Ethical Guidance for Hard Decisions: A Critical Review of Early International COVID-19 ICU Triage Guidelines

Abstract

This article provides a critical comparative analysis of the substantive and procedural values and ethical concepts articulated in guidelines for allocating scarce resources in the COVID-19 pandemic. We identified 21 local and national guidelines written in English, Spanish, German and French; applicable to specific and identifiable jurisdictions; and providing guidance to clinicians for decision making when allocating critical care resources during the COVID-19 pandemic. US guidelines were not included, as these had recently been reviewed elsewhere. Information was extracted from each guideline on: 1) the development process; 2) the presence and nature of ethical, medical and social criteria for allocating critical care resources; and 3) the membership of and decision-making procedure of any triage committees. Results of our analysis show the majority appealed primarily to consequentialist reasoning in making allocation decisions, tempered by a largely pluralistic approach to other substantive and procedural values and ethical concepts. Medical and social criteria included medical need, co-morbidities, prognosis, age, disability and other factors, with a focus on seemingly objective medical criteria. There was little or no guidance on how to reconcile competing criteria, and little attention to internal contradictions within individual guidelines. Our analysis reveals the challenges in developing sound ethical guidance for allocating scarce medical resources, highlighting problems in operationalising ethical concepts and principles, divergence between guidelines, unresolved contradictions within the same guideline, and use of naïve objectivism in employing widely used medical criteria for allocating ICU resources.

Public voices on tie-breaking criteria and underlying values in COVID-19 triage protocols to access critical care: a scoping review

“…The patient's prognosis depends not only on the acute disease (pandemic disease). It also depends on other acute, chronic, and mixed clinical criteria [23,69,119].…”

“…We found systematic reviews on the allocation of health resources during the in uenza pandemic and disaster situations, some containing public consultations [13,14,15,16]. There were also recent literature reviews related to the COVID-19 pandemic and prioritization protocols [17,18,19,20,21,22,23]. For example, a systematic review found 83 published protocols for the COVID-19 pandemic, as well as other pandemics.…”

“…It is important to note that some protocols for ICU access include both initial clinical criteria and tiebreaker criteria, the latter considered by some to be non-clinical, with underlying values [16,17,19,23,24]. Initial clinical criteria are core criteria that are used at the rst point of contact for patients requiring admission to the ICU.…”

“…For example, they consider the urgency and severity of the patient's illness, and the vital prognosis such as acute and chronic comorbidities or the probability of death for poor prognosis diseases or degenerative diseases, among other aspects. These primary prioritization criteria can be based on both standardized clinical scales or scores, without missing the clinical judgment of the physicians or the triage team [23,24,25]. In contrast, criteria considered tiebreakers or supplementary or non-clinical criteria, have been developed for secondary use in ICU admission decisions.…”

Monkeypox and the legacy of prejudice in targeted public health campaigns

“…In the context of targeted campaigns, both informative and persuasive functions raise ethical issues, although in varying degrees. Public health statements from the WHO are considered norm-setting advisories to governments around the world, and targeted campaigns, especially those that fulfil persuasive functions, must be carefully assessed as they may do more harm than good to marginalised sectors particularly with regards to issues of social justice and health equity 10…”