt particular foreign policies, it appears to have little if any practical political relevance. However, where the distribution of benefits and burdens which are individually consumed or borne is concerned, the significance of the matter and its practical relevance grow hugely.
As a matter of justice, in the distribution of burdens and benefits that are enjoyed or borne by individual citizens, the state, its agencies and agents have a moral duty to treat individual citizens impartially. The citizens individually have a moral right to receive such impartial treatment. This means treating them the same unless the differences in treatment between particular individual citizens is purposefully and consciously related to morally relevant and proportionate differences between them. It means too, I suggest, giving explicit and implicit request to receive such benefits and to be spared such burdens equal and appropriate consideration.
If some particular people are, say, known to have cancer of a particular sort, they have a need for treatment for it which other people are not known to have. They could reasonably be said to, in some sense, deserve to receive scarce appropriate treatment rather than those who are not known to have such a need. It would be plausible to say that it would be just to discriminate in their favour in the allocation of NHS health treatment that was appropriate to their needs.
However, it would not be just to allocate such treatment only to those people in some arbitrarily demarcated category – the ‘elderly’, for instance – which had the highest proportion of sufferers from cancer. To give such treatment to all members of such a category would be not be just. Proxy justice is not justice any more than fools’ gold is gold.
Screening for cancer in general or cancers in particular is not a need in the same sense that treatment for them is. Some people might have a psychological need of such screening but there is no obvious reason for restricting the allocation of the procedure solely to them. The real or supposed benefits of screening for breast cancer could be enjoyed by any and all citizens. People who are women, people who are men, people who are both and people who are neither might all get and can all suffer from the fear that they will get breast cancer. Each and all of them can have a legitimate interest in having and knowing the results of such a scan. In the planning of their own lives and with regard to the thoughts and feeling with those with whom they interact, this information can be, or seem to them to be, important. That a person belongs to a category that has few or, even, hardly any members who will get breast cancer need not make the results of a screen test for breast cancer of any less significance to that person.8,9
To restrict free NHS breast screening for cancer to women is unjust discrimination.10 The likelihood of saving more lives by devoting a particular amount of resources to the screening solely of women rather than, indiscriminately, to those who want to receive it might (or might not) be a moral justification of the discrimination but that would not automatically make it just. The differences in treatment are not justified as deserved differences. Similarly, to give higher marks to the essays of male or female students might, in some circumstances, have a morally desirable outcome. That might (or might not) morally justify the discrimination but it would not thereby render it just.
Suppose that it were discovered that the incomes of the fathers of students was a reliable proxy for the allocation of the likely worth of their essays. It would be very wrong to allocate marks to essays on such a basis rather than reading them no matter how accurate and cost-effective such a procedure turned out to be. We could not say that it was slightly just or as just as we could manage. Proxies might be useful with regard to expedience, but they have no proper role in the exercise of justice.
Similarly, too, the difference in treatment of elderly people by the state that is implied by the proposed selective lockdown policy of Savulescu and Cameron is unjust. The difference in treatment is not a deserved difference even if it were to be successfully morally justified on grounds other than justice.
We can typically choose to waive our moral rights to benefits that we are offered. Thus, for instance, women are not compelled to have free screening for breast cancer on the NHS. Burdens, penalties and punishments rather than benefits are compulsory and they are more usually more difficult to justify than the allocation of benefits. In this regard, a coercive selective lockdown of the elderly is fundamentally different from and even more morally abhorrent than a selective, sexually discriminatory distribution of NHS. Elderly people do not in any sense deserve such treatment any more than other people do no matter how beneficial Savulescu and Cameron suggest that it might be for the NHS or society in general.
If there is a second wave of COVID-19, infection, not all elderly people will catch it and not all of those who do will require intensive, scarce and expensive hospital treatment whether or not there is a lockdown of any sort. Similarly, not all of those who catch it and require intensive, scarce and expensive hospital treatment will be elderly. If all citizens should be treated the same unless they are more likely to require intensive, scarce and expensive hospital treatment if the catch Covid-19, it follows that, as a matter of justice, those who are likely to require such treatment should be treated differently. Not all who are elderly should be treated the same and not all who are non-elderly should be treated the same. Those who are elderly but would not require intensive, scarce and expensive hospital treatment should be treated differently from those who are elderly and would do so. The same can be said for those who are non-elderly.
However, it would be, in my view, unjust to lockdown those who would require intensive, scarce and expensive hospital treatment. They do not deserve to be treated thus differently to obviate their need for such treatment. If we want to deviate from the principle of the allocation of NHS treatment on the basis of medical need, we should do so without selectively prohibiting potentially needy people from coming and going from their homes as they please.
The argument of Savulescu and Cameron which I have considered is unconvincing. It is based on an under-developed, underspecified and implausible account of distributive justice.

