Perin and De Panfilis BMC Med Ethics (2021) 22:36 https://doi.org/10.1186/s12910-021-00603-9

RESEARCH ARTICLE

Among equity and dignity: an argument-based review of European ethical guidelines under COVID-19Marta Perin1,2* and Ludovica De Panfilis1

Abstract

Background: Under COVID-19 pandemic, many organizations developed guidelines to deal with the ethical aspects of resources allocation. This study describes the results of an argument-based review of ethical guidelines developed at the European level. It aims to increase knowledge and awareness about the moral relevance of the outbreak, espe-cially as regards the balance of equity and dignity in clinical practice and patient’s care.

Method: According to the argument-based review framework, we started our research from the following two questions: what are the ethical principles adopted by the ethical guidelines produced at the beginning of the COVID-19 outbreak related to resource allocation? And what are the practical consequences in terms of ’priority’ of access, access criteria, management of the decision-making process and patient care?

Results: Twenty-two ethical guidelines met our inclusion criteria and the results of our analysis are organized into 4 ethical concepts and related arguments: the equity principle and emerging ethical theories; triage criteria; respecting patient’s dignity, and decision making and quality of care.

Conclusion: Further studies can investigate the practical consequences of the application of the guidelines described, in terms of quality of care and health care professionals’ moral distress.

Keywords: COVID-19 pandemic, Allocation of Health Care Resources, Human Dignity, Ethics

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BackgroundAfter the spread of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the related COronaVIrus Disease 2019 (COVID-19), many national health care systems had to deal with a dramatic re-organ-ization of services. At the beginning of the outbreak, COVID-19 positive patients with severe illness required highly specialized care, such as mechanical ventilation and extracorporeal membrane oxygenation, which were not readily available or not applicable to a significant number of cases [1–3]. Moreover, the scarce availability

of intensive care unit (ICU) beds is common all over the word [4]. It forces health care professionals and health care organizations to continuously balance the principle of patient-centered care, the focus of clinical ethics under normal conditions, and that of public-focused duty to promote equality of persons, which is the focus of public health ethics [5]. More than usual, the spread of Covid-19 highlighted this difficult balancing.

In a short time, the hardest-hit countries, China, USA, Italy and Spain [3, 4] had to deal with issues of alloca-tion of scarce resource. Rationing intensive care beds or specialized services has clinical and ethical implications. The “decision about initiating or terminating mechanical intervention is often truly a life-or-death choice” [7], even if, in the case of Covid-19, data have shown uncertainty

Open Access

*Correspondence: marta.perin@ausl.re.it1 Bioethics Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, ItalyFull list of author information is available at the end of the article

Page 2 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

regarding the efficacy of mechanical ventilation as the outbreak has progressed [8]. However, the allocation of intensive care treatments remains crucial.

The central question regards how to establish a fair resource allocation and how to guarantee that the deci-sions are made “ethically and consistently, rather than based on individual institution’s approaches or a clini-cian’s institution in the heat of the moment” [9].

Resource allocation is a crucial ethical issue because it most fundamentally involves questions of justice. The identification and definition of an equal distribution of resources, opportunities and outcomes among the popu-lation represent a concern for national governments and health care facilities. Due to the nature of the pandemic itself, this ethical issue reached a global dimension.

According to the World Health Organization (WHO) [9], developing guidelines on the allocation of scarce resources in outbreak situations require governments, health-care facilities and other involved in such effort to consider the tension between the principles of util-ity (allocating resources to maximize benefit and mini-mize burdens) and equity (fair distribution of benefit and burdens); the definition of utility; the needs of vul-nerable populations; the fulfillment of reciprocity-based obligations and the provision of supportive and pallia-tive care. The principle of equity in access to health care plays a central role in fair allocation: it “must be upheld, because it lays down in the respect for human dignity and human right framework” (namely, Article 3 of the Oviedo Convention and article 14 of the Unesco Declaration on Bioethics and Human rights, 2005) even in a context of scarce resources [10, 11].

There are multiple ethically permissible approaches to allocating scarce life-sustaining resources, but these theories yield conflicting definitions. For instance, utili-tarianism focuses on the maximization of benefit, while egalitarianism focuses on equality of opportunity and need [12].

With COVID-19, health departments, local and national clinical ethics committees, and scientific socie-ties had urgently developed new (or have revised exist-ing) ethical guidelines or ethical recommendations, identifying which criteria should be used to ethically allo-cate scarce resources and what process should be used to fairly implement allocation decisions [13].

Because the public will bear the consequences of these decisions, knowledge of perspectives and moral points of reference on these issues is critical [14]: unjustified vari-ation could exacerbate structural inequalities, squander valuable resources and undermine public health [13, 14], as demonstrated by the debates about exclusion criteria and discrimination against age and disability that have already arisen in Italy and in the USA [15].

It can be useful to understand and compare the various ethical perspectives involved in ethical guidelines devel-oped during COVID-19 through a full set of published rea-sons for or against the view in question, which is the central scope of an argument-based review [16].

This study describes the results of an argument-based review of the ethical guidelines developed at the European level to face the health care emergency at the beginning of COVID-19 pandemic.

We analyzed the underpinnings and ethical concepts, as well as their practical consequences, with the aim of increasing knowledge and awareness related to the ethical meanings of the outbreak.

MethodsThe argument-based review represents one of the different methods for systematic reviews developed in the field of bioethics, and it aims to present an up-to-date comprehen-sive overview of the ethical arguments and underpinning concepts identified in relation to a certain topic [16–18]. This approach is particularly suitable for our study because it led the researchers to acquire evidence for decision-mak-ing in the delivery of healthcare, development of policy, and conduct of medical research [18].

To grasp the underpinnings of ethical theories, their principles and related practical consequences regarding the ethical aspect of allocation resources, we performed the argument-based systematic review of ethical guidelines fol-lowing the model developed by McCullough et al. [16, 17].

We first articulated our research questions into two rel-evant conceptual ethical questions; then, we performed a literature search, and finally, we identified, described and analyzed the ethical arguments in connection with the con-ceptual-ethical questions.

Research questionsTo understand how European countries dealt with the ethi-cal allocation of scarce health resources at the beginning of the COVID-19 pandemic, we developed the following research questions:

a. What are the ethical principles adopted by the ethical guidelines produced at the beginning of COVID-19 outbreak, related to resource allocation?

b. What are the practical consequences in terms of ’pri-ority’ of access, access criteria, management of the decision-making process and patient care?

Literature searchArticles were selected based on the following prede-termined eligibility criteria for their relevance to our research question:

Page 3 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

a. they must be guidelines or recommendation policies;b. they must be published between March and May

2020;c. they must be developed in response to the COVID-

19 health emergency;d. they have been developed by institutions suitable to

formulate such guidelines (such as local or National Ethical Committees, Health Ministerial Depart-ments, and Scientific Societies);

e. they explicitly deal with the allocation of resource according to an ethical framework;

f. they have been written in English or have been trans-lated in English.

We excluded scientific articles, editorials, book chap-ters and position papers. Finally, we included further publications using the snowball sampling method and gray literature research. Due to the characteristics of the search literature, we used the following resources: national ethics committee websites, scientific society websites, international organization’s websites, collecting specific ethical resources on COVID-19 (see Additional file 1—Appendix 1).

Data extraction and synthesisWe performed a qualitative analysis, adapting the Quali-tative Analysis Guide of Leuven—QUAGOL [19]. It offers a comprehensive, systematic but not rigid method to guide the process of qualitative data analysis. Its charac-teristics lie in the iterative process of digging deeper, con-stantly moving between the various stages of the process [19].

MP and LDP identified the eligible ethical guidelines. They read each document entirely the first time to have an overview of the topics and relevant arguments; after-wards, they read the documents a second time, focus-ing specifically on: (a) the ethical framework described and (b) the section describing the allocation of scarce resources.

MP collected the relevant information of each docu-ment into a conceptual scheme. It is a synthetic frame where different and relevant concepts are presented and integrated with each others to answer the research ques-tions [18, 19]. Each conceptual scheme highlights the relationships between the ethical framework described in the guideline, the allocation resources argumentation and their practical consequences in clinical practice and decision making process (an example of a conceptual scheme is provided as Additional file 2: Appendix 2). The schemes’ adequateness was checked by LDP.

Successively, MP unified all the schemes into a sin-gle table (Table  1) to create an overview and provide a comprehensive answer to our research questions.

LDP overviewed the process. The table describes the responses to our research questions reporting the ethi-cal principles (question 1) and practical consequences (question 2). We specified the relationships between ethical principles and practical consequences in terms of ’priority’ of access, access criteria, management of the decision-making process and the emerging patient’s care (question 2).

The documents’ full texts, their relative conceptual schemes, and the final table were iteratively evaluated and checked against previous QUAGOL steps to ensure that they were consistent.

Finally, MP and LDP synthesized a description of the results to be presented in the Results section.

ResultsWe collected 42 ethical guidelines, and their characteris-tics are described in Table 2.

The most represented are UK (7 published ethical guidelines), France (6 published guidelines) and Spain (4 published guideline), followed by Switzerland, Germany (3 published guidelines) and Italy (2 ethical guidelines). The majority of the ethical guidelines was published by Scientific Society (21 ethical guidelines) and National Ethic Committees (16 ethical guidelines). 14 ethi-cal guidelines were published in English and 10 ethical guidelines present the English translations and could be included in our analysis. We then excluded an ethical guideline because it presented an updated version.

Finally, twenty-two ethical guidelines met our inclusion criteria and were analyzed by argument-based analysis (as reported in Table 1).

As a result of the analysis and synthesis of the 22 individual guidelines, we ultimately identified the fol-lowing ethical concepts and their related arguments, as described in Table 3:

1. Equity principle and emerging ethical theories.2. Triage criteria.3. Respecting patient dignity.4. Decision making and quality of care.

Equity principle and the emerging ethical theoriesThe analysis of the ethical guidelines highlights the cen-tral role of equity principle showing different meanings based on its theoretical relationship with three main ethi-cal theories: egalitarianism, utilitarianism, and ethics of care.

The egalitarian approach: equity and non‑discriminationInspired by the egalitarian approach, 14 ethical guide-lines balance the principle of equity intended as equal

Page 4 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

Tabl

e 1

Ethi

cal g

uide

lines

’ arg

umen

t-ba

sed

anal

ysis

: the

fina

l con

cept

ual s

chem

e

Coun

try

Gui

delin

es’ T

itle

Ethi

cal p

rinci

ples

(q

uest

ion

1)Pr

iorit

y of

acc

ess

(que

stio

n 2)

Acc

ess

crite

ria

(que

stio

n 2)

Un-

ethi

cal a

cces

s ci

riter

ia (q

uest

ion

2)D

ecis

ion

mak

ing

proc

ess

(que

stio

n2)

Patie

nt’s

care

app

roac

h (q

uest

ion

2)

Aus

tria

Man

agem

ent o

f sc

arce

reso

urce

in

hea

lthca

re in

th

e co

ntex

t of

the

COVI

D-1

9 pa

ndem

ic

4 et

hica

l prin

cipl

es;

Equi

tyeq

ualit

y

Bett

er p

rogn

osis

Chr

onic

sho

rt-t

erm

di

seas

esSu

rviv

al p

roba

bilit

ySe

verit

y of

the

dise

ase

Stat

us o

f oth

er p

revi

-ou

s pa

thol

ogie

sPh

ysic

al c

ondi

tions

Scor

e sy

stem

Age

Soci

al s

tatu

sPe

rson

al re

latio

nshi

ps

with

dec

isio

n m

aker

s

Ethi

cs s

uppo

rt s

ervi

ce/

ethi

cal c

onsu

ltatio

n se

rvic

es

Prom

otin

g A

dvan

ce

care

pla

nnin

g (A

CP)

Redu

cing

to th

e m

ini-

mum

the

dam

ages

/su

fferin

gs re

sulti

ng

from

the

trea

tmen

t, bo

th fo

r the

pat

ient

an

d fo

r the

sta

ffO

fferin

g th

e be

st,

thou

gh n

ot o

ptim

al,

care

for t

he p

atie

nt

and

palli

ativ

e ca

re

whe

n is

not

pos

sibl

e to

trea

tA

pply

a fa

ir de

cisi

on

mak

ing

Ass

ista

nce

to a

ll pe

ople

w

ithou

t dis

tinct

ions

ba

sed

on n

on-m

edic

al

crite

riaPr

ovid

e th

ose

who

nee

d it

with

mor

e re

sour

ces

to b

e ab

le to

exe

rcis

e th

eir r

ight

s (e

.g. p

hysi

-ca

l or m

enta

l/cog

ni-

tive

impa

irmen

t)

