These articles relate to questions regarding allocation of scarce and necessary resources in the COVID19 pandemic. As the pandemic unfolds, so does the content on this website. Please share and visit often.
Physicians for Human Rights; October 30, 2020
This report, co-authored by Matthew Wynia, MD, MPH, concludes that political considerations must not be allowed to taint the process of ensuring the safety and efficacy – and subsequent equitable access to and distribution of – vaccines and therapeutics to prevent and mitigate harms from COVID-19. It will only be possible to successfully contain, prevent, and treat communicable diseases – or any public health challenge – if there is public confidence in the integrity and transparency of the scientific process. .
Recommended by Meleah Himber.
New York Times; April 22, 2020
LeRhonda S. Manigault-Bryant demands our attention. She describes the terrible reality of her mother’s painful dying and imminent death, a death that has everything and nothing to do with Covid-19. In an opinion piece for the New York Times with the heartbreaking title, “My Mother is Busy Getting Ready to Die,” she writes that her mother is a living example of what we already know about race, class, and suffering and that her mother’s body is the body of all black people at the bottom of the pandemic. Professor Manigault-Bryant has also produced a powerful video about her mother, titled Death. Everything. Nothing for Independent Shorts Awards. While both essay and film are challenging to sit with in these harsh times, it is our responsibility to bear witness.
Recommended by Tess Jones.
PLOS ONE; November 4, 2020
This article that uses a relatively novel approach to better understand public views of ethical issues in crisis triage. They use methods derived from experimental social psychology and find that Americans tend to favor triage protocols that prioritize the worst off, and that we are generally willing to accept some tradeoffs of utility and equity to help address disadvantages faced by communities of color. The findings are nuanced and will be of interest to those working on triage protocols, especially as we face new and worse surges of COVID-19 cases.
Recommended by Matthew Wynia and Christine Baugh.
American Journal of Bioethics; May 28, 2020
This clinical ethics perspective by Tia Powell and Elizabeth Chuang is from NYC’s COVID “round one” experience. If you believe, as I do, that we’re just in the second round of this challenge, it is important to share lessons learned. I took two important and underreported lessons from this essay related to broadening the duty to plan, to focus on more than cure. The first is the need for better standards for CPR – indications and exclusions. And the second is that palliative care resources were vital but, without planning, rapidly became overwhelmed. In a Research Letter published in JAMA on June 5, 2020, (doi:10.1001/jamainternmed.2020.2713) Jihae Lee reported that virtual conversations with palliative care specialists in the ED at the time of a COVID admission for very elderly patients decreased the number wanting “full code” status from 83% to 18%. Goals-of-care conversations are only one of many specialty services palliative care offers in achieving goal-concordant care during a pandemic and beyond.
Recommended by Jean Abbott.
Journal of the American Medical Association; June 12, 2020.
Donald Berwick who started out as a pediatrician, founded Health Partners in Boston, served as director of CMS, became a leader in the Patient Safety movement, founded the Institute for Healthcare Improvement (IHI) and has done many other good works in his long career. In this JAMA article he refers to Immanuel Kant's concept of the "moral heart" and writes about the moral imperative for health care workers and institutions to adopt a broad vision of their responsibilities and opportunities for improving the health of society. He talks about the "subway stop" phenomenon, something Robin Johnson called our attention to recently, namely, the importance of neighborhood or zip code in determining health status and longevity. He refers to our present very expensive model of health care metaphorically in the mold of a car repair shop industry when there is so much potential for prevention which is sadly short changed. He lays out several possible interventions that could have profound effects on the health status of our fellow residents. I'm hoping to stimulate our collective concern about the social determinants of health.
Recommended by Don Parsons.
New York State Bar Association; June 1, 2020.
When it comes to COVID-19, Arizona, Texas and Florida apparently learned nothing from New York City… or did they? This question is what makes this trenchant piece by Joseph Fins, MD, professor of medical ethics and chief of the Division of Medical Ethics at Weill Cornell Medical College, my pick for today even though it came out at the beginning of June. Fin writes, “Despite public declarations to the contrary, there was scarcity and resorting to crisis standards of care in New York City during the COVID-19 surge…History will show that there is absolutely no doubt usual standards of care became impossible during the crisis posed by the pandemic.” Yet New York never acknowledged that fact, and never provided sufficient guidance or protection for health care teams forced to make triage decisions. In Arizona however, the state Disaster Medical Advisory Committee unanimously recommended the declaration of crisis standards (providing guidance and legal protections for those forced into making triage decisions) on June 26th. The declaration now sits on the Governor’s desk. It’s an unspeakable tragedy that Arizona (and other states) couldn’t learn from New York how to avoid needing to resort to triage in the first place, but it’s not too late for Arizona to show they did learn that when triage is required, failing to acknowledge that fact doesn’t make it go away.
