An evolving debate in healthcare is the allocation of limited resources in a crisis, and the theories around crisis standards of care (CSCs) have evolved over time. The COVID-19 pandemic and responses to it from the government and healthcare industry bring this issue to the forefront of ethics. People who are older, immunocompromised, and disabled are disproportionately impacted by healthcare crises, as seen in the current pandemic. These groups are more likely to be severely infected by SARS-CoV-2 and require hospitalization and intensive care. Furthermore, it is important to consider how standard care resource allocation is different from crisis standards of care. Ethical guidance for crisis standards of care must be “theoretically sound and practically useful” to build strategies for responding to crises (Leider et al., 2017). Some of the most prominent ethical concepts included in CSCs include ethical justifications of or need for guidance on CSCs, triage, international issues, duty to care, duty to plan, and utilitarianism (Leider et al., 2017).  

Triage is one of the most essential important parts of CSCs. It is employed in standard situations as well. For example, emergency departments in the U.S. function by deprioritizing patients for care, determining patients who may be past the point of requiring care and those that do not need medical attention immediately. These are quite controversial, especially in case of denying care for a patient whose situation is extremely deteriorated (Leider e al., 2017). However, in a crisis triage, there may be too many people for the current system. Jecker and colleagues state “During pandemic triage, more people are likely to survive with a scarce lifesaving resource and die without it than can be helped” (Jecker et al., 2022).  

One proposed method to triage patients is by prioritizing saving life years. Instead of attempting to save the most lives, this method would focus on save the most years of life total. However, this may lead to care being denied for older people and focus on prioritizing younger folks. It is controversial to conflate age with life expectancy (Jecker et al., 2022). The concept of “repeat triage” asks health providers to continually reassess the situation at hand which could potentially lead to change of resource distribution (Leider et al, 2017). Conversely, earlier in the COVID-19 pandemic, health professionals raised concern for how children should be considered in CSCs. While children were less likely to have severe disease, children with certain chronic illnesses or other conditions would be unfairly treated by this oversight (Laventhal et al, 2020). It is still debated how a resource allocation system should consider children, especially in the situations of neonates or extremely young children who may have lesser chances of survival.  

CSCs must also address scarcity of resources and staffing in the situation of a disaster. In an ideal world, healthcare providers can adequately serve each patient while also supporting public health. Different CSCs may have varying scopes on practice and allocations which will have important ethical principles (Leider et al., 2017). Inclusivity and transparency are central to the development of CSCs as healthcare systems must not exacerbate already existing health inequities (Laventhal et al., 2020).  

Ultimately, these ethical frameworks that policymakers, community leaders and other parties use to respond to healthcare crises must be morally sound and practical in a clinical setting. Planning before a crisis is essential, and hospital systems must be proactive to explore potential demands for care, especially for populations that are often neglected or exploited in times of crisis.  

References 

Jecker NS. Too old to save? COVID-19 and age-based allocation of lifesaving medical care [published online ahead of print, 2022 May 9]. Bioethics. 2022;10.1111/bioe.13041. doi:10.1111/bioe.13041 

Laventhal N, Basak R, Dell ML, et al. The Ethics of Creating a Resource Allocation Strategy During the COVID-19 Pandemic. Pediatrics. 2020;146(1):e20201243. doi:10.1542/peds.2020-1243 

Leider JP, DeBruin D, Reynolds N, Koch A, Seaberg J. Ethical Guidance for Disaster Response, Specifically Around Crisis Standards of Care: A Systematic Review. Am J Public Health. 2017;107(9):e1-e9. doi:10.2105/AJPH.2017.303882