Belg

ium

Ethi

cal p

rinci

ples

con

-ce

rnin

g pr

opor

tion-

ality

of c

ritic

al c

are

durin

g th

e CO

VID

-19

pand

emic

: adv

ice

by

the

Belg

ian

Soci

ety

of IC

med

icin

e

Avo

id d

ispr

opor

tion-

ate

trea

tmen

tap

ply

the

tria

ge c

rite-

ria fa

irly

Prio

rity

to u

rgen

cies

App

ly ‘fi

rst c

ome,

firs

t se

rved

’ app

roac

h to

th

ose

with

the

sam

e ur

genc

y

Patie

nt’s

Adv

ance

D

irect

ives

Pres

ence

of f

ragi

lity/

com

orbi

dity

Clin

ical

Fra

ilty

Scor

eCo

gniti

ve d

isor

ders

in

elde

rly p

atie

nts

Term

inal

onc

holo

gica

l di

seas

esPr

esen

ce o

f sev

ere

chro

nic

co-m

orbi

d-iti

es

Age

Team

dis

cuss

ion

Tran

spar

ency

and

ev

alua

tion

of d

eci-

sion

s (u

sing

a tr

iage

de

cisi

ons

regi

ster

)Ps

ycho

logi

cal a

nd

ethi

cal s

uppo

rt fo

r pr

ofes

sion

als

Prom

otin

g A

CP

App

lyin

g tr

iage

crit

eria

to

all

patie

nts

Cons

ider

age

with

oth

er

clin

ical

par

amet

ers

(frag

ility

and

cog

nitiv

e ab

ility

)

Page 5 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

Tabl

e 1

(con

tinue

d)

Coun

try

Gui

delin

es’ T

itle

Ethi

cal p

rinci

ples

(q

uest

ion

1)Pr

iorit

y of

acc

ess

(que

stio

n 2)

Acc

ess

crite

ria

(que

stio

n 2)

Un-

ethi

cal a

cces

s ci

riter

ia (q

uest

ion

2)D

ecis

ion

mak

ing

proc

ess

(que

stio

n2)

Patie

nt’s

care

app

roac

h (q

uest

ion

2)

Coun

cil o

f Eur

ope

COM

MIT

TEE

ON

BI

OET

HIC

S (D

H-B

IO)

DH

-BIO

Sta

tem

ent

on h

uman

righ

ts

cons

ider

atio

ns re

l-ev

ant t

o th

e CO

VID

-19

pan

dem

ic

Resp

ect f

or h

uman

di

gnity

and

hum

an

right

App

ly th

e pr

inci

ple

of

equi

ty o

f acc

ess

to

heal

th c

are

syst

emCo

nsid

erin

g hu

man

rig

ht in

the

field

of

med

icin

e (O

vied

o Co

nven

tion)

Solid

arity

and

resp

on-

sibi

lity

Med

ical

crit

eria

Prot

ectio

n of

the

mos

t vul

nera

ble

peop

le (p

erso

ns w

ith

disa

bilit

ies,

olde

r pe

rson

s, re

fuge

es

and

mig

rant

s)

The

acce

ss to

exi

stin

g re

sour

ces

shou

ld b

e gu

ided

by

med

ical

cri-

teria

, to

ensu

re n

amel

y th

at v

ulne

rabi

litie

s do

no

t lea

d to

dis

crim

ina-

tion

in th

e ac

cess

to

heal

thca

re

Esto

nia

Reco

mm

enda

tions

on

clin

ical

eth

ics

for

Esto

nian

hos

pita

ls

for d

istr

ibut

ion

of

limite

d he

alth

car

e re

sour

ces

durin

g th

e CO

VID

-19

pand

emic

Equa

l tre

atm

ent

4 pr

inci

ples

of m

edic

al

ethi

csA

void

the

grea

ter

dam

age

and

pro-

mot

e th

e m

axim

um

bene

fitho

nest

and

tran

spar

-en

t dis

trib

utio

n of

lim

ited

reso

urce

s

Prog

nosi

s re

gard

ing

the

trea

tmen

t’s

succ

ess

The

patie

nt’s

futu

re

qual

ity o

f life

The

curr

ent p

atie

nt’s

clin

ical

sta

tus

Pres

ence

of c

omor

-bi

ditie

sTh

e ge

nera

l pat

ient

’s he

alth

-rel

ated

sta

tus

Pres

ence

of o

ther

re

leva

nt in

dica

tors

re

late

d to

pro

gnos

isPa

tient

’s w

illeff

ectiv

enes

s of

med

i-ca

l ser

vice

s

Age

Gen

der

Ethn

icity

Soci

al s

tatu

s

Add

ition

al re

sour

ces

(psy

chol

ogis

ts,

cons

ulta

nts..

)

Trea

t all

patie

nts

equa

llySa

ve a

s m

any

lives

as

poss

ible

equa

l dis

trib

utio

n of

ex

istin

g re

sour

ces

ensu

re th

at th

e pr

otec

-tio

n of

hea

lth w

orke

rs

beco

mes

incr

easi

ngly

es

sent

ial

EGE

Stat

emen

t on

Euro

-pe

an S

olid

arity

and

th

e Pr

otec

tion

of

Fund

amen

tal R

ight

s in

the

COVI

D-1

9 Pa

ndem

ic

Der

ogat

ions

of h

uman

rig

hts,

albe

it in

the

inte

rest

s of

the

publ

ic

good

, mus

t be

tem

-po

rary

, and

crit

ical

ly.

Ther

e m

ust b

e cl

ear,

tran

spar

ent c

riter

ia

Fran

ce C

OVI

D-1

9 Co

ntri-

butio

n fro

m th

e Fr

ench

Nat

iona

l Co

nsul

tativ

e Et

hics

Co

mm

ittee

. Eth

ical

is

sues

in th

e fa

ce o

f a

pand

emic

Resp

ect f

or th

e di

gnity

of

the

pers

onPr

inci

ple

of e

quity

defin

ition

of p

riorit

ies

requ

ires

crite

ria

whi

ch a

re a

lway

s qu

estio

nabl

e

Uni

t of e

thic

s su

ppor

t fo

r hea

lth c

are

prof

essi

onal

s

Prov

ide

assi

stan

ce

base

d on

the

patie

nt’s

need

sG

uara

ntee

con

tinui

ty o

f ca

re fo

r oth

er p

atie

nts

who

do

not a

cced

e to

in

tens

ive

trea

tmen

ts

Page 6 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

Tabl

e 1

(con

tinue

d)

Coun

try

Gui

delin

es’ T

itle

Ethi

cal p

rinci

ples

(q

uest

ion

1)Pr

iorit

y of

acc

ess

(que

stio

n 2)

Acc

ess

crite

ria

(que

stio

n 2)

Un-

ethi

cal a

cces

s ci

riter

ia (q

uest

ion

2)D

ecis

ion

mak

ing

proc

ess

(que

stio

n2)

Patie

nt’s

care

app

roac

h (q

uest

ion

2)

Ger

man

ySo

lidar

ity a

nd R

espo

n-si

bilit

y du

ring

the

Coro

navi

rus

Cris

is

Dig

nity

Abs

olut

e va

lue

of li

feCo

nstit

utio

nal p

rin-

cipl

es

The

law

doe

s no

t id

entif

y an

y cr

iteria

by

whi

ch to

iden

tify

the

patie

nts

to b

e de

nied

the

trea

t-m

ent

Gen

der

Ethn

icity

Age

Soci

al ro

le, v

alue

or

pres

umed

life

-spa

n

Cons

ider

atio

ns

rega

rdin

g al

loca

tion

reso

urce

s sh

ould

be

wei

ghte

d, ju

stifi

ed,

tran

spar

ent,

and

crite

ria s

houl

d be

ap

plie

d un

iform

ly

Equa

l acc

ess

for a

ll to

he

alth

car

eTh

e st

ate

mus

t ref

rain

fro

m n

orm

s w

ith

whi

ch li

ves

are

cate

goriz

ed o

n th

e ba

sis

of g

ende

r/et

h-ni

city

/age

/soc

ial r

ole/

pres

umed

val

ue o

r du

ratio

n of

life

;Th

e m

easu

res

requ

ired

to s

ave

as m

any

lives

as

pos

sibl

e m

ust n

ot

go b

eyon

d th

e co

n-st

itutio

nal f

ram

ewor

k an

d th

e sa

fegu

ard

of

the

lega

l sys

tem

mus

t be

con

side

red.

Irela

ndEt

hica

l Fra

mew

ork

for

Dec

isio

n-M

akin

g in

a

Pand

emic

Fairn

ess,

min

imis

ing

harm

, sol

idar

ity a

nd

reci

proc

ity

Patie

nts

with

a

grea

ter c

hanc

e of

be

nefit

ting

from

the

inte

rven

tion;

Som

e gr

oups

at r

isk

and

thos

e es

sent

ial

for t

he m

anag

emen

t of

a p

ande

mic

Patie

nt’s

heal

th s

tatu

s be

fore

the

viru

sPa

tient

’s w

illPr

esen

ce o

f com

or-

bidi

ties

Frai

lty (r

egar

dles

s of

ag

e)Es

timat

ion

onto

tal n

umbe

r of l

ives

sa

ved;

tota

l life

yea

rs

save

dho

w lo

ng p

atie

nts

coul

d liv

e in

the

long

te

rm

Age

Soci

al s

tatu

sSo

cial

val

ueEt

hnic

ityG

ende

r

Reas

onab

lene

ssO

penn

ess

and

Tran

s-pa

renc

yIn

cusi

vene

ssRe

spon

sive

ness

Acc

ount

abili

ty

Max

imiz

e th

e be

nefit

s ob

tain

ed w

ith s

carc

e re

sour

ces

Dis

trib

ute

bene

fits

and

risks

equ

ally

thro

ugh

a m

ulti-

prin

cipl

ed

appr

oach

Italy

Clin

ical

Eth

ics

Rec-

com

enda

tions

fo

r the

Allo

ca-

tion

of In

tens

ive

Care

Tre

atm

ents

in

Exc

eptio

na,

reso

urce

-lim

ited

circ

umst

ance

s

Clin

ical

app

ropr

iate

-ne

ss a

ndPr

opor

tiona

lity

of c

are;

Dis

trib

utiv

e ju

stic

e an

dA

ppro

pria

te a

lloca

tion

of re

sour

ces

Age

thre

shol

d: p

riorit

y fo

r tho

se p

atie

nts

who

are

mos

t lik

ely

to s

urvi

vean

d w

ho’ll

hav

e se

vera

l yea

rs o

f life

sa

ved

Pres

ence

of c

omor

-bi

ditie

sEv

alua

tion

of p

atie

nt’s

func

tiona

l sta

tus

Pres

ence

of p

atie

nt’s

Adv

ance

Dire

ctiv

es

or A

dvan

ce C

are

Plan

ning

‘Inap

prop

riate

ness

’ is

just

ified

by

the

extr

aord

inar

y na

ture

of

the

situ

atio

n

Shar

ed d

ecis

ion

mak

-in

g pr

oces

s am

ong

mul

tiple

clin

icia

nsU

se a

idea

l lis

t of

patie

nts

Dai

ly re

asse

ssm

ent o

f ap

prop

riate

ness

/ca

re o

bjec

tives

/pro

-po

rtio

nalit

ySu

ppor

t to

heal

th c

are

prof

essi

onal

s

Max

imiz

ing

bene

fits

for

mos

t peo

ple

Palli

ativ

e ca

re (a

lso

seda

tion)

Eval

uatio

n of

the

situ

a-tio

n’s

impl

icat

ions

on

fam

ily m

embe

rs

Page 7 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

Tabl

e 1

(con

tinue

d)

Coun

try

Gui

delin

es’ T

itle

Ethi

cal p

rinci

ples

(q

uest

ion

1)Pr

iorit

y of

acc

ess

(que

stio

n 2)

Acc

ess

crite

ria

(que

stio

n 2)

Un-

ethi

cal a

cces

s ci

riter

ia (q

uest

ion

2)D

ecis

ion

mak

ing

proc

ess

(que

stio

n2)

Patie

nt’s

care

app

roac

h (q

uest

ion

2)

Repu

blic

of S

an M

arin

oSt

atem

ent o

n et

hica

l is

sues

rega

rdin

g to

th

e us

e of

inva

sive

as

sist

ed v

entil

atio

n in

pat

ient

s a

ll ag

e w

ith s

erio

us d

is-

abili

ties

in re

latio

n to

Co

vid-

19 p

ande

mic

Resp

ect f

or h

uman

di

gnity

and

hum

an

right

sEq

ualit

y an

d no

n-di

scrim

inat

ion

(due

to

dis

abili

ty)

Equa

l opp

ortu

nitie

s to

ac

cess

Clin

ical

app

ropr

iate

-ne

ssPr

opor

tiona

lity

of c

are

Age

,G

ende

rSo

cial

sta

tus,

ethn

icity

, di

sabi

lity

The

only

par

amet

er fo

r th

e al

loca

tion

deci

-si

ons

cons

ists

in a

co

rrec

t app

licat

ion

of th

e tr

iage

whi

ch is

ba

sed

on:

