Allocating Scarce Healthcare Resources During The COVID-19 Pandemic

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This page contains links to existing guidance for allocation of scarce resources, especially ICU beds, during the COVID-19 pandemic.

AABHL has created this page to serve the Australasian bioethics, clinical and public health communities. The goal is to prevent duplication of effort, to maximise support for health services that do not have ready access to ethicists, and to encourage consistent, justifiable and legitimate decision-making across health services. We have especially prioritised locally-developed resources, and resources from well-respected bioethics centres and scholars around the world. Readers will note some variation in the recommendations in these documents. These are not official positions of AABHL.

The list was collated by Stacy Carter with participation from other members of AABHL. It has drawn on other such lists, including those developed by the Hastings Centre and the Nuffield Council on Bioethics. Nathan Emmerich (ANU) has created a Zotero library which anyone can access and which has some overlap with the list below. The University of Pittsburgh Centre for Bioethics and Health Law is keeping a list, as is Douglas MacKay from the University of North Carolina Center for Bioethics.

As more guidance is completed AABHL will endeavour to update rapidly.

If you are aware of, or have developed, relevant guidance that is not on this list—especially if from Australasia—please email admin@aabhl.org as soon as you can so we can keep the resource current as the pandemic develops.

Australasia

Sydney Health Ethics / Sydney Clinical Ethics Network statement on Resource Allocation during COVID-19 is now published on the Sydney Health Ethics webpage.

The NSW South Eastern Sydney Local Health District Clinical Ethics Committee will complete COVID-19 triage guidelines soon. Please contact Jackie Leach Scully for more information. 

Wendy Rogers and Stacy Carter prepared a discussion paper which is available at this link.

The Queensland Clinical Senate authored guidance which is now published by Queensland Health: Queensland ethical framework to guide clinical decision making in the COVID-19 pandemic.

Ruth Townsend and Michael Eburn have published guidance for Australasian paramedics.

Jackie Leach Scully has published on Disablism in a Time of Pandemic at the IJFAB blog.

Angela Ballantyne has published this reflection on the tension between utility and equity in allocation.

Planning for and managing COVID-19: Ethical decision-making tool Rosalind McDougall (Melbourne) and Linda Sheahan (Sydney) 

The Health Issues Centre held this Community Forum on COVID-19 Ethical Triage on April 2nd (Video)

Getting Through Together: Ethical Values for a Pandemic (NZ National Ethics Advisory Committee 2007, not COVID-specific)  

Towards an ethical response to COVID-19 in Malaysia (March 2020)

The Centre for Biomedical Ethics (National University of Singapore) is involved in development of Singaporean guidance – contact CBME for more information. 

Australian and New Zealand Intensive Care Society COVID-19 Guidelines 

Australasian College for Emergency Medicine Clinical Guidelines

European Union

Academy of Ethics in Medicine, Germany: Possibilities and limits of institutional ethics services in response to the COVID-19 pandemic 

Swiss Academies of Arts and Sciences and the Swiss Society for Intensive Care Medicine (SGI) Intensive care medicine: triage in case of bottlenecks

An English-language summary of the Swedish Guidelines for ICU priority setting in exceptional circumstances from Prof Christian Munthe.

Report on an ad-hoc public health ethics consultation from a group of EU ethicists led by Verina Wild published at the JME blog

United Kingdom

The Royal College of Physicians Committee on Ethical Issues in Medicine, chaired by Alexis Paton, has developed guidance for frontline staff, which is now supported by a large group of Royal Colleges and medical faculties.

NICE Critical Care Guidelines Supporting clinical decision making 

Nuffield Council: Responding to the COVID-19 pandemic – ethical considerations

Nuffield Council: Ongoing series of activities responding to COVID-19

British Medical Association: COVID-19 – ethical issues. A guidance note.

Daniel Sokol has published this updated guide and flowchart for COVID-19 Critical Care Admission

Daniel Sokol, with Benjamin Gray, has also published this opinion on the legality of prioritising healthcare workers in triage protocols in the BMJ.

Dominic Wilkinson has published this editorial in JME: Uncertainty, Pre-Emption and Preparation.

United States of America

The Pittsburgh Protocol is being adopted in many jurisdictions and facilities in the USA. University of Pittsburgh Department of Critical Care Medicine: Allocation of Scarce Critical Care Resources During a Public Health Emergency (see also: White DB, Lo B. A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic. JAMA. Published online March 27, 2020. doi:10.1001/jama.2020.5046 https://jamanetwork.com/journals/jama/fullarticle/2763953)

Lisa Rosenbaum. The Untold Toll – the pandemic’s effects on patients without COVID-19. NEJM April 17, 2020 DOI: 10.1056/NEJMms2009984

Hastings Centre: Katie Savin and Laura Guidry-Grimes on Confronting Disability Discrimination During the Pandemic

Hastings Centre: Ethical Framework for Health Care Institutions & Guidelines for Institutional Ethics Services Responding to the Coronavirus Pandemic

Hastings Centre COVID-19: Supporting Ethical Care and Responding to Moral Distress in a Public Health Emergency (Slide deck)

Institute of Medicine (2010). Crisis Standards of Care: Summary of a Workshop Series.

Harvard University Edmond J. Safra Center for Ethics Securing Justice, Health, and Democracy against the COVID-19 Threat 

Not about ICU triage, but an important reflection on the social structures that increase the risk of infection for those who already experience entrenched discrimination: an essay in Vice, Black Communities Need Support, Not a Coronavirus Police State by Robyn Maynard and Andrea J. Ritchie.

Washington State Department of Health/Northwest Healthcare Response Network Adult Critical Care Triage Algorithm March 2020

University of Pittsburgh Department of Critical Care Medicine: Allocation of Scarce Critical Care Resources During a Public Health Emergency (see also: White DB, Lo B. A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic. JAMA. Published online March 27, 2020. doi:10.1001/jama.2020.5046 https://jamanetwork.com/journals/jama/fullarticle/2763953)   

Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. NEJM 2020.

Daugherty Biddison EL, Faden R, Gwon HS, Mareiniss DP, Regenberg AC, Schoch-Spana M, et al. Too Many Patients: A Framework to Guide Statewide Allocation of Scarce Mechanical Ventilation During Disasters. Chest. 2019;155(4):848-54.

Americans With Disabilities Are Terrified: They fear they could be denied lifesaving treatment if they end up in the hospital with COVID-19. Essay by Elaine Godfrey in The Atlantic.

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