The University of California Crisis Standards of Care: Public Reasoning for Socially Responsible Medicine

Ethical prioritization of critical care resources during COVID-19: perspectives from Italy and the United States

This article examines some of the ethical challenges of prioritizing intensive care resources during the Covid-19 pandemic by comparing the Italian and United States contexts. After presenting an overview to the clinical, ethical, and public debates in Italy, the article will discuss the development of triage allocation protocols in United States hospitals. Resource allocation criteria underwent increased scrutiny and critique in both countries, which resulted in modified professional and expert guidance regarding healthcare ethics during times of emergency and resource scarcity.

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

Background

To reduce the arbitrariness in the allocation of rare resources in intensive care units (ICU) in the context of the pandemic, tiebreakers were considered in some COVID-19 triage algorithms. They were also contemplated to facilitate the tragic decisions of healthcare workers when faced with two patients with similar prognosis and only one ICU bed available. Little is known about the public's perspective on tiebreakers.

Objectives

To consolidate the available scientific literature on public consultations, particularly on tiebreakers and their underlying values. Also, to obtain an overview of the key arguments presented by the participating public and to identify potential gaps related to this topic.

Methods

The steps described by Arksey and O'Malley was the preferred method to our approach. Seven electronic databases were searched from January 2020 to April 2022, using keywords for each database: PubMed, Medline, EMBASE, Web of Science, PsycINFO, EBM reviews, CINAHL complete. We also searched in Google and Google Scholar, and in the references of the articles found. Our analysis was mainly qualitative. A thematic analysis was performed to consider the public's perspectives on tiebreakers and their underlying values, according to these studies.

Results

Of 477 publications found, 20 were selected. They carried out public consultations through various methods: surveys (80%), interviews (20%), deliberative processes (15%) and others (5%) in various countries: Australia, Brazil, Canada, China, France, Germany, India, Iran, Italy, Japan, Korea, Netherlands, Portugal, Spain, Switzerland, Thailand, United Kingdom, and United States. Five themes emerged from our analysis. The public favored the life cycle (50%) and absolute age (45%) as a tiebreaker. Other values considered important were reciprocity, solidarity, equality, instrumental value, patient merit, efficiency, and stewardship. Among the new findings were a preference for patient nationality and those affected by COVID-19.

Conclusions

There is a preference for favoring younger patients over older patients when there is a tie between similar patients, with a slight tendency to favor intergenerational equity. Variability was found in the public's perspectives on tiebreakers and their values. This variability was related to socio-cultural and religious factors. More studies are needed to understand the public's perspective on tiebreakers.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44250-023-00027-9.

The Ethics of Implementing Emergency Resource Allocation Protocols

AbstractWe explore the various ethical challenges that arise during the practical implementation of an emergency resource allocation protocol. We argue that to implement an allocation plan in a crisis, a hospital system must complete five tasks: (1) formulate a set of general principles for allocation, (2) apply those principles to the disease at hand to create a concrete protocol, (3) collect the data required to apply the protocol, (4) construct a system to implement triage decisions with those data, and (5) create a system for managing the consequences of implementing the protocol, including the effects on those who must carry out the plan, the medical staff, and the general public. Here we illustrate the complexities of each task and provide tentative solutions, by describing the experiences of the Coronavirus Ethics Response Group, an interdisciplinary team formed to address the ethical issues in pandemic resource planning at the University of Rochester Medical Center. While the plan was never put into operation, the process of preparing for emergency implementation exposed ethical issues that require attention.

Avoiding Crisis Conditions in the Healthcare Infrastructure: 2 Case Studies in Statewide Collaboration

In fall 2020, COVID-19 infections accelerated across the United States. For many states, a surge in COVID-19 cases meant planning for the allocation of scarce resources. Crisis standards of care planning focuses on maintaining high-quality clinical care amid extreme operating conditions. One of the primary goals of crisis standards of care planning is to use all preventive measures available to avoid reaching crisis conditions and the complex triage decisionmaking involved therein. Strategies to stay out of crisis must respond to the actual experience of people on the frontlines, or the "ground truth," to ensure efforts to increase critical care bed numbers and augment staff, equipment, supplies, and medications to provide an effective response to a public health emergency. Successful management of a surge event where healthcare needs exceed capacity requires coordinated strategies for scarce resource allocation. In this article, we examine the ground truth challenges encountered in response efforts during the fall surge of 2020 for 2 states-Nebraska and California-and the strategies each state used to enable healthcare facilities to stay out of crisis standards of care. Through these 2 cases, we identify key tools deployed to reduce surge and barriers to coordinated statewide support of the healthcare infrastructure. Finally, we offer considerations for operationalizing key tools to alleviate surge and recommendations for stronger statewide coordination in future public health emergencies.

Structural Inequities, Fair Opportunity, and the Allocation of Scarce ICU Resources

The September-October 2021 issue of the Hastings Center Report highlights the important topic of allocating scarce critical care resources during the Covid-19 pandemic. The article by Alex Rajczi and colleagues urges that policy-makers use public reasoning, not private reasoning, when developing triage policies. We completely agree. We show how the allocation framework we developed as private scholars, the "Pittsburgh framework," has been supported by public reasoning. The article by MaryKatherine Gaurke and colleagues criticizes rationing based on maximizing life-years saved and mistakenly claims that our framework recommended this approach. We explain that our framework never contained such a criterion but instead included a more limited consideration of near-term prognosis. In December 2020, in response to emerging data and important criticisms, we modified our framework to further strengthen equity. We are committed to improving allocation guidelines during crisis standards of care through reflective discussions and debates.

Centering Social Justice for Covid-19 Resources and Research

In the September-October 2021 issue of the Hastings Center Report, neither the article by MaryKatherine Gaurke et al. nor the article by Alex Rajczi et al. offers a comprehensive analysis of a just allocation of scarce resources-one "rooted in a collective agreement about what constitutes health in/justice." This omission reflects a larger problem in bioethics: the field's praxis continues to fail to recognize and respond to the obligation to address the fair distribution of burdens and benefits that comes with the principle of justice. This commentary calls on bioethics to incorporate a community-based participatory research (CBPR) framework as part of its praxis. The cocreation of crisis standards of care with community stakeholders, whether the standards were focused on treatments, vaccines, or novel community-engagement strategies, could set a new gold standard for the practice of social justice in research.