(a) t

he re

spec

t for

eve

ry

hum

an li

fe(b

) crit

eria

of c

linic

al

appr

opria

tene

ss a

nd

prop

ortio

nalit

y of

the

trea

tmen

ts

Port

ugal

CN

ECV

stat

emen

t: Co

vid-

19 k

ey c

onsi

d-er

atio

n

Valu

e of

life

, dig

nity

an

d in

tegr

ity o

f in

divi

dual

sPr

inci

ple

of n

eces

sity

Prin

cipl

e of

sol

idar

ity

The

eval

uatio

n of

the

clin

ical

crit

eria

and

th

e te

chni

cal a

nd

scie

ntifi

c re

com

-m

enda

tions

mus

t be

acc

ompa

nied

by

a c

aref

ul e

thic

al

refle

ctio

n ba

sed

on

the

case

stu

dies

Perm

anen

t sup

port

fro

m th

e m

embe

rs

of th

e lo

cal e

thic

s co

mm

ittee

s to

hel

p pr

ofes

sion

als

in th

e de

cisi

on-m

akin

g pr

oces

s

Prot

ect t

he h

ealth

of

each

citi

zen

Miti

gate

asy

mm

etrie

s an

d in

equa

litie

s

Pub

lic h

ealth

em

er-

genc

y si

tuat

ion

due

to th

e CO

VID

-19

pan

dem

ic

- Rel

evan

t eth

ical

as

pect

s

Prin

cipl

e of

nec

essi

tyPr

ecau

tiona

ry p

rinci

ple

Prop

ortio

nalit

y pr

in-

cipl

eTr

ansp

aren

cySo

lidar

itySu

bsid

iarit

y

Med

ical

crit

eria

Eval

uatio

n of

the

resp

ectiv

e cl

inic

al

crite

ria, i

nclu

ding

th

e te

chni

cal a

nd

scie

ntifi

c re

com

men

-da

tions

issu

ed b

y th

e he

alth

aut

horit

ies,

prof

essi

onal

bod

ies

and

scie

ntifi

c so

cie-

ties

Supp

ort f

or d

ecis

ion-

mak

ing

thro

ugh

mem

bers

of t

he

heal

th in

stitu

tion

not d

irect

ly in

volv

ed

in in

tens

ive

care

(h

ospi

tal e

thic

s co

m-

mitt

ees)

Prin

cipl

e of

dec

isio

n-m

akin

g pr

oces

s:re

ason

able

ness

, tra

ns-

pare

ncy,

incl

usio

n,

reac

tivity

and

inst

itu-

tiona

l res

pons

ibili

ty

Dec

isio

ns re

gard

ing

the

allo

catio

n re

sour

ces

are

base

d on

med

ical

cr

iteria

whi

ch is

bas

ed

on s

olid

eth

ical

prin

ci-

ples

(pro

port

iona

lity,

re

cipr

ocity

, equ

ity,

trus

t and

sol

idar

ity);

care

ful e

thic

al c

onsi

d-er

atio

n is

requ

ired

on

a ca

se-b

y-ca

se b

asis

Page 8 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

Tabl

e 1

(con

tinue

d)

Coun

try

Gui

delin

es’ T

itle

Ethi

cal p

rinci

ples

(q

uest

ion

1)Pr

iorit

y of

acc

ess

(que

stio

n 2)

Acc

ess

crite

ria

(que

stio

n 2)

Un-

ethi

cal a

cces

s ci

riter

ia (q

uest

ion

2)D

ecis

ion

mak

ing

proc

ess

(que

stio

n2)

Patie

nt’s

care

app

roac

h (q

uest

ion

2)

Spai

nRe

port

of t

he M

inis

try

of H

ealth

on

ethi

cal

aspe

cts

in p

ande

mic

si

tuat

ions

: SA

RS-

CoV-

2

Equi

ty a

nd n

on d

is-

crim

inat

ion

Solid

arity

Just

ice

Prop

ortio

nalit

yTr

ansp

aren

cy

A h

iera

rchy

of

prio

ritie

s m

ust b

e es

tabl

ishe

dG

ravi

ty o

f the

pat

ient

’s co

nditi

onO

bjec

tive

expe

cta-

tions

on

the

patie

nt’s

shor

t-te

rm re

cove

ry

to h

is p

revi

ous

stat

e of

hea

lthD

ate

of a

rriv

al (n

ot a

s th

e on

ly c

riter

ion)

Exis

tenc

e or

abs

ence

of

ser

ious

con

com

i-ta

nt p

atho

logi

es th

at

wou

ld in

dica

te a

fa

tal p

rogn

osis

(suc

h as

a te

rmin

al d

isea

se

with

a p

rogn

osis

of

irre

vers

ibili

ty o

r irr

ever

sibl

e co

ma)

, ev

en if

this

cou

ld

lead

to fu

rthe

r clin

i-ca

l ass

ista

nce

Age

Dis

abili

tyVu

lner

able

chi

ldre

n

It is

reco

mm

ende

d th

at g

uide

lines

ar

e re

ques

ted

and

rece

ived

, for

exa

m-

ple,

by

the

hosp

ital’s

et

hics

and

hea

lth

com

mitt

ee, w

ithin

th

e tim

e av

aila

ble

Prio

ritie

s’defi

nitio

n w

ill

be b

ased

on

obje

c-tiv

e, g

ener

aliz

able

, tr

ansp

aren

t, pu

blic

an

d co

nsen

sus-

base

d cr

iteria

, des

pite

the

poss

ibili

ty o

f eva

luat

-in

g th

e un

ique

and

in

divi

dual

cha

ract

er-

istic

s of

eac

h pe

rson

w

ho h

as c

ontr

acte

d th

e vi

rus

The

max

imum

ben

efit

in s

avin

g liv

es, w

hich

m

ust b

e m

ade

com

patib

le w

ith th

e co

ntin

uatio

n of

the

trea

tmen

t sta

rted

w

ith e

ach

indi

vidu

al

patie

nt)

Cons

ider

alte

rnat

ive

trea

tmen

ts to

inva

sive

m

echa

nica

l ven

tilat

ion

prov

ided

in in

tens

ive

care

, eve

n in

cas

es

whe

re th

is d

oes

not

seem

to b

e in

dica

ted

Switz

erla

ndPa

ndem

ic C

ovid

-19:

tr

iage

of i

nten

sive

ca

re tr

eatm

ents

in

case

of s

carc

ity o

f re

sour

ces

Indi

catio

ns

for t

he im

plem

enta

-tio

n of

cha

pter

9.3

of

the

dire

ctiv

es o

f th

e A

SSM

"Mea

sure

s of

inte

nsiv

e ca

re"

(201

3), u

pdat

ed

vers

ion

of M

arch

24,

20

20

4 Pr

inci

ples

of m

edic

al

ethi

cseq

uity

Save

as

man

y lif

es a

s po

ssib

lePr

otec

tion

of th

e he

alth

car

e pr

ofes

-si

onal

s in

volv

ed

Patie

nts

who

can

be

nefit

mos

t fro

m

the

hosp

italiz

atio

nIt

also

indi

rect

ly

incl

udes

the

patie

nt’s

age

(eve

n if

is n

ot c

onsi

dere

d as

a v

alid

crit

erio

n its

elf)

The

patie

nt’s

age

≪ fi

rst p

rinci

ple

such

as

, firs

t ser

ved ≫

, pri-

ority

to p

eopl

e w

ithA

hig

h so

cial

val

ue e

tc

Early

iden

tifica

tion

of

patie

nts’

wis

hes

If IC

U tr

eatm

ents

are

de

nied

, ade

quat

e pa

lliat

ive

care

mus

t be

ensu

red

Det

erm

inin

g cr

iterio

n fo

r tria

ge a

nd s

hort

-te

rm p

rogn

osis

Furt

her c

riter

ia s

uch

as fi

rst c

ome,

firs

t se

rved

and

, prio

rity

to

pers

ons

with

A h

igh

soci

al v

alue

etc

. sh

ould

be

avoi

ded

Page 9 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

Tabl

e 1

(con

tinue

d)

Coun

try

Gui

delin

es’ T

itle

Ethi

cal p

rinci

ples

(q

uest

ion

1)Pr

iorit

y of

acc

ess

(que

stio

n 2)

Acc

ess

crite

ria

(que

stio

n 2)

Un-

ethi

cal a

cces

s ci

riter

ia (q

uest

ion

2)D

ecis

ion

mak

ing

proc

ess

(que

stio

n2)

Patie

nt’s

care

app

roac

h (q

uest

ion

2)

The

Hol

y Se

e P

ande

mic

and

uni

-ve

rsal

Bro

ther

hood

: N

ote

on th

e Co

vid-

19 e

mer

genc

y

Equa

l val

ue o

f hum

an

life

and

the

dign

ity

of th

e pe

rson

(the

y ar

e al

way

s th

e sa

me

and

pric

eles

s)Ju

stic

e

Patie

nt’s

need

patie

nt’s

prog

nosi

sTh

e se

verit

y of

pa

tient

’s ill

ness

and

hi

s ne

ed fo

r tre

at-

men

tTh

e ev

alua

tion

of th

e cl

inic

al b

enefi

ts

obta

ined

by

the

trea

tmen

t, in

term

s of

pro

gnos

is

Age

can

not b

e ta

ken

as a

sin

gle

and

auto

mat

ic c

hoic

e cr

iterio

n

The

allo

catio

n cr

iteria

sh

ould

be

shar

ed

and

reas

onab

ly

foun

ded,

to a

void

ar

bitr

arin

ess

or

impr

ovis

atio

n in

em

erge

ncy

situ

a-tio

ns

Prov

ide

trea

tmen

ts in

th

e be

st p

ossi

ble

way

ba

sed

on th

e pa

tient

’s ne

eds

The

sick

per

son

shou

ld

be n

ever

aba

ndon

ed,

even

whe

n th

ere

are

no m

ore

trea

tmen

ts

avai

labl

e: p

allia

tive

care

, pai

n tr

eatm

ent

and

acco

mpa

nim

ent

shou

ld n

ever

be

over

look

ed

UN

ESCO

Inte

rnat

iona

l Bi

oeth

ics

Com

mitt

ee

(IBC

)and

theU

NES

CO

Wor

ld C

omm

issi

on

on th

e Et

hics

of

Scie

ntifi

c Kn

owle

dge

and

Tech

nolo

gy

(CO

MES

T)

Sta

tem

ent o

n CO

VID

-19

: Eth

ical

con

-si

dera

tions

from

a

glob

al p

ersp

ectiv

e

Prin

cipl

e of

just

ice,

be

nefic

ence

Equi

tyRe

spec

t for

hum

an

dign

ityH

uman

righ

ts fr

ame-

wor

k re

cogn

ize

the

prot

ectio

n of

hea

lth

as a

righ

t of e

ach

hum

an b

eing

right

to h

ealth

can

be

guar

ante

ed o

nly

by

our d

uty

to h

ealth

Reco

gniti

on o

f a

colle

ctiv

e re

spon

-si

bilit

ies

for t

he

prot

ectio

n of

vul

ner-

able

per

sons

and

the

need

to a

void

any

fo

rm o

f stig

mat

iza-

tion

and

disc

rimin

a-tio

n

Proc

edur

es n

eed

to b

e tr

ansp

aren

t an

d sh

ould

resp

ect

hum

an d

igni

ty

The

high

est a

ttai

nabl

e st

anda

rd o

f hea

lth is

a

fund

amen

tal r

ight

of

ever

y hu

man

bei

ng,

whi

ch m

eans

the

acce

ss to

the

high

est

avai

labl

e he

alth

care

UK

Gui

danc

e: R

espo

ndin

g to

CO

VID

-19:

the

ethi

cal f

ram

ewor

k fo

r ad

ult s

ocia

l car

e

Resp

ect

Reas

onab

less

Min

imis

ing

harm

Incl

usiv

enes

sFl

exib

ility

Prop

ortio

nalit

yCo

mm

unty

Just

ifica

tion

of th

e de

cisi

on-m

akin

g pr

oces

s, co

nsid

erin

g al

tern

ativ

e co

urse

s of

act

ion,

cle

ar,

tran

spar

ent d

ecis

ion-

mak

ing

proc

ess

Be tr

ansp

aren

t abo

ut

why

cer

tain

dec

i-si

ons

are

mad

e

Patie

nt’s

info

rmed

co

nsen

tM

inim

ize

ineq

ualit

ies

Ethi

cal c

onsi

dera

tions

in

resp

ondi

ng to

the

COVI

D-1

9 pa

ndem

ic

Prop

ortio

nalit

y, In

ter-

vent

on’s

effec

tive-

ness

and

nec

essi

tyFa

ir an

d re

spec

tful

tr

eatm

ent

Solid

arie

ty

All

the

peop

le s

houl

d be

trea

ted

as m

oral

eq

uals

, wor

thy

of

resp

ect

Inte

rven

tions

sho

uld

be

evid

ence

-bas

ed a

nd

prop

ortio

nate

Peop

le s

houl

d be

tr

eate

d as

mor

al

equa

ls, w

orth

y of

re

spec

t

Page 10 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

Tabl

e 1

(con

tinue

d)

Coun

try

Gui

delin

es’ T

itle

Ethi

cal p

rinci

ples

(q

uest

ion

1)Pr

iorit

y of

acc

ess

(que

stio

n 2)

Acc

ess

crite

ria

(que

stio

n 2)

Un-

ethi

cal a

cces

s ci

riter

ia (q

uest

ion

2)D

ecis

ion

mak

ing

proc

ess

(que

stio

n2)

Patie

nt’s

care

app

roac

h (q

uest

ion

2)