REFERENCES
1 Savulescu J, Cameron J. Why lockdown of the elderly is not ageist and why levelling down equality is wrong. J Med Ethics 2020;0:1–5. doi:10.1136/medethics-2020-106336.

2 Savulescu J, Cameron J. Why lockdown of the elderly is not ageist and why levelling down equality is wrong. J Med Ethics 2020;0:1–5. doi:10.1136/medethics-2020-106336.
3 Anton-Hermann Chroust & David L. Osborn, Aristotle's Conception of Justice, 17 Notre Dame L. Rev. 129 (1942). https://scholarship.law.nd.edu/cgi/viewcontent.cgi?article=3967&context=...
4 https://plato.stanford.edu/entries/equality/

5 https://orb.binghamton.edu/cgi/viewcontent.cgi?article=1106&context=sagp

6 https://iep.utm.edu/justwest/#SH1b

7 Savulescu J, Cameron J. Why lockdown of the elderly is not ageist and why levelling down equality is wrong. J Med Ethics 2020;0:1–5. doi:10.1136/medethics-2020-106336.
8 McLachlan HV. A proposed non-consequentialist policy for the ethical distribution of scarce vaccination in the face of an influenza pandemic. J Med Ethics May 2012, 38 (5) 317-318.
9 McLachlan HV. On the random distribution of scarce doses of vaccine in response to the threat of an influenza pandemic: a response to Wardrope. J Med Ethics Feb 2015, 41 (2) 191-194.
10 As my wife, Sheila, has pointed out to me, the allocation of breast screening in the UK is also unjustly ageist.

O’Byrne et. al raise the important issue of pandemic preparedness in medical students’ readiness to deal with the covid-19 pandemic. Healthcare professionals have a moral obligation to volunteer to help, however, there has been a lack of strict consideration for the preparedness and clinical competency of medical students in these circumstances. The article correctly highlights that medical students’ desire to help is insufficient alone, and there is a need for adequate medical education and training to better prepare students for any potential moral trauma and adverse risks to mental health. However, for those newly graduated students, we feel as though the need for a break from clinical activity is a concept that has been overlooked and may be imperative to true pandemic preparedness amongst this cohort.

The majority of medical students will complete an intensive 5-year curriculum before graduating and applying to the foundation programme to continue their training, 43% of whom will have had no break from education up to this point.(1) As highlighted in the article by O’Byrne et. al, many of these students face problems with their mental wellbeing during medical school and thereon after. These problems regarding mental and emotional wellbeing are heightened in situations where students feel anxious or unprepared, such as clinical placements and rotations.(2) The importance of breaks to aid mental wellbeing are well recognised throughout the curriculum, such as time-outs and project periods to break-up clinical activity.(3) The concern is that those deployed early onto the frontline will not have had the adequate break required to replenish their wellbeing in preparation for their lifelong career ahead.
The obligation to patient care and dire need for volunteers will see most graduating medical students quickly enter clinical practice. However, stress, anxiety and burnout are well recognised issues amongst medical students, and may be exacerbated for this cohort.(4) The covid-19 pandemic is likely to cause heightened moral distress for newly graduated doctors, as they are required to make increasingly challenging decisions regarding patient care.(5) This highlights the need to build moral resilience to reduce the chance of moral injury or burnout.
It is well recognised that breaks during work are important to avoid burnout, particularly for healthcare professionals. A study conducted on doctors working in a stressful intensive care environment showed that taking breaks from the intensive care unit environment was one important strategy to rejuvenate from moral distress.(6) However, the concern is that those more junior faced with the existing anxiety of a new job role and responsibilities may have a lower tolerable threshold for morally distressing situations; as a result increasing likelihood of burnout. Additionally, many more doctors are taking time out from foundation training in recent years due to stress and exhaustion.(7)
Reflexivity is important in developing as a practitioner and may be crucial in the period between graduating and becoming a medical professional. Coates et. al(1) showed that this transitional period is an important time for life skill development, such as through increasing confidence, emotional stability and independence; important traits of a medical professional. The importance of a break is recognised throughout, with trainees now opting to take a break during medical training, of which the result has been an addition of valuable experience to the development of their future profession.(7)
Therefore, whilst providing newly graduated students with the invaluable learning opportunity of assisting during a global pandemic, it must also be remembered that students must receive an adequate break from clinical studies in order to develop moral resilience, boost mental wellbeing and reduce the chances of burnout during foundation training.