Recommended by Matthew Wynia.
Human Rights Council of the UN General Assembly; March 20, 2020.
A study on the impact of ableism in medical and scientific practice…The report contains recommendations to assist States to develop and implement legal and policy reforms oriented to embracing disability as part of human diversity, in line with the standards set forth in the Convention on the Rights of Persons with Disabilities. They include adopting measures to raise awareness, implementing rights-based prevention policies, respecting and protecting personal autonomy, the right to life and the right to personal integrity of persons with disabilities, and promoting their participation in decision-making, especially during the COVID-19 pandemic.
Annotation: from the Report Summary.
New England Journal of Medicine; May 19, 2020.
This NEJM perspective article underscores the ethical obligation of the healthcare system to honor commitments to equally and fairly value the lives of people with disabilities when planning for crisis standards of care and allotment of scarce resources. It explores problems with existing discriminatory codes in certain states such as Utah, Alabama, and Pennsylvania and how they have been challenged, revised and revoked in response to a need for clear and equitable triage guidelines around the COVID-19 pandemic, with a special emphasis on the ethical justification for including near term prognosis in triage scoring systems. It concludes with six practical guideposts that States and hospitals should consider when creating, reviewing or revising triage and crisis standards of care protocols.
Annotation: Meleah Himber.
New England Journal of Medicine; May 19, 2020.
This NEJM perspective article provides a timely analysis of the tension in crisis standards of care that seek to maximize lives saved and also protect the worth of all persons. The authors discuss the views of disability rights advocates who wish to challenge recently released critical care triage protocols. The authors provide an argument against the disabilities rights community's desire to have a first come, first served triage standard and offer ways to provide triage guidelines that do not unfairly discriminate against people with disabilities. The authors describe a fluid process that is transparent and open for community input and a requirement that research into the effects of the triage standards is essential. In addition to the value of saving the most lives and protecting the worth of all persons, the authors emphasize the importance of preserving integrity and trust and the ability of the community to heal in the wake of a once-in-a-century pandemic.
Annotation: Jackie Glover.
Hastings Center; April 29, 2020.
Useful document for regional collaboration safeguarding the health care workforce (such as equitable distribution of PPE to home care, nursing homes, hospice programs, etc.) and joint action to safeguard vulnerable populations in a region, as well as effective communications and patient care.
Annotation: Matthew Wynia.
University of Kentucky Program for Bioethics & The UK Healthcare Ethics Committee; March 19, 2020.
The UK Program for Bioethics Educational Resource on Pandemic Ethics summarizes the history of pandemic ethics and ethical issues and principles in a pandemic. This comprehensive, evidence-based resource could be a useful tool for decision-making and planning in the COVID-19 pandemic. It includes links to pandemic ethics plans for resource allocation from Arizona, Maryland, Michigan, Tennessee, and Utah, as well as ethical framework for pandemic preparedness that public health practitioners, researchers, and students, ethics consultants, healthcare workers, and policy makers may find useful.
Annotation: Angela Lee-Winn.
The Hastings Center; March 16, 2020.
This ethical framework and guidelines document represents the collaborative work of many ethicists who were brought together by the Hastings Center. It includes an excellent summary of the ethical issues when public health ethics is in tension with bedside clinical ethics; a discussion of three ethical duties (to plan, safeguard and guide); examples of institutional policies and processes; and selected resources. It is a go-to resource for ethics committees and consult services to help them prepare for this Pandemic.
Annotation: Jackie Glover
JAMA; March 12, 2020.
This JAMA Viewpoint article by two Emergency Medicine physicians outlines very practical ways to support the health care workforce during this Pandemic. It reviews guidelines for advancing safety including the widespread use of barrier precautions; processes particular to Emergency Departments; and decontamination processes. The review of obligations to health care worker's families is particularly valuable, as is the discussion of the obligation to support self-care efforts and transparent and thoughtful communication.
Annotation: Jackie Glover
NEJM; March 23, 2020.
A "perspectives" piece outlining the rationale for triage teams for allocation and re-allocation of ventilators and the justifications that do and do not work in a pandemic. Includes a suggested process for decision-making and for withdrawal of vent support. As an essay, the evidence review is not exhaustive, but it is a state-of-the-thinking compelling essay about an ethical approach.