COVI

D-1

9—et

hica

l is

sues

. A g

uida

nce

note

max

imis

ing

the

over

all

redu

ctio

n of

mor

tal-

ity a

nd m

orbi

dity

Nee

d to

mai

ntai

n vi

tal

soci

al fu

nctio

ns

Clin

ical

ly re

leva

nt e

le-

men

ts a

bout

eac

h pa

tient

Patie

nt’s

poss

ibili

ties

to b

enefi

ting

From

ava

ilabl

e re

sour

ces

(you

nger

pa

tient

s w

ill n

ot

auto

mat

ical

ly h

ave

prio

rity

over

old

er

ones

)

The

pres

ence

of

com

orbi

ditie

sD

ecis

ions

rega

rdin

g tr

eatm

ents

of t

hose

w

ho la

ck d

ecis

ion-

mak

ing

capa

city

sh

ould

be

mad

e in

th

e sa

me

way

as

all

the

othe

rsPa

tient

s re

quiri

ng

trea

tmen

tIt

wou

ld n

ot b

e et

hica

lap

ply

thes

e lim

its

in h

ealth

car

e ac

cess

diff

eren

tly

to p

atie

nts

with

or

with

out a

ppoi

nted

or

sur

roga

te d

ecis

ion

mak

ers,

or th

ose

with

or

with

out p

artic

ular

re

ligio

us o

pini

ons

The

deci

sion

mak

ing

proc

ess

shou

ld b

e ba

sed

on th

e be

st

avai

labl

e cl

inic

al

data

and

opi

nion

s; co

nsis

tent

with

eth

i-ca

l prin

cipl

es a

nd

reas

onin

gA

gree

d in

adv

ance

w

here

pos

sibl

e,

whi

le re

cogn

izin

g th

at d

ecis

ions

may

ne

ed to

be

mad

e qu

ickl

yRe

vise

d in

cha

ngin

g ci

rcum

stan

ces

as fa

r as

poss

ible

co

here

nt b

etw

een

Diff

eren

t pro

fes-

sion

als

Com

mun

icat

ed

open

ly a

nd tr

ansp

ar-

ently

Subj

ecte

d to

cha

nge

and

revi

ew a

s th

e si

tuat

ion

deve

lops

Prov

ide

adeq

uate

sup

-po

rt, i

nclu

ding

sup

-po

rt fr

om th

e cl

inic

al

ethi

cs c

omm

ittee

an

d ps

ycho

logi

sts

to

heal

th c

are

prof

es-

sion

als

Prio

ritis

atio

n po

licie

s:Re

fuse

som

eone

pot

en-

tially

life

-sav

ing

trea

t-m

ent w

here

som

eone

el

se is

exp

ecte

d to

be

nefit

mor

e fro

m th

e av

aila

ble

trea

tmen

tN

o au

tom

atic

prio

rity

Patie

nts

who

se tr

eat-

men

t is

susp

ende

d or

with

draw

n m

ust

rece

ive

com

pas-

sion

ate

care

and

de

dica

ted

med

ical

as

sist

ance

Page 11 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

Tabl

e 1

(con

tinue

d)

Coun

try

Gui

delin

es’ T

itle

Ethi

cal p

rinci

ples

(q

uest

ion

1)Pr

iorit

y of

acc

ess

(que

stio

n 2)

Acc

ess

crite

ria

(que

stio

n 2)

Un-

ethi

cal a

cces

s ci

riter

ia (q

uest

ion

2)D

ecis

ion

mak

ing

proc

ess

(que

stio

n2)

Patie

nt’s

care

app

roac

h (q

uest

ion

2)

Ethi

cal d

imen

sion

of

COVI

D-1

9 fo

r fro

nt-

line

staff

Ensu

ring

fair

and

equi

tabl

e ca

reCa

ring

for C

OVI

D-1

9 an

d no

n-CO

VID

-19

patie

nts

Ther

e w

ill b

e so

me

patie

nts

(with

or

with

out c

onfir

med

CO

VID

-19)

for w

hom

ad

mis

sion

to IC

U

wou

ld b

e in

appr

o-pr

iate

(pro

port

ion-

ality

)

Ass

essm

ent a

nd

prio

ritis

atio

n de

ci-

sion

s ar

e ca

rrie

d ou

t by

mor

e th

an o

ne

clin

icia

n co

lleag

ue

(mul

tidis

cipl

inar

y te

am)

Trea

tmen

t sho

uld

be

prov

ided

, ind

epen

-de

ntly

of t

he in

di-

vidu

al’s

back

grou

nd

(e.g

. dis

abili

ty),

whe

re

it is

con

side

red

that

it

will

hel

p th

e pa

tient

su

rviv

e an

d no

t har

m

thei

r lon

g-te

rm h

ealth

an

d w

ellb

eing

.M

any

front

-line

sta

ff w

ill

alre

ady

be c

arin

g fo

r pa

tient

s fo

r who

m

any

esca

latio

n of

ca

re, r

egar

dles

s of

the

curr

ent p

ande

mic

, w

ould

be

inap

pro-

pria

te, a

nd m

ust b

e pr

oper

ly m

anag

ed. A

ll fro

nt-li

ne s

taff

shou

ld

have

dis

cuss

ions

w

ith th

ose

rele

vant

pa

tient

s fo

r who

m a

n ad

vanc

e ca

re p

lan

is

appr

opria

te

Page 12 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

Tabl

e 1

(con

tinue

d)

Coun

try

Gui

delin

es’ T

itle

Ethi

cal p

rinci

ples

(q

uest

ion

1)Pr

iorit

y of

acc

ess

(que

stio

n 2)

Acc

ess

crite

ria

(que

stio

n 2)

Un-

ethi

cal a

cces

s ci

riter

ia (q

uest

ion

2)D

ecis

ion

mak

ing

proc

ess

(que

stio

n2)

Patie

nt’s

care

app

roac

h (q

uest

ion

2)

Covi

d-19

Gui

danc

e:

Ethi

cal A

dvic

e an

d Su

ppor

t Fra

mew

ork

Resp

ect

Fairn

ess

Min

imis

ing

harm

Wor

king

togh

ethe

rFl

exib

ility

Reci

proc

ityCa

paci

ty a

nd c

onse

nt

Whe

re th

ere

is a

dec

i-si

on th

at a

trea

tmen

t is

not

clin

ical

ly

appr

opria

te th

ere

is

not a

n ob

ligat

ion

to

prov

ide

itN

o ac

tive

step

s sh

ould

be

take

n to

sho

rten

or

end

the

life

of a

n in

divi

dual

, how

ever

th

e ap

prop

riate

cl

inic

al d

ecis

ion

may

be

to w

ithdr

aw li

fe

prol

ongi

ng o

r life

su

stai

ning

trea

tmen

t

Clin

icia

ns s

houl

d ac

t w

ith h

ones

ty a

nd

inte

grity

in th

eir

com

mun

icat

ion

with

pa

tient

s an

d sh

ould

co

mm

unic

ate

clin

i-ca

l dec

isio

ns a

nd th

e re

ason

ing

behi

nd

them

tran

spar

-en

tly. T

his

shou

ld

be d

ocum

ente

d ap

prop

riate

lyEt

hica

l adv

ice

and

supp

ort g

roup

s w

ill

be e

stab

lishe

d as

a

prio

rity.

Ther

e m

ust b

e im

med

iate

acc

ess

to

ethi

cal a

dvic

e if

this

oc

curs

, to

offer

an

inde

pend

ent v

iew

an

d su

ppor

t in

dif-

ficul

t circ

umst

ance

s

All

patie

nts

shou

ld b

e off

ered

goo

d qu

ality

an

d co

mpa

ssio

nate

ca

rePa

tient

s sh

ould

be

trea

ted

as in

divi

dual

s, an

d no

t dis

crim

inat

ed.

Whe

re th

ere

are

reso

urce

con

stra

ints

, pa

tient

s sh

ould

re

ceiv

e th

e be

st

care

pos

sibl

e, w

hile

re

cogn

isin

g th

at th

ere

may

be

a co

mpe

t-in

g ob

ligat

ion

to th

e w

ider

pop

ulat

ion

Coro

navi

rus:

Your

fre

quen

tly a

sked

qu

estio

ns

Reac

t res

pons

ibly

and

re

ason

ably

to th

e ci

rcum

stan

ces

Take

acc

ount

of

curr

ent l

ocal

and

na

tiona

l pol

icie

s th

at s

et o

ut a

gree

d cr

iteria

for a

cces

s to

tr

eatm

ent

Take

acc

ount

of

patie

nt w

ishe

s an

d ex

pect

atio

ns

Be c

onfid

ent t

hat d

eci-

sion

s ar

e ba

sed

on

clin

ical

nee

d an

d th

e lik

ely

effec

tiven

ess

of

trea

tmen

ts

Don

’t un

fairl

y di

s-cr

imin

ate

agai

nst

part

icul

ar g

roup

s

Be o

pen

and

hone

st

with

pat

ient

s an

d th

e re

st o

f the

he

alth

care

team

ab

out t

he d

ecis

ion-

mak

ing

proc

ess

and

the

crite

ria fo

r se

ttin

g pr

iorit

ies

in

indi

vidu

al c

ases

.Ke

ep a

reco

rdD

iscu

ssio

n w

ith

colle

ague

s an

d, if

po

ssib

le, w

ith in

put

from

loca

l eth

ics

com

mitt

ees.

Reco

gnis

e th

e si

g-ni

fican

t em

otio

nal

dist

ress

Prov

ide

the

best

ser

vice

po

ssib

le w

ithin

the

reso

urce

s av

aila

ble.

Whe

re d

ecis

ions

are

m

ade

to w

ithho

ld

or w

ithdr

aw s

ome

form

s of

trea

tmen

t fro

m p

atie

nts,

doc-

tors

sho

uld

still

take

al

l pos

sibl

e st

eps

to

alle

viat

e th

e pa

tient

’s sy

mpt

oms

and

dis-

tres

s an

d re

spec

t the

ir di

gnity

Page 13 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

treatment for equal needs with the principle of equality, that is equal treatment regardless of needs. The guide-lines describe equality in terms of the respect for the absolute value of life and dignity of the person, as defined by the human rights framework [10, 11, 20–27]. As a result of this approach, triage criteria should be applied to every patient without discrimination or distinction among COVID and non-COVID patients [10, 11, 24–26, 28–31]. Following this perspective, some guidelines apply the “first come, first served” approach to choose between patients with the same urgency and needs [29, 30], even if it cannot be considered as the only criterion for alloca-tion resources.

The utilitarian approach: equity and the best use of resources10 guidelines balance the principle of equity with the principle of utility, which requires first to identify the type of outcomes that will be counted as improve-ments to the greatest common benefit. Utility princi-ple is widely described as maximizing the benefits from scarce resources for the greatest number of people. It also consists of the “best value use” of resources [32–34] by reducing mortality and incrementing benefits in the soci-ety [5, 35–38]. Following the utilitarian approach, the total number of lives saved [32], the number of years of life saved [36] or the total number of years saved in rela-tion to the quality of life and the capacity of the patient to benefit from the treatment are crucial aspects [30, 32–34, 37, 39]. The Italian ethical guidelines developed by the Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) highlight that the “extraor-dinary nature of the situation” can justify the clinicians’ judgment about the inappropriate access of a patient to intensive treatment, namely to the pursuit of the great-est common benefit [36]. The Estonian ethical guidelines developed by the University of Tartu underlines that the

Table 2 Published guidelines characteristics

Characteristics Number of published ethical guidelines

Country

Austria 1

Belgium 1

Estonia 1

France 6

Finland 1

Germany 3

Greece 1

Ireland 1

Italy 2

Luxembourg 1

Norway 1

R. of San Marino 1

Portugal 2

slovenia 1

Spain 4

Sweden 1

Switzerland 3

The Holy See 1

UK 7

International organization 3

Published by

Scientific Society (professionals) 21

National Ethics Committee 16

Department of Health 2

International European institution 3

Language

Just national language 18

National language and English translation 10

Just English 14

Table 3 Identification of the ethical concept, their related arguments and the reference’ s guideline

Ethical Concepts Related Arguments Guidelines

Equity principle and emerging ethical theories The egalitarian approach: equity and non discrimination 10, 11, 20–31

The utilitarian approach: equity and the best use of resources

5, 30, 32–39

The relationship between the equity principle and the Ethics of care framework

21, 22, 24, 25, 26, 27–31, 33, 34, 37–39

Triage criteria Quantitative health-related triage criteria 28–30, 32, 33, 35–37, 39

Patient-related clinical judgment and ‘questionable criteria’ 10, 21, 22, 24–28, 30, 31, 33, 38

Ethically unacceptable criteria and controversial application 11, 22, 24, 26, 28–30, 32, 33, 35, 39

Respecting Patient dignity Palliative care 11, 24, 26, 28, 30, 33–37

Considering patient’s will and wishes 28, 29, 32–36

Individualized patient’s care 10, 11, 21, 25, 26, 27, 28, 31–32, 34, 36, 38

Decision making and quality of care Ethical aspect of communication and triage management 11, 22, 25, 26, 34, 36–39

Need of ethical support 21, 25, 28–30, 32, 34, 36, 37

Page 14 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

patient-centered approach should be replaced with the community-centered approach. Consequently, physicians are not obliged to provide intensive care to a patient with a negative prognosis if that care is needed for the treat-ment of a patient with a better prognosis [32].