References
1. Coates WC, Spector TS, Uijtdehaage S. Transition to Life—A Sendoff to the Real World for Graduating Medical Students. Teaching and Learning in Medicine 2012;24(1):36-41. doi: 10.1080/10401334.2012.641485
2. Hill MR, Goicochea S, Merlo LJ. In their own words: stressors facing medical students in the millennial generation. Medical education online 2018;23(1):1530558-58. doi: 10.1080/10872981.2018.1530558
3. Tolhurst HM, Stewart SM. Balancing work, family and other lifestyle aspects: a qualitative study of Australian medical students’ attitudes. Medical Journal of Australia 2004;181(7):361-64. doi: 10.5694/j.1326-5377.2004.tb06326.x
4. Wang Q, Wang L, Shi M, et al. Empathy, burnout, life satisfaction, correlations and associated socio-demographic factors among Chinese undergraduate medical students: an exploratory cross-sectional study. BMC Medical Education 2019;19(1):341. doi: 10.1186/s12909-019-1788-3
5. Wald HS. Optimizing resilience and wellbeing for healthcare professions trainees and healthcare professionals during public health crises - Practical tips for an ‘integrative resilience’ approach. Medical Teacher 2020:1-12. doi: 10.1080/0142159X.2020.1768230
6. Henrich NJ, Dodek PM, Gladstone E, et al. Consequences of Moral Distress in the Intensive Care Unit: A Qualitative Study. American Journal of Critical Care 2017;26(4):e48-e57. doi: 10.4037/ajcc2017786
7. Rizan C, Montgomery J, Ramage C, et al. Why are UK junior doctors taking time out of training and what are their experiences? A qualitative study. Journal of the Royal Society of Medicine 2019;112(5):192-99. doi: 10.1177/0141076819831872

Medethics-2020-106709 – see decision 23-July-2020

NIPT is the only ethical test

Abstract
Bunnik et al and Schmitz interchange about the public funding of NIPT surprisingly lacks consideration of Wilson’s and Jungner’s classic principles of screening as well as broader issues relating to women’s autonomy. In addition, overall healthcare costs must be considered no matter the system of their financing (public purse, private insurance or direct cost to families).

I have followed the interchange between Bunnik et al and Schmitz [1 – 3] because NIPT is a topic I have published on for 5 years now, most recently in English [4].
The most important reason for making NIPT publicly funded and for it to replace First Trimester Combined (FTC) in screening is that NIPT is a much better test than FTC [4]. According to the principles laid down by Wilson and Jungner in their classic essay [5], in this situation screening should be done with a test with as low a false negativity as possible so that the pregnant can truly trust the message that she does not carry a foetus with a genetic abnormality. NIPT misses far fewer cases than FTC and is a classic rule-out test.
Where it has been studied, the biggest unease with NIPT among pregnant women is the risk of sex-selection, that is that female foetuses are selectively aborted only because they are female [4, 6, 7]. Notwithstanding, Schmitz raises the spectre of “unease with NIPT causing discriminatory messages especially about Down’s syndrome and those being obviously distressing” [2]. Sometimes it feels like special interest groups have hijacked the debate at the expense of women’s autonomy [4].
The current Covid-19 pandemic has stressed the healthcare systems to breakpoint in most if not all countries affected and in some even beyond. The pandemic has not only meant that large resources has had to be put into Covid-19 but it has caused financial chaos with bankruptcies and reduced incomes. Companies are struggling to survive. We thus have a reduced tax base at the same time as tax money must be redirected to get the economy back on its feet. The reality which we live in is that there is a limit to what percentage of GDP but also absolute money a country can spend on health care. Before the pandemic most European countries spent 10 – 12 % of their GDP on health care with the USA as an outlier at 18 %, while 50 years ago it was only about 6 – 7 %. The absolute sums are probably more important than the percentages because certain costs, such as medicines and instruments, are becoming more and more uniform throughout the world.
Bunnik et al are correct in justifying “public funding of NIPT because it will save the public money” [3]. Three studies – one each from Mexico, South-Korea and the USA [4, 8, 9, 10] – confirm the substantial financial aspects of managing Down’s syndrome. In healthcare systems where the costs directly hit the families, they can be ruinous. In systems where the tax-payers defray this cost we can expect to find an increased resistance to such expenses. This attitude will have been exacerbated in the path of the current Covid-19 pandemic.
In short, in countries with limited resources or where costs of care fall on the individuals and their families, it is pressing to introduce fine rule-out tests.