Annotation: Jean Abbott
Chest: Contemporary Reviews in Critical Care Medicine; April, 2019.
Informed by public deliberative sessions and expert consultation, this article proposes a framework for the allocation of mechanical ventilation during disasters, including infectious pandemics. The framework for ventilator priority is founded on two main criteria: short term survival (based upon validated scoring systems) and survival at 12 months (based upon assessment of comorbid conditions). The latter criterion is meant to mitigate equity concerns that could arise regarding unfairly disadvantaging those who experience persistent health disparities, systematic disadvantage, and disability, among others. Additional exclusion criteria, adjustments for pregnancy, and "tie breaks" are also discussed. Unlike some systems, health care workers are not prioritized. A proposed structure for triage teams and appeals is also described. Major strengths of this paper include its empirical basis with an informed public and its explicit recognition of equity concerns. Limitations include its single geographic site (Maryland), the high likelihood that the scoring system will result in ties (a limitation the authors embrace), and because the deliberative sessions were held in 2012-2014, the possibility that public attitudes may have shifted.
Annotation: Matthew DeCamp
CDC; July, 2011.
This document presents recommendations of the Advisory Committee to the Director of the US Centers for Disease Control and Prevention (CDC), approved in 2011, that supplement a 2007 CDC document. The document describes several distinct domains, including the ethically-relevant distinction between routine and emergency practice, the contrast between allocation of vaccines/antiviral medicines (where the ethically relevant principle is preserving a functioning society) and allocation of ventilators (where the basic bioethics principles of respect for autonomy, beneficence and justice are cornerstones). Aspects of procedural justice, including public engagement, transparency, and accountability, are highlighted. The document also includes a comparison and contrast between the allocation goals of maximizing lives saved, maximizing years of life saved, social value, instrumental value, life cycle principles, and fair chances. A strength of the document is its comprehensive treatment of various ethical principles and concepts, which can be useful as a “primer” for those new to the field (or a “refresher” for others). A weakness of the document is that those looking for discrete guidance points will not find them here; as the authors acknowledge, the document is not intended to provide such recommendations but instead an overall framework of principles.
Annotation: Matthew DeCamp
Royal College of Physicians; March 31, 2020.
The Royal College of Physicians (UK) document refers to prior work under the auspices of NICE (National Institute for Health and Care Excellence) where more specific guidelines are available, for examples, a Clinical Frailty Scoring Algorithm, and a Critical Care Index. It outlines principles and practice guidelines for patient care, including withholding and withdrawing care, including all critical patients, not only COVID-19. Specifically, it also addresses the issues of health care front line personnel safety and speaks directly to the issue of physicians practicing outside of their specialty. This is an excellent resource but does not, by itself, establish triage scoring systems or the use of triage teams apart from the front line workers.
Annotation: Don Parsons
New York Times; March 23, 2020.
This NYT op-ed from a leading disability rights activist and scholar challenges some of the utilitarian perspectives that dominate approaches to triage ethics and crisis standards of care. The author argues that the long history of de-valuing disabled lives in the U.S. affects even triage determinations that reject "quality-of-life" approaches to allocating scarce resources in a public health emergency. The author advocates for nondiscrimination above all, suggesting a "first come first served" approach is ethically preferable to the utilitarian focus on "most lives saved," and is more consistent with the mandates of disability law.
Annotation: Daniel Goldberg
National Academy of Medicine; March 5, 2020.
This paper summarizes key principles and practices for implementing crisis standards of care (CSC) in healthcare settings to ensure fair and equitable decisions about the allocation of scarce medical resources during epidemics. The manuscript describes a menu of CSC strategies tailored to specific settings including outpatient, pre-hospital, emergency department, inpatient critical care, and alternate care facilities. Specific CSC planning strategies relevant to the COVID-19 pandemic are highlighted, including allocation of personal protective equipment, ventilators, and regional triage protocols. The authors stop short of recommending specific decision algorithms for the use of CSC strategies due to the importance of tailoring these strategies to local circumstances.
Annotation: Glen Mays
NEJM; March 23, 2020.
This commentary tackles some of the primary issues of scarcity and resource allocation during a public health emergency like COVID19. It focuses on questions of triage ethics, including access to mechanical ventilators, and highlights the key ethical appeals supporting various options for triaging access. It offers six specific recommendations for how a triage calculus should look, and considers several objections to those recommendations.
Annotation: Daniel Goldberg