The relationship between equity principle and the ethics of care framework15 guidelines balance the Beauchamp and Childress’ four principles of medical ethics [25, 27, 31–33], proportion-ality and appropriateness of care [24, 38, 39], and the health care professional’s responsibility to care [34]. The emerging meaning of equity in allocation resources lies in the concept of decisions taken “case by case”, without automatisms or criteria according to which the sick per-son would be excluded based on belonging to a category established a priori [22, 37] and providing assistance based on the needs of the individual patient, the realis-tic goal of care and the will of the individual concerned [21, 24–26, 28, 38]. This approach can be related to the ethics of care theoretical framework. It recognizes the value of each personal experience but also that human beings are interdependent [40, 41]. According to ethics of care, every moral choice or ethical issue is conceived as inserted in the relationship of care [42].

Triage criteriaTo apply the allocation resources in a practical situation, the guidelines identify a set of “triage criteria”, which identify who and how patients should access or be pri-oritized to intensive care. The most favorable progno-sis is widely considered the main criterion to prioritize patients.[43] According with the equity principle dis-cussed above, this criterion is defined by 2 different approaches: quantitative health-related triage criteria and patient-related clinical judgment.

Quantitative health‑related triage criteriaThe ethical guidelines here described define the most favorable prognosis in the patient’s expected treatment outcomes in terms of duration and quality of life after intensive treatment [32, 33, 35, 37, 39]. The presence of life-short chronic diseases, severe comorbidities and the disease severity are also central criteria for non admis-sion to ICU, and they are usually assessed by score sys-tem tools (e.g., the Clinical Frailty Score) [28–30, 32, 33, 35–37].

Some guidelines include age as a possible criterion. For example, two guidelines specify that triage criteria should also be based on the appraisal of the total number of lives saved, life years saved and patient’s years of life [35, 36]. One guideline specifies the possibility to introduce an age threshold to a patient’s access to intensive care due to the

extraordinary situation [36], while others specify that age cannot be considered as a criterion in itself but in rela-tion to the current clinical evaluation [29, 33].

Following this approach and the quantity of life-related criteria, some guidelines define those categories of peo-ple who do not access treatment: the terminally ill [29], those who do not consent to treatments through Advance Directives [29, 32, 35, 36] or Advance Care Planning [28, 29, 33], and patients with specific clinical diagnoses, such as dementia or cognitive impairments [29]. In this regard, other guidelines specify that the lack of ability to give consent and disability should not be considered a discriminatory factor to access to treatment [28]. One guideline specifies that priority should be a guarantee to a specific group, namely, people at risk and people with essential responsibilities and roles in the pandemic man-agement, due to the principle of reciprocity [35].

The majority of guidelines do not expressly distinguish between withholding and withdrawing treatments. How-ever, according to two guidelines, the physician has the right to withdraw the ICU resources from a patient with a negative prognosis if they are needed for the treatment of a patient with a better prognosis [32, 37]. This prac-tice is linked with the regular assessment of patients: in facts daily re-evaluation of ICU patients is required by all the guidelines to determine whether criteria to undergo intensive treatment are still met.

Patient‑related clinical judgment and “questionable criteria”A number of ethical guidelines do not apply specific health-related clinical triage criteria but adopts a more general patient-related clinical judgment [10, 21, 24–27, 30, 31, 38]. In particular, the guideline developed by the French national Consultative Ethics Committee openly affirms that criteria are always questionable [21], and the German Ethics Committee affirms that any criteria should not overcome the human rights framework [22]. Following this approach, the triage criteria are defined by a case-by-case assessment of the patient’s clinical condi-tion [25] and should take into consideration the urgency, the severity of comorbidity, the proportionality and appropriateness of the invasive treatments, and the treat-ment’s prognostic efficacy in terms of probable healing [24–26, 28–30]. Timely identification of disproportionate care is also required [29], and there is not an obligation to provide treatment which is not clinically appropriate [38]. In this regard, futility, proportionality or dispro-portionate care emerged among the ethical guidelines as criteria for withholding treatments and redirecting the therapeutic goal towards palliative care, only when ICU treatments are considered no more beneficial for the patient him/herself.

Page 15 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

Moreover the health care professionals’ duty of care, which is linked to the ethics of solidarity between them and members of society [44], is also considered a rel-evant aspect to apply triage criteria in such a situation. Ethical guidelines underline clinicians’ responsibility to timely inform patients and their families about triage cri-teria and, principally, the responsibility to promote a dis-cussion about the patient’s access to intensive care with timely advanced care planning [28–30, 33].

Ethically unacceptable criteria and controversial applicationThe majority of the guidelines report a set of ethically unacceptable criteria, including gender, ethnicity, sexual orientation, religion and political vision. They are justi-fied on the basis of the equality principle with respect to human dignity and the human rights framework [22, 24, 28, 30, 32, 35]. Most of the guidelines place specific attention on age, which cannot be assumed as the only criterion [26, 29, 33], and disability [24, 28, 30, 39]; these groups are considered vulnerable people, and specific attention and particular effort should be made to ensure them equal rights and treatments [11].

Despite this, it is important to point out that there is controversy on the age issue. For example, the Swiss ethi-cal guideline, while declaring to avoid any discrimination based on age, uses the age limit as an exclusion criteria in certain situation [33]. The Belgian document states that age in isolation cannot be used for triage decisions, but should be integrated with other clinical parame-ters: frailty and reduced cognition. They are specifically described as ‘independent predictors of  outcome when elderly patients are admitted to the ICU’, but, as men-tioned above, they would be effective only in combina-tion with age [29].

Respecting patient dignityRespecting human dignity is a central aspect of the ana-lyzed guidelines.

While the term ‘dignity’ is cited in each guideline, no explicit description of its meaning is provided. How-ever, the general significance of dignity arose, and it can be described in terms of respecting the intrinsic value of each human beings (equality) while differentiating resources among people with different needs (equity) (Table 4).

Moreover, ethical guidelines describe how to respect dignity through the application of palliative care, consid-eration of patients’ wills, and an individualized patient care.

Palliative careMost of the guidelines include the provision of palliative care for all patients who will not receive ICU treatments.

Two ethical guidelines explicitly argue that palliative care represents an approach to respect human dignity: people affected by a serious illness does not lose their intrinsic value as a person nor the right to be supported and pro-tected [24, 34]. Patients who do not meet the triage cri-teria and cannot accede to intensive treatments, patients at the end of life, or patients who refuse the interven-tion should all be referred to palliative care, which aims to ensure a death without suffering and proximity to the family, despite the difficulties imposed by the situa-tion [24, 26, 28, 34–37]. Some guidelines emphasize that patients who do not accede to the intensive treatment (or the ones whose treatments should be withdrawn) have the right to receive the best available alternative and compassionate care, that lies in the principle of continu-ity of care [11, 28, 30, 33, 37], and is supported by the principle of justice [35].

Considering the patient’s will and wishesAnother emerging way to respect patient dignity is deal-ing with patient’s will. A significant number of ethical guidelines include that physicians should take into con-sideration patient’s Advance Directives and his/her con-sent to intensive treatment or other treatment. Knowing the patient’s will and discussing the possibility of invasive treatment are associated with respect for the patient’s autonomy and moral values underlined by the 4 princi-ples of medical ethics [28, 29, 32, 33]. The patient’s will represents a tool to help clinicians to make triage deci-sions and should be carefully evaluated in advance [29, 32, 34–36].

Individualized patient careSome ethical guidelines highlight the necessity to pro-vide individualized and person-centered care, even in the context of a public health emergency. This approach requires paying attention to vulnerabilities and to differ-entiating treatment considering the individual needs of each patient as the optimal way to avoid discrimination in access to health care [10, 21, 25, 26, 28, 30]. It devel-ops the consideration that all patients should be offered good quality and compassionate care and treated as indi-viduals, while recognizing that there may be a competing obligation to the wider population [11, 27, 38]. According to this approach, ICU treatments would be interrupted or not initiated only if they are considered not beneficial for the individual patient.

The communicative aspects of care and its implication on patients and familiars are also important for strength-ening the care relationship [31, 32, 36, 38]. As specifically noted in the ethical guidelines provided by the General Medical Council, the health care professions should com-municate openly and honestly with patients and the rest

Page 16 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

Tabl

e 4

Emer

ging

mea

ning

of d

igni

ty a

mon

g et

hica

l gui

delin

es

Coun

try

Gui

delin

es’ t

itle

Men

tion

of d

igni

tyA

ppro

pria

tene

ss a

nd

prop

ortio

nalit

yEq

ualit

yEq

uity

Emer

ging

mea

ning

of

dign

ity

Aus

tria

Man

agem

ent o

f sca

rce

reso

urce

s in

hea

lthca

re

in th

e co

ntex

t of t

he

COVI

D-1

9 pa

ndem

ic

The

prot

ectio

n of

the

indi

vidu

als

and

thei

r di

gnity

pro

vide

d fo

r in

thes

e fu

ndam

enta

l rig

hts

impl

ies

the

duty

to

pro

vide

hea

lthca

re to

ev

ery

pers

on re

gard

-le

ss o

f who

they

are

, in

othe

r wor

ds, w

ithou

t di

stin

ctio

n fo

llow

ing

non-

med

ical

crit

eria

Ther

e is

no

right

to m

edi-

cal t

reat

men

t tha

t is

not

or n

o lo

nger

med

ical

ly

indi

cate

d

Equa

lity

is c

onsi

dere

d as

a

bind

ing

fund

amen

tal

right

Ever

yone

has

a ri

ght t

o lif

e (A

rtic

le 2

EC

HR)

and

ot

her r

elev

ant

Fund

amen

tal r

ight

s in

the

med

ical

con

text

, suc

h as

in p

artic

ular

the

right

to

resp

ect f

or p

rivat

e lif

e (A

rtic

le 8

EC

HR)

. (…

) Th

ere

is n

o ju

stifi

catio

n fo

r exc

ludi

ng a

per

son

from

trea

tmen

t bas

ed

on c

riter

ia s

uch

as th

eir

rem

aini

ng li

fetim

e or

qu

ality

of l

ife. A

t the

sa

me

time,

it n

eeds

to b

e em

phas

ized

that

ther

e is

no

right

to m

edic

al

trea

tmen

t tha

t is

not

or n

o lo

nger

med

ical

ly

indi

cate

d

Equi

ty: S

ome

peop

le

are

in n

eed

of s

peci

al

supp

ort t

o be

abl

e to

eff

ectiv

ely

exer

cise

thei

r fu

ndam

enta

l rig

ht to

life

an

d th

e ac

cess

to a

ssoc

i-at

ed m

edic

ally

indi

cate

d tr

eatm

ent,

e.g.

if th

ey

have

a p

hysi

cal o

r men

-ta

l/cog

nitiv

e im

pair-

men

t. Su

ch c

ases

requ

ire

not o

nly

the

sam

e, b

ut

poss

ibly

mor

e re

sour

ces

to e

nsur

e th

at th

ey

have

the

sam

e ch

ance

as

peo

ple

with

out s

uch

impa

irmen

ts

Resp

ectin

g th

e in

trin

sic

valu

e of

hum

an b

eing

s—no

dis

crim

inat

ion

(equ

al-

ity) w

hile

diff

eren

tiate

re

sour

ces

amon

g pe

ople

w

ith d

iffer

ent n

eeds

(e

quity

)

Belg

ium

Ethi

cal p

rinci

ples

con

cern

-in

g pr

opor

tiona

lity

of

criti

cal c

are

durin

g th

e CO

VID

-19

pand

emic

: ad

vice

by

the

Belg

ian

Soci

ety

of IC

med

icin

e

Dis

prop

ortio

nate

car

e sh

ould

be

defin

ed o

n a

scie

ntifi

cally

fund

ed

estim

ate

of th

e ex

pect

ed

outc

ome,

whi

ch im

plie

s kn

owle

dge

of a

n ad

vanc

ed c

are

plan

, the

m

edic

al c

ondi

tion

of th

e pa

tient

, the

ant

eced

ents

, th

e ac

ute

evol

utio

n of

his

con

ditio

n, a

nd

a fu

nded

est

imat

e of

hi

s pr

ogno

sis

with

and

w

ithou

t int

ensi

ve c

are

In a

dditi

on, n

on-C

OVI

D-1

9 pa

tient

s sh

ould

be

eval

uate

d ac

cord

ing

to

the

sam

e cr

iteria

in o

rder

to

avo

id d

iscr

imin

atio

n be

twee

n bo

th g

roup

s. A

lthou

gh a

n in

crea

sed

age

is a

ssoc

iate

d w

ith

wor

se o

utco

mes

in

COVi

D-1

9, a

ge in

isol

a-tio

n ca

nnot

be

used

for

tria

ge d

ecis

ions

, but

sh

ould

be

inte

grat

ed

with

oth

er c

linic

al

para

met

ers.