References:
1. Bunnik EM, Kater-Kuipers A, Galjaard RH, de Beaufort ID. Should pregnant women be charged for non-invasive prenatal testing? Implications for reproductive autonomy and equal access. J Med Ethics. 2020 Mar; 46(3):194-8. doi: 10.1136/medethics-2019-105675.2019.

2. Schmitz D. Why public funding for non-invasive prenatal testing (NIPT) might still be wrong: a response to Bunnik and colleagues. J Med Ethics 2019; doi: 10.1136/medethics-2019-105885

3. Bunnik EM, Kater-Kuipers A, Galjaard RH, de Beaufort ID. Why NIPT should be publicly funded. J Med Ethics 2020; doi: 10.1136/medethics-2020-106218

4. Breimer LH. Non-invasive prenatal testing: Special interest groups vs women’s autonomy. Ind J Med Ethics 2020; Published online on June 20, 2020. DOI:10.20529/IJME.2020.069.

5. Wilson JMG, Jungner G. Principles and practice of screening for disease. Geneva: World Health Organization; Public Health Paper 34. 1968. Pp 163.

6. Vanstone M, Cernat A, Nisker J, Schwartz L. Women's perspectives on the ethical implications of non-invasive prenatal testing: a qualitative analysis to inform health policy decisions. BMC Med Ethics. 2018 Apr 16;19(1):27-39.

7. Hu T. Woman caught trying to smuggle 203 blood samples for baby gender tests into Hong Kong. South China Morning Post. 2017 Jul 28 [cited 2020 Jun 12]: Available from : https://www.scmp.com/news/china/society/article/2104458/woman-caught-try...

8. Park GW, Kim NE, Choi EK, Yang HJ, Won S, Lee YJ. Estimating nationwide prevalence of live births with Down syndrome and their medical expenditures in Korea. J Korean Med Sci 2019 aug 12[cited2020 May 12]; 34(31):e207. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6689486/

9. Martínez-Valverde S, Salinas-Escudero G, García-Delgado C, Garduño-Espinosa J, Morán-Barroso VF, Granados-García V, et al. Out-of-pocket expenditures and care time for children with Down syndrome: A single-hospital study in Mexico City. PLoS ONE. 2019 Jan 10 [cited 2020 May 12]; 14(1): e0208076. Available from: https://doi.org/10.1371/journal.pone.0208076

10. Kageleiry A, Samuelson D, Duh MS, Lefebvre P, Campbell J, Skotko BG. Out-of-pocket medical costs and third-party healthcare costs for children with Down syndrome. Am J Med Genet A. 2017 Mar; 173(3):627-37.

Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper. This work was written independently; no company or institution supported the author financially or by providing a professional writer.

Lars H Breimer, MA PhD, BM BCh, FRCPath, Dip Pharm Med
Örebro University Institution for Medical Sciences
School of Health and Medical Sciences
Dept of Laboratory Medicine, Clinical Chemistry division
Örebro University Hospital
SE-701 85 Örebro, Sweden
Tel: + 46 19 602 78 17 mobile: + 46 705 827 817
e-mail: lars.breimer@regionorebrolan.se