Frai

lty a

nd

redu

ced

cogn

ition

, mor

e th

an a

ge, a

re in

de-

pend

ent p

redi

ctor

s of

ou

tcom

e w

hen

elde

rly

patie

nts

are

adm

itted

to

the

ICU

Dig

nity

as

resp

ect o

f pa

tient

’s au

tono

my

and

patie

nt’s

choi

ces

and

resp

ectin

g th

e in

trin

sic

valu

e of

hum

an b

eing

s—no

dis

crim

inat

ion

(equ

ality

)

Page 17 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

Tabl

e 4

(con

tinue

d)

Coun

try

Gui

delin

es’ t

itle

Men

tion

of d

igni

tyA

ppro

pria

tene

ss a

nd

prop

ortio

nalit

yEq

ualit

yEq

uity

Emer

ging

mea

ning

of

dign

ity

Coun

cil o

f Eur

ope

COM

MIT

TEE

ON

BIO

ETH

-IC

S (D

H-B

IO) D

H-B

IO

Stat

emen

t on

hum

an

right

s co

nsid

erat

ions

re

leva

nt to

the

COVI

D-

19 p

ande

mic

It is

ess

entia

l tha

t dec

i-si

ons

and

prac

tices

m

eet t

he fu

ndam

enta

l re

quire

men

t of r

espe

ct

for h

uman

dig

nity

and

th

at h

uman

righ

ts a

re

uphe

ld

The

prin

cipl

e of

equ

ity o

f ac

cess

to h

ealth

car

e la

id d

own

in A

rtic

le 3

of

the

Ovi

edo

Conv

entio

n m

ust b

e up

held

, eve

n in

a c

onte

xt o

f sca

rce

reso

urce

s. It

requ

ires

that

acc

ess

to e

xist

ing

reso

urce

s be

gui

ded

by m

edic

al c

riter

ia, t

o en

sure

nam

ely

that

vu

lner

abili

ties

do n

ot

lead

to d

iscr

imin

atio

n in

th

e ac

cess

to h

ealth

-ca

re. T

his

is c

erta

inly

re

leva

nt fo

r the

car

e of

CO

VID

-19

patie

nts,

but a

lso

for a

ny o

ther

ty

pe o

f car

e po

tent

ially

m

ade

mor

e di

fficu

lt w

ith

confi

nem

ent m

easu

res

and

the

real

loca

tion

of

med

ical

reso

urce

s to

fig

ht th

e pa

ndem

ic. T

he

prot

ectio

n of

the

mos

t vu

lner

able

peo

ple

in

this

con

text

is in

deed

at

stak

e, s

uch

as p

erso

ns

with

dis

abili

ties,

olde

r pe

rson

s, re

fuge

es a

nd

mig

rant

s. Th

is c

once

rns

deci

sion

s to

allo

cate

sc

arce

reso

urce

s, to

pr

ovid

e ne

cess

ary

assi

stan

ce to

thos

e m

ost

in n

eed

Resp

ectin

g th

e in

trin

sic

valu

e of

hum

an b

eing

s—no

dis

crim

inat

ion

(equ

al-

ity) w

hile

diff

eren

tiate

re

sour

ces

amon

g pe

ople

w

ith d

iffer

ent n

eeds

—vu

lner

able

peo

ple

(equ

ity)

Page 18 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

Tabl

e 4

(con

tinue

d)

Coun

try

Gui

delin

es’ t

itle

Men

tion

of d

igni

tyA

ppro

pria

tene

ss a

nd

prop

ortio

nalit

yEq

ualit

yEq

uity

Emer

ging

mea

ning

of

dign

ity

Esto

nia

Reco

mm

enda

tions

on

clin

ical

eth

ics

for

Esto

nian

hos

pita

ls fo

r di

strib

utio

n of

lim

ited

heal

th c

are

reso

urce

s du

ring

the

COVI

D-1

9 pa

ndem

ic

Bene

ficen

ce, p

atie

nts’

auto

nom

y (in

clud

ing

info

rmed

con

sent

) and

th

e pr

inci

ple

of h

uman

di

gnity

con

tinue

to b

e in

effe

ct

Equa

l tre

atm

ent.

The

med

icin

e sy

stem

tr

eats

all

patie

nts

equa

lly

rega

rdle

ss w

heth

er th

ey

have

CO

VID

-19

infe

ctio

n or

som

e ot

her s

ever

e ill

ness

Earli

er a

rriv

ing

for t

reat

-m

ent d

oes

not g

ive

any

patie

nt a

ny a

dvan

tage

co

mpa

red

to th

ose

who

co

me

late

r

Resp

ectin

g th

e in

trin

sic

valu

e of

hum

an b

eing

s—no

dis

crim

inat

ion

(equ

ality

)

EGE

Stat

emen

t on

Euro

pean

So

lidar

ity a

nd th

e Pr

o-te

ctio

n of

Fun

dam

enta

l Ri

ghts

in th

e CO

VID

-19

Pand

emic

The

prot

ectio

n of

hum

an

heal

th is

acc

orde

d a

muc

h hi

gher

prio

rity

in th

e sy

stem

of v

alue

s of

the

Euro

pean

Uni

on

than

eco

nom

ic in

ter-

ests

. EU

mem

ber s

tate

s sh

ould

join

tly p

ursu

e th

e pr

otec

tion

of h

ealth

of

EU

citi

zens

Prot

ectio

n of

Hum

an h

ealth

an

d hu

man

righ

ts

Fran

ce C

OVI

D-1

9 Co

ntrib

u-tio

n fro

m th

e Fr

ench

na

tiona

l Con

sulta

tive

Ethi

cs C

omm

ittee

: Et

hica

l iss

ues

in th

e fa

ce o

f a p

ande

mic

A p

erso

n’s

dign

ity d

oes

not d

epen

d on

his

or

her u

sefu

lnes

s. Th

us, i

n a

situ

atio

n of

sca

rcity

of

reso

urce

s, m

edic

al

choi

ces,

alw

ays

diffi

cult,

ha

ve to

be

guid

ed b

y et

hica

l refl

ectio

n th

at

take

s in

to a

ccou

nt

resp

ect f

or th

e di

gnity

of

per

sons

and

the

prin

cipl

e of

fairn

ess

The

need

for t

riage

of

patie

nts

rais

es a

maj

or

ethi

cal q

uest

ion

of

dist

ribut

ive

just

ice,

w

hich

in th

is c

ase

may

le

ad to

a d

iffer

entia

l tr

eatm

ent f

or p

atie

nts

infe

cted

with

CO

VID

-19

and

thos

e w

ith

othe

r dis

ease

s. Th

ose

choi

ces

mus

t alw

ays

be

expl

aine

d an

d re

spec

t th

e pr

inci

ples

of h

uman

di

gnity

and

fairn

ess.

It w

ill a

lso

be n

eces

sary

to

be

vigi

lant

abo

ut th

e co

ntin

uity

of c

are

for

othe

r pat

ient

s

Diff

eren

tiate

reso

urce

s am

ong

peop

le w

ith d

if-fe

rent

nee

ds (e

quity

)

Page 19 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

Tabl

e 4

(con

tinue

d)

Coun

try

Gui

delin

es’ t

itle

Men

tion

of d

igni

tyA

ppro

pria

tene

ss a

nd

prop

ortio

nalit

yEq

ualit

yEq

uity

Emer

ging

mea

ning

of

dign

ity

Ger

man

ySo

lidar

ity a

nd R

espo

nsib

il-ity

dur

ing

the

Coro

navi

-ru

s C

risis

The

guar

ante

eing

of

hum

an d

igni

ty n

eces

si-

tate

s eg

alita

rian

equa

lity

and

thus

pro

vide

s fo

r co

rres

pond

ing

basi

c pr

otec

tion

for a

ll ag

ains

t di

scrim

inat

ion

Resp

ectin

g th

e in

trin

sic

valu

e of

hum

an b

eing

s—no

dis

crim

inat

ion

(equ

al-

ity) w

hile

diff

eren

tiate

re

sour

ces

amon

g pe

ople

w

ith d

iffer

ent n

eeds

(e

quity

)

Irela

ndEt

hica

l Fra

mew

ork

for

Dec

isio

n-M

akin

g in

a

Pand

emic

The

prin

cipl

e of

fairn

ess

mea

ns th

at e

very

one

mat

ters

equ

ally

, and

un

der n

orm

al c

ircum

-st

ance

s al

l ind

ivid

uals

ha

ve a

n eq

ual c

laim

to

heal

thca

re

Resp

ectin

g th

e in

trin

sic

valu

e of

hum

an b

eing

s—no

dis

crim

inat

ion

(equ

ality

)

Italy

Clin

ical

eth

ics

reco

m-

men

datio

ns fo

r ad

mis

sion

to in

tens

ive

care

and

for w

ithdr

aw-

ing

trea

tmen

t in

exce

ptio

nal c

ondi

tions

of

imba

lanc

e be

twee

n ne

eds

and

avai

lble

re

sour

ces

All

acce

ss to

inte

nsiv

e ca

re

mus

t be

cons

ider

ed

and

com

mun

icat

ed a

s an

“IC

U tr

ial”

only

and

th

eref

ore

unde

rgo

daily

re

asse

ssm

ent o

f its

ap

prop

riate

ness

, bas

ed

on g

oals

of c

are

and

prop

ortio

nalit

y of

car

e

It m

ay b

e ne

cess

ary

to

esta

blis

h an

age

lim

it fo

r ad

mis

sion

to th

e IC

U.

It is

not

a q

uest

ion

of

mak

ing

choi

ces

mer

ely

acco

rdin

g to

wor

th, b

ut

to re

serv

e re

sour

ces

that

cou

ld b

ecom

e ex

trem

ely

scar

ce to

th

ose

who

, in

the

first

in

stan

ce, h

ave

a gr

eate

r lik

elih

ood

of s

urvi

ving

an

d w

ho, s

econ

daril

y,

will

hav

e m

ore

year

s of

lif

e sa

ved,

with

a v

iew

to

max

imiz

ing

the

bene

fits

for t

he g

reat

est n

umbe

r of

peo

ple

Diff

eren

tiate

reso

urce

s am

ong

peop

le w

ith d

if-fe

rent

nee

ds—

vuln

erab

le

peop

le (e

quity

)

Page 20 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

Tabl

e 4

(con

tinue

d)

Coun

try

Gui

delin

es’ t

itle

Men

tion

of d

igni

tyA

ppro

pria

tene

ss a

nd

prop

ortio

nalit

yEq

ualit

yEq

uity

Emer

ging

mea

ning

of

dign

ity

Repu

blic

of S

an M

arin

oSt

atem

ent o

n et

hica

l is

sues

rega

rdin

g to

the

use

of in

vasi

ve a

ssis

ted

vent

ilatio

n in

pat

ient

s

all a

ge w

ith s

erio

us

disa

bilit

ies

in re

latio

n to

Co

vid-

19 p

ande

mic

Resp

ect f

or h

uman

di

gnity

is c

oncr

etiz

ed

allo

win

g ea

ch p

erso

n to

exp

erie

nce

a go

od

deat

h, th

roug

h th

e pr

e-ci

ous

tool

of P

allia

tive

Care

, whi

ch g

uara

ntee

th

e co

ntro

l of p

ain

and

suffe

ring,

in th

e de

ep a

war

enes

s th

at a

pe

rson

’s lif

e se

rious

ly il

l an

d in

cura

ble,

it n

ever

lo

ses

its in

trin

sic

valu

e no

r the

righ

t to

be s

up-

port

ed a

nd p

rote

cted

, th

eref

ore

it re

itera

tes

that

equ

al d

igni

ty m

ust

also

be

guar

ante

ed to

"n

on-t

reat

able

" vic

tims,

thro

ugh

taki

ng c

harg

e an

d an

y se

datio

n of

pa

in

The

foun

ding

prin

cipl

es

of th

e Co

nven

tion

can

be b

riefly

indi

cate

d in

equ

ality

and

non

di

scrim

inat

ion

and

in th

e eq

ualit

y of

opp

ortu

nity

(…) E

qual

ity o

f opp

or-

tuni

ty c

once

rns

the

reco

gniti

on o

f the

righ

t of

acc

ess

to g

oods

an

d se

rvic

es, p

rimar

ily

heal

th-r

elat

ed s

ervi

ces

Resp

ectin

g th

e in

trin

sic

valu

e of

hum

an b

eing

s—no

dis

crim

inat

ion

(equ

ality

)Re

spec

ting

dign

ity m

eans

off

er p

atie

nts

good

dea

th

and

no s

uffer

Port

ugal

CN

ECV

stat

emen

t: Co

vid-

19 k

ey c

onsi

dera

tion

The

prot

ectio

n of

life

, di

gnity

and

inte

g-rit

y of

citi

zens

is a

n et

hica

l res

pons

ibili

ty

that

invo

lves

pol

itica

l au

thor

ities

at d

iffer

ent

leve

ls, n

amel

y in

the

prep

arat

ion

of h

ealth

an

d sa

nita

ry re

spon

ses,

whi

le p

lann

ing

and

orga

nisi

ng a

cces

s to

he

alth

care

Resp

ectin

g di

gnity

as

ethi

-ca

l res

pons

ibili

ty to

Resp

ectin

g th

e in

trin

sic

valu

e of

hum

an b

eing

s—no

dis

crim

inat

ion

(equ

ality

)

Page 21 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

Tabl

e 4

(con

tinue

d)

Coun

try

Gui

delin

es’ t

itle

Men

tion

of d

igni

tyA

ppro

pria

tene

ss a

nd

prop

ortio

nalit

yEq

ualit

yEq

uity

Emer

ging

mea

ning

of

dign

ity

Pub

lic h

ealth

em

erge

ncy

situ

atio

n du

e to

the

COVI

D-1

9 pa

ndem

ic-

Rele

vant

eth

ical

as

pect

s

Dut

y to

pro

tect

hum

an

heal

th s

houl

d be

giv

en

prec

eden

ce w

hen

con-

front

ed w

ith p

ossi

ble

econ

omic

inte

rest

s

Care

team

s ar

e re

spon

-si

ble

for a

sses

sing

the

clin

ical

nee

ds o

f eac

h pa

tient

, nam

ely

thei

r se

verit

y an

d ur

genc

y,

and

wei

ghin

g th

e re

spon

se a

ccor

ding

to

the

prin

cipl

e of

equ

ita-

ble

dist

ribut

ion

of a

vail-

able

reso

urce

s, w

hich

, in

a c

onte

xt o

f sca

rcity

, is

a h

ighl

y de

man

ding

re

spon

sibi

lity

Diff

eren

tiate

reso

urce

s am

ong

peop

le w

ith d

if-fe

rent

nee

ds—

vuln

erab

le

peop

le (e

quity

)

Spai

nRe

port

of t

he M

inis

try

of H

ealth

on

ethi

cal

aspe

cts

in p

ande

mic

si

tuat

ions

: SA

RS-C

oV-2

The

very

foun

datio

ns o

f ou

r rul

e of

law

, in

par-

ticul

ar o

ur re

cogn

ition

of

the

equa

l int

rinsi

c di

gnity

of e

very

hum

an

bein

g

Acc

eptin

g di

scrim

inat

ion

of th

is k

ind

wou

ld m

ean

givi

ng le

ss v

alue

to

cert

ain

hum

an li

ves

due

to th

eir l

ife-c

ycle

sta

ge,

cont

radi

ctin

g th

e ve

ry

foun

datio

ns o

f our

rule

of

law

, in

part

icul

ar o

ur

reco

gniti

on o

f the

equ

al

intr

insi

c di

gnity

of e

very

hu

man

bei

ng

It w

ill b

e ne

cess

ary

to

com

bine

the

gene

ral

fram

ewor

k fo

r suc

h cr

iteria

with

a th

orou

gh

refle

ctio

n on

the

situ

a-tio

n an

d ci

rcum

stan

ces

of e

ach

part

icul

ar

patie

nt, a

nd a

sses

sing

-w

ithin

that

gen

eral

fra

mew

ork

of g

uidi

ng

prin

cipl

es—

the

uniq

ue-

ness

and

indi

vidu

ality

of

each

per

son

affec

ted

Resp

ectin

g th

e in

trin

sic

valu

e of

hum

an b

eing

s—no

dis

crim

inat

ion

(equ

al-

ity) d

iffer

entia

te re

sour

ces

amon

g pe

ople

with

di

ffere

nt n

eeds

—vu

lner

-ab

le p

eopl

e (e

quity

)In

divi

dual

ized

car

e

Switz

erla

ndPa

ndem

ic C

ovid

-19:

tria

ge

of in

tens

ive

care

trea

t-m

ents

in c

ase

of s

carc

ity

of re

sour

ces

Indi

catio

ns

for t

he im

plem

enta

tion

of c

hapt

er 9

.3 o

f the

di

rect

ives

of t

he A

SSM

"M

easu

res

of in

tens

ive

care

" (20

13),

upda

ted

vers

ion

of M

arch

24,

20

20

Equi

ty: A

vaila

ble

reso

urce

s ar

e to

be

allo

cate

d w

ith-

out d

iscr

imin

atio

n—i.e

. w

ithou

t unj

ustifi

ed

uneq

ual t

reat

men

t on

grou

nds

of a

ge, s

ex,

resi

denc

e, n

atio

nalit

y,

relig

ious

affi

liatio

n, s

ocia

l or

insu

ranc

e st

atus

, or

chro

nic

disa

bilit

y

Resp

ectin

g th

e in

trin

sic

valu

e of

hum

an b

eing

s—no

dis

crim

inat

ion

Page 22 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

Tabl

e 4

(con

tinue

d)

Coun

try

Gui

delin

es’ t

itle

Men

tion

of d

igni

tyA

ppro

pria

tene

ss a

nd

prop

ortio

nalit

yEq

ualit

yEq

uity

Emer

ging

mea

ning

of

dign

ity

The

Hol

y Se

e P

ande

mic

and

Uni

vers

al

Brot

herh

ood

Dec

isio

ns c

anno

t be

base

d on

diff

eren

ces

in

the

valu

e of

a h

uman

lif

e an

d th

e di

gnity

of

ever

y pe

rson

, whi

ch

are

alw

ays

equa

l and

pr

icel

ess

The

deci

sion

con

cern

s ra

ther

the

use

of tr

eat-

men

ts in

the

best

pos

-si

ble

way

on

the

basi

s of

th

e ne

eds

of th

e pa

tient

, th

at is

, the

sev

erity

of

his

or h

er d

isea

se a

nd

need

for c

are,

and

the

eval

uatio

n of

the

clin

ical

be

nefit

s th

at tr

eatm

ent

can

prod

uce,

bas

ed o

n hi

s or

her

pro

gnos

is. A

ge

cann

ot b

e co

nsid

ered

th

e on

ly, a

nd a

utom

atic

, cr

iterio

n go

vern

ing

choi

ce. D

oing

so

coul

d le

ad to

a d

iscr

imin

ator

y at

titud

e to

war

d th

e el

derly

and

the

very

w

eak

Resp

ectin

g th

e in

trin

sic

valu

e of

hum

an b

eing

s—no

dis

crim

inat

ion

UN

ESCO

Inte

rnat

iona

l Bi

oeth

ics

Com

mitt

ee

(IBC

)and

theU

NES

CO

Wor

ld C

omm

issi

on o

n th

e Et

hics

of S

cien

tific

Know

ledg

e an

d Te

ch-

nolo

gy (C

OM

EST)

Sta

tem

ent o

n CO

VID

-19:

Et

hica

l con

side

ratio

ns

from

a g

loba

l per

spec

-tiv

e

Proc

edur

es n

eed

to b

e tr

ansp

aren

t and

sho

uld

resp

ect h

uman

dig

nity

. Et

hica

l prin

cipl

es

ensh

rined

in th

e hu

man

rig

hts

fram

ewor

k re

cog-

nize

the

prot

ectio

n of

he

alth

as

a rig

ht o

f eac

h hu

man

bei

ng

Resp

ectin

g th

e in

trin

sic

valu

e of

hum

an b

eing

s—no

dis

crim

inat

ion;

hum

an

right

to h

ealth

car

e

UK

Gui

danc

e: R

espo

ndin

g to

CO

VID

-19:

the

ethi

cal

fram

ewor

k fo

r adu

lt so

cial

car

e

Resp

ect

This

prin

cipl

e is

defi

ned

as

reco

gnis

ing

that

eve

ry

pers

on a

nd th

eir h

uman

rig

hts,

pers

onal

cho

ices

, sa

fety

and

dig

nity

m

atte

rs

(Incl

usiv

enes

s): c

onsi

der

any

disp

ropo

rtio

nate

im

pact

s of

a d

ecis

ion

on p

artic

ular

peo

ple

or

grou

ps

Incl

usiv

enes

sTh

is p

rinci

ple

is d

efine

d as

en

surin

g th

at p

eopl

e ar

e gi

ven

a fa

ir op

port

unity

to

und

erst

and

situ

atio

ns,

be in

clud

ed in

dec

i-si

ons

that

affe

ct th

em,

and

offer

thei

r vie

ws

and

chal

leng

e. In

turn

, de

cisi

ons

and

actio

ns

shou

ld a

im to

min

imis

e in

equa

litie

s as

muc

h as

po

ssib

le

Dig

nity

as

resp

ect o

f pa

tient

’s au

tono

my

and

patie

nt’s

choi

ces

and

re

spec

ting

the

intr

insi

c va

lue

of h

uman

bei

ngs—

no d

iscr

imin

atio

n (e

qual

ity)

Page 23 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

Tabl

e 4

(con

tinue

d)

Coun

try

Gui

delin

es’ t

itle

Men

tion

of d

igni

tyA

ppro

pria

tene

ss a

nd

prop

ortio

nalit

yEq

ualit

yEq

uity

Emer

ging

mea

ning

of

dign

ity

Ethi

cal c

onsi

dera

tions

in

resp

ondi

ng to

the

COVI

D-1

9 pa

ndem

ic

Peop

le s

houl

d be

trea

ted

as m

oral

equ

als,

wor

thy

of re

spec

t

Resp

ectin

g th

e in

trin

sic

valu

e of

hum

an b

eing

s—no

dis

crim

inat

ion

COVI

D-1

9—et

hica

l iss

ues.

A g

uida

nce

note

Equa

l res

pect

eve

ryon

e m

atte

rs a

nd e

very

one

mat

ters

equ

ally

, but

th

is d

oes

not m

ean

that

ev

eryo

ne w

ill b

e tr

eate

d th

e sa

me

Fairn

ess e

very

one

mat

ters

eq

ually

. Peo

ple

with

an

equa

l cha

nce

of b

en-

efitin

g fro

m a

reso

urce

sh

ould

hav

e an

equ

al

chan

ce o

f rec

eivi

ng it

—al

thou

gh it

is n

ot u

nfai

r to

ask

peo

ple

to w

ait i

f th

ey c

ould

get

the

sam

e be

nefit

late

r

Resp

ectin

g th

e in

trin

sic

valu

e of

hum

an b

eing

s—no

dis

crim

inat

ion

(equ

al-

ity) w

hile

diff

eren

tiate

re

sour

ces

amon

g pe

ople

w

ith d

iffer

ent n

eeds

(e

quity

)

Ethi

cal d

imen

sion

of

COVI

D-1

9 fo

r fro

nt-li

ne

staff

Fron

t-lin

e st

aff, p

olic

ymak

-er

s, m

anag

emen

t and

go

vern

men

t hav

e a

resp

onsi

bilit

y to

pat

ient

s to

ens

ure

that

any

sy

stem

use

d to

ass

ess

patie

nts

for e

scal

atio

n or

de-

esca

latio

n of

car

e do

es n

ot d

isad

vant

age

any

one

grou

p di

spro

-po

rtio

nate

ly. T

reat

men

t sh

ould

be

prov

ided

, irr

espe

ctiv

e of

the

indi

vidu

al’s

back

grou

nd

(eg

disa

bilit

y), w

here

it

is c

onsi

dere

d th

at it

will

he

lp th

e pa

tient

sur

vive

an

d no

t har

m th

eir

long

-ter

m h

ealth

and

w

ellb

eing

Resp

ectin

g pe

ople

whi

le

diffe

rent

iate

reso

urce

s am

ong

peop

le w

ith d

if-fe

rent

nee

ds (e

quity

)

Page 24 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

Tabl

e 4

(con

tinue

d)

Coun

try

Gui

delin

es’ t

itle

Men

tion

of d

igni

tyA

ppro

pria

tene

ss a

nd

prop

ortio

nalit

yEq

ualit

yEq

uity

Emer

ging

mea

ning

of

dign

ity

Covi

d-19

Gui

danc

e: E

thi-

cal A

dvic

e an

d Su

ppor

t Fr

amew

ork

Resp

ect

All

patie

nts

shou

ld b

e off

ered

goo

d qu

ality

an

d co

mpa

ssio

nate

car

eFa

irnes

s P

atie

nts

shou

ld b

e tr

eate

d as

indi

vidu

als,

and

not d

iscr

imin

ated

ag

ains

t

Min

imis

ing

harm

Whe

re th

ere

is a

dec

isio

n th

at a

trea

tmen

t is

not

clin

ical

ly a

ppro

pria

te

ther

e is

not

an

oblig

a-tio

n to

pro

vide

it, b

ut

the

reas

ons

shou

ld b

e ex

plai

ned

to th

e pa

tient

an

d ot

her o

ptio

ns

expl

ored

8

No

activ

e st

eps

shou

ld b

e ta

ken

to s

hort

en o

r end

th

e lif

e of

an

indi

vidu

al9 ,

how

ever

the

appr

opria

te

clin

ical

dec

isio

n m

ay b

e to

with

draw

life

pro

long

-in

g or

life

sus

tain

ing

trea

tmen

t, or

cha

nge

man

agem

ent t

o de

liver

en

d of

life

car

e

It is

impo

rtan

t tha

t pa

tient

s ar

e tr

eate

d in

de-

pend

ent o

f sus

pect

ed

or c

onfir

med

CO

VID

-19

stat

us, a

nd th

at a

ny c

lini-

cal d

ecis

ion

guid

ance

ap

plie

s eq

ually

to a

ll pa

tient

s.Th

e in

tere

sts

of e

ach

pers

on a

re th

e co

ncer

n of

all

of u

s, an

d of

soc

iety

∙ T

he h

arm

that

mig

ht b

e su

ffere

d by

eve

ry p

erso

n m

atte

rs, a

nd s

o m

inim

is-

ing

the

harm

that

a

pand

emic

mig

ht c

ause

is

a ce

ntra

l con

cern

10

Resp

ectin

g th

e in

trin

sic

valu

e of

hum

an b

eing

s—no

dis

crim

inat

ion

(equ

al-

ity) w

hile

diff

eren

tiate

re

sour

ces

amon

g pe

ople

w

ith d

iffer

ent n

eeds

(e

quity

)

Coro

navi

rus:

Your

fre-

quen

tly a

sked

que

stio

nsIf

a de

cisi

on is

take

n no

t to

sta

rt o

r to

with

draw

so

me

form

s of

trea

t-m

ent f

rom

a p

atie

nt,

doct

ors

shou

ld s

till t

ake

all p

ossi

ble

step

s to

al

levi

ate

the

patie

nt’s

sym

ptom

s an

d di

stre

ss

and

resp

ect t

heir

dign

ity. T

he p

atie

nt’s

wis

hes,

pref

eren

ces

and

fear

s in

rela

tion

to th

eir

futu

re tr

eatm

ent a

nd

care

sho

uld

be e

xplo

red

as fa

r as

poss

ible

Dec

isio

ns a

re b

ased

on

clin

ical

nee

d an

d th

e lik

ely

effec

tiven

ess

of

trea

tmen

ts, a

nd d

on’t

unfa

irly

disc

rimin

ate

agai

nst p

artic

ular

gro

ups

Resp

ectin

g th

e in

trin

sic

valu

e of

hum

an b

eing

s—no

dis

crim

inat

ion

(equ

al-

ity) w

hile

diff

eren

tiate

re

sour

ces

amon

g pe

ople

w

ith d

iffer

ent n

eeds

(e

quity

).Re

spec

ting

dign

ity

mea

ns to

offe

r pat

ient

s go

od d

eath

and

no

suffe

r.D

igni

ty a

s re

spec

t of

patie

nt’s

auto

nom

y

Page 25 of 29Perin and De Panfilis BMC Med Ethics (2021) 22:36

of the health care team about the decision-making pro-cess and the criteria for establishing priorities in individ-ual cases [34].

Decision making and quality of careThe decision-making process for allocation of resources is a frequent element of all guidelines. It is also built on ethical principles and represents an important aspect to ensure high-quality care and to strengthen the health care relationship, even in the urgency context. The insti-tution of ethics support and ethics committee (or any other form of support for health care professionals) are also frequently required.

Ethical aspects of communication and triage managementTransparency, reasonableness, inclusiveness, openness and the uniform application of triage criteria at the dif-ferent levels of care are important reference principles to ensure the non-arbitrariness of the final decision [11, 22, 25, 26, 37]. Procedures for decision making should respect human dignity [11], and clinicians should act with honesty and integrity [38]. The involvement of health care professionals not directly involved in the provision of intensive care is also underlined to mitigate the negative effects of pressure on doctors and teams [25], and a collective decision made by an ad hoc medi-cal committee is often required [34, 36, 39]. An on-going revision of the guidelines, triage criteria and decisions is also a reiterated aspect to ensure that the best possible treatments are always guaranteed to each patient [36, 37].

Need of ethical supportSince these are very difficult decisions, the presence of local ethics committees, ethicists, or any other form of support, including psychological, aimed at managing and reducing the moral distress of health care professionals [21, 25, 28–30, 32, 34, 36, 37], is considered as an impor-tant aid for distributing and strengthening their sense of responsibility, applying ethical guidelines in their daily practice and, finally, making difficult decisions and facing direct dilemmas, especially in those extremely complex situations where suspension of already initiated treat-ments is required. Ethical guidelines have also noted that the application of a structured decision-making process and the identification of the persons responsible for the decision are fundamental to guarantee the patient, his family members and the community itself the trust pact and alliance on which the relationship of care is based and that the current emergency could dramatically cor-rupt [21].

DiscussionThe purpose of our study was to analyze how the Euro-pean countries dealt with the allocation of scarce clinical resources at the beginning of the COVID-19 pandemic. We analyzed the ethical concepts and their practical con-sequences described in the ethical guidelines developed under COVID-19 by different institutional bodies (such as national ethics committees and health departments) among the European countries.

Our results are in line with similar articles compar-ing ethical guidelines developed under COVID-19 [43, 45, 46]. Differently from them, our analysis compared an higher number of guidelines and emphasized all the rel-evant ethical approaches, such as ethics of care and indi-vidualized patient care.

Each guideline analyzed recognizes respect for each human life’s intrinsic value and the value of health as a human right as milestones to implement respect for human dignity.

Specifically, the emerging meaning of dignity is the intrinsic value of all the individuals who share the essen-tial properties of human beings (“intrinsic dignity”). In recognition of that value, the health care professionals have a moral duty towards those who are suffering from disease and injury [47]. According with Jobgsen et al., the reference to equality and equity principle represents an area of consensus among European guidelines, and con-sequently the respect for human dignity lies in the princi-ple of equal worth of people [45].

Nevertheless, during a pandemic, also the value of maximizing benefit emerged as an area of consensus [45]. Our results highlighted an implicit tension between respect for the equal right to health and risk of taking triage decision, including potential discriminatory cri-teria (such as patient’s frailty, short-term prognosis and cognitive impairment, which are linked to age). Then, the risk of applying a strictly utilitarian approach emerged, even if it was not a predominant approach for allocating resources among European guidelines [43]. This utilitar-ian consideration is most important, according to other non-European ethical guidelines, and in particular with American [9, 13] and Australian [48] guidelines. As noted by Emanuel et  al., priority for limited resources should aim “both at saving the most lives and at maximizing improvements in individuals’ post treatment length of life”, which is “consistent both with utilitarian ethical per-spective, focused on population outcomes, and with non-utilitarian views which emphasize the paramount value of each human life” [9]. The patient’s benefit and post-treatment outcomes are frequently cited in the European guidelines. It is often supported [5, 49, 50] the duty to care as the responsibility to respect the rights of patients to autonomy, transparency, privacy, and confidentiality

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of personal informations. These guidelines also require that procedures for taking informed consent and advance directives shall be observed and, where appropriate, legally authorized substitute decision-makers shall be consulted. Different from our results, the last guide-line provided by The Hastings Center [51] affirms that an ethical allocation resource strategy first requires the protection of health care workers delivering care in the midst of the crisis, for without them and their extraor-dinary efforts, the entire health system would collapse. Subsequently, decisions about who receives treatment must center on prevention of SARS-CoV-2 transmis-sion (public health), protection of individuals at highest risk, meeting societal needs, and promoting social jus-tice [51]. Consequently, groups at highest risk, such as older adults, people with compromised immune systems, and people with underlying conditions (such as heart or lung diseases or diabetes) are another priority, as they are most likely to become seriously ill and die. This is in line with the concept of taking care of vulnerable groups, which was also underlined in our results.

Previous studies [52, 53] related to end-of –life care practices in ICU, highlight that decisions on withholding and withdrawing intensive treatments are mostly affected by patient age, acute and chronic diagnosis, number of days in ICU and cultural and religious beliefs [53]. Only 4 [28, 29, 35, 36] guidelines on COVID-19 pandemic are in line with those results, while a high number of guidelines underlined the importance of the individual-ized approach. It is essential to mention the difference between an acute and chronic diagnosis and COVID-19 illness. While in the first case can be clear what is over-treatment and the meaning of deterioration, during COVID-19 rapid deterioration does not necessary cor-respond to end of life, and thracheostomy can save the patient’s life. Consequently, short terms survival should be considered cautiously because it is not yet well known in Covid-19 [45].

Our results emphasize the need to respect the patient’s choices and will through advanced discussion on the access to intensive care and open and transparent com-munication about triage criteria. This reflects the attempt of health care professionals in non-pandemic situations to take individualized decision on the access to ICU, accordingly with clinical judgment and patient’s goals of care [54]. The importance of patient’s advance directives and patient’s will and the explicit recommendation to offer palliative care to patients whose treatment is with-drawn or withheld represent a consensus area among European ethical guideline [43, 45].

Despite our results recognize the value of both per-sonalized care and relationship of care, many concerns regarding the effective possibility to respect patient’s

consent and will arise in clinical practice, above all in pandemic situations: as noted by Angelos P et  al., as scarcities increase, clinicians will increasingly be in a position in which they cannot respect all of their patient’s wishes, leading them to assume a paternalistic approach [55].

According to this study, the discussion of prognosis is central to obtaining informed consent for intubation, but, as noted by Zareifopoulos et  al., in the absence of definitive data, it is not clear exactly what this discus-sion should entail [56]. Moreover, one of our guidelines affirms that the clinician’s judgment of inappropriateness would be justified by the critical situation’s extraordinari-ness, which reflects a paternalistic approach. This is in line also with Emanuel et al., who confirm that in a criti-cal situation “the decision to withdraw a scarce resource to save others is not an act of killing and does not require the patient’s consent” [9].

According with similar studies [43, 45], our results show that the European ethical guidelines are very sensi-tive to the risk of discrimination arising from strict triage criteria, and particularly regarding age and disability. The difficult choices regarding admission to ICU of patients with advanced disease or elderly patients with multiple comorbidities was considered a ‘grey zone’ also in non-pandemic situations [54]. Discrimination based on age correlates the maximum benefit obtainable with the pri-oritization of younger people over old people, who have less life expectancy (both in terms of quantity and qual-ity) and have already lived much more than young peo-ple [57]. This is widely spread among the American and Mexican ethical guidelines [58]. Particularly, White and Lo, 2020 justify “ageism” on the number of year saved [59], while the American Society of Geriatrics (ASG) assesses that rationing strategies that are based in part on age cutoffs could lead to persistent beliefs that older adults’ lives are less valuable than others’ lives or are even expendable [23].

Fighting the ageistic approach, Cesari and al. 2020 replaced the age criterion for the allocation of resources with a parameter more robust than age but equally easy to obtain and that can be used for critical and rapid decision-making, namely, the careful evaluation of the presence of comorbidity and functional status in addi-tion to age. This is also marked by Auriemma et al. 2020 [59], who argue that an optimal policy for critical care resource allocation should not use categorical exclusions, in order to mitigate discrimination: ‘the feasibility virtues offered by such coarse systems are readily outweighed by their threats to justice, public trust, and clinician morale’. When the decision of using a ventilator for a person with respiratory distress is based on his/her birth date or other categorical exclusion criteria “we must realize that

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modern medicine may be at risk of having lost the mean-ing and value of the human life” [60].

Compared to European concerns, in the United States, the discussion on resource allocation and triage criteria dealt more deeply with issues of potential unjust dis-crimination for specific citizen group (namely elderly and disables). It  led to an open discussion and public engage-ment process to ensure equal access to health care that failed among European countries [46]. European ethical guidelines have been developed mainly by profession-als societies or national bodies, resulting in a total lack of public involvement in identifying and discussing the principles that could guide scarce resources allocation.

Our results mention the importance of trust communi-cation among health care professionals and patients and their familiars. The inclusion of a patient’s representative in developing ethical guidelines could improve health care professionals to make well-founded decisions in the interest of their patients.

As noted by Mannelli, the novelty of the current emer-gency has to do with the extraordinarily high number of people who find themselves personally affected by the implications of scarce resources allocation and who suddenly realize that the principle of “equals should be treated equally” may no longer be applicable [2].

ConclusionAccording to the ethical guidelines developed at the beginning of the COVID-19 pandemic, promoting how to figure out a way to personalize care during COVID-19 still represents a moral duty [5]. Being guided by the ethi-cal reflection that considers respect for persons’ dignity and the principle of equity, the difficult choices regarding patient prioritization and allocation of scarce resources should avoid unfair discrimination. At the same time, this kind of ethical reflection guarantees a relational approach to ethics, which includes appropriate and proportion-ate care, transparency and trust communication and, mostly, considering interconnection, vulnerability and shared humanity [44]. Personalized care in such a critical situation develops concretely by (a) a multidisciplinary, multidimensional and individualized evaluation of each patient; (b) the contextualization of ethical guidelines, involving who is directly called to their application; (c) an effective palliative care approach; and (d) the implemen-tation of clinical ethics support, which represents a very important resource to help health care professionals in making difficult decisions [61].

Further studies can investigate the practical conse-quences of the application of the guidelines described in terms of quality of care and health care professionals’ moral distress.

AbbreviationsSARS-CoV-2: Severe acute respiratory syndrome coronavirus 2; COVID-19: COronaVirus Disease 2019; ICU: Intensive Care Unit; WHO: World Health Organization; QUAGOL: Qualitative Analysis Guide of Leuven; SIAARTI: Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care; ASG: Ameri-can Society of Geriatrics.

Supplementary InformationThe online version contains supplementary material available at https:// doi. org/ 10. 1186/ s12910- 021- 00603-9.

Additional file 1: Appendix 1. European ethical guidelines developed at the beginning of Covid-19 pandemic.

Additional file 2: Appendix 2. Conceptual scheme example.

AcknowledgementsNot applicable.

Authors’ contributionsMP: conceptualization, data curation, formal analysis, writing—original draft; LDP: conceptualization, methodology, supervision, writing—original draft; Both authors read and approved the final manuscript.

FundingThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Availability of data and materialsAll data generated or analysed during this study are included in this published article (and its supplementary information files).

Declarations

Ethics approval and consent to participateNot applicable.

Consent for publicationNot applicable.

Competing interestsThe authors declare that they have no competing interests.

Author details1 Bioethics Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy. 2 PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy.

Received: 13 November 2020 Accepted: 22 March 2021

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