Pandemic Ethics Resources

Pandemic and other emergency preparedness and response efforts raise difficult ethical issues related to quarantine and isolation; allocation of scarce resources, including ventilators, and priority setting; triage; public risk communication; and appropriate uses and users of health information technology, including Big Data and Artificial Intelligence. 

Following is a selection of resources addressing some of these issues. This is a joint effort of the Florida Bioethics Network, the University of Miami, and Florida International University. (Click here for selected site annotations by FIU medical students.) 

United States 

• Agency for Healthcare Research and Quality, Emergency Severity Index (ESI): A Triage Tool for Emergency Departments (2012); Pandemic Influenza Triage Tools algorithm; and Altered Standards of Care in Mass Casualty Events (2011)
• Centers for Disease Control and Prevention, Pandemic Influenza Triage Tools; clinical guidance for state and local readiness; Optimizing Surge Capacity: Hospital Assessment and Planning
• Centers for Medicare & Medicaid Services, Current Emergencies
• Department of Health and Human Services, Healthcare Emergency Preparedness Information Gateway
• Department of Defense, DoD COVID-19 Practice Management Guide (2020)
• Federal Register, Guidance Documents Related to Coronavirus Disease
• House of Representatives, Select Subcommittee on the Coronavirus Crisis, Preparing for and Preventing the Next Public Health Emergency: Lessons Learned from the Coronavirus Crisis (2022)
• National Academy of Medicine, Crisis Standards of Care and COVID-19: What Did We Learn? How Do We Ensure Equity? What Should We Do? (2021)
• National Library of Medicine, "LitCovid," a "curated lterature hub" ...cf. University of Michigan, "Best Evidence Front Door"
• Veterans Administration National Center for Ethics in Health Care, Ethical issues in Pandemic Influenza Preparedness and Response, which includes Meeting the Challenge of Pandemic Influenza: Ethical Guidance for Leaders and Health Care Professionals in the Veterans Health Administration (2010)

Florida

• Florida Bioethics Network, Ethics Guidelines for Crisis Standards of Care in Public Health Emergencies (2020)
• Florida Court Education Council, Pandemic Influenza Benchguide: Legal Issues Concerning Quarantine and Isolation (2019)
• Florida Department of Health, Pandemic Influenza: Triage and Scarce Resource Allocation Guidelines (2011; draft)
• Florida Hospital Association, COVID-19 Updates; FHA endorses FBN guidelines for crisis standards, news release (April 13, 2020)
• Florida Public Health Association 
• Food & Drug Administration and Centers for Disease Control and Prevention letter to Florida Surgeon General Joseph A. Ladapo on vaccine misinformation (2023)
• Miami-Dade County Healthcare Preparedness Coalition, Crisis Standards of Care: A Guideline (2023)
  

Other States and Institutions

• Arizona Department of Health Services, Pandemic Influenza Response Plan
  
• California Department of Public Health, California SARS-CoV-2 Pandemic: Health Care Surge Crisis Care Guidelines
  
• Colorado Crisis Standards of Care
  
• Illinois Department of Public Health, ESF-8 Plan
  
• Maryland, Framework for the Allocation of Scarce Life-sustaining Medical Resources in a Catastrophic Public Health Emergency
  
• Massachusetts Department of Public Health, Crisis Standards of Care Planning Guidance for the COVID-19 Pandemic
  
• Michigan Department of Community Health Office of Public Health Preparedness, Guidelines for Ethical Allocation of Scarce Medical Resources and Services During Public Health Emergencies in Michigan
  
• Minnesota Department of Health, Patient Care Strategies for Scarce Resource Situations 
• New York State Task Force on Life and the Law, New York State Department of Health, Ventilator Allocation Guidelines 
  
• Pennsylvania Department of Health, Ethical Allocation Framework for Emerging Treatments of COVID-19 
• Pittsburgh, University of, Department of Critical Care Medicine, A Model Hospital Policy for Allocating Scarce Critical Care Resources 
  
• Pittsburgh, University of, A Model Hospital Policy for Fair Allocation of Medications to Treat COVID-19 
  
• Tennessee Altered Standards of Care Workgroup, Guidance for the Ethical Allocation of Scarce Resources during a Community-Wide Public Health Emergency as Declared by the Governor of Tennessee 
  
• Texas: North Texas Mass Critical Care Guideline; Southwest (San Antonio) Region Guideline
• Utah Department of Health, Disease Investigation Plan 

Municipalities

• Los Angeles County Medical and Health Operational Area Coordination Program, Allocation of Scarce Resources Guide (2017)

Professional Societies and Organizations

• American College of Epidemiology, COVID-19 Resources
• The AMA Journal of Ethics offers curated resources of ethical relevance to the COVID-19 pandemic
• bioethics.net and American Journal of Bioethics, Bioethics Toolkit
• Hastings Center, Ethical Framework for Health Care Institutions and Guidelines for Institutional Ethics Services Responding to the Novel Coronavirus Pandemic (2020)
• Institute of Medicine, crisis standards of care
• National Academies of Sciences, Engineering, and Medicine, Coronavirus Disease 2019 (COVID-19) News and Resources; and Crisis Standards of Care, Ten Years of Successes and Challenges: Proceedings of a Workshop (2020)
• Society of Critical Care Medicine,  Crisis Standard of Care Recommendations for Triaging Critical Resources During the COVID-19 Pandemic (2020); Emergency Resources: COVID-19; and Disaster Triage and Allocation of Scarce Resources (2013) (online course)

Special Topics  

Disability 

• U.S. Department of Health and Suman Services Office of Civil Rights, Discrimination on the Basis of Disabliity
• Applying HHS’s Guidance for States and Health Care Providers on Avoiding Disability-Based Discrimination in Treatment Rationing: https://www.centerforpublicrep.org/wp-content/uploads/2020/04/Guidance-to-States-Hospitals_FINAL.pdf
• Partnership for Inclusive Disaster Strategies: http://www.disasterstrategies.org/
  COVID language resources: http://equalaccesslanguageservices.com/covid-19-lep/ ; https://mycielo.org/resources-in-indigenous-languages/
• COVID-19 Medical Communication Access for Deaf and Hard of Hearing: https://www.nad.org/covid19-communication-medical-access-for-deaf-hard-of-hearing/
• COVID-19 Deaf and Hard of Hearing Communication Access Recommendations for the Hospital: https://www.nad.org/covid19-communication-access-recs-for-hospital/
• Confronting Disability Discrimination During the Pandemic by Katie Savin & Laura Guidry-Grimes:  https://www.thehastingscenter.org/confronting-disability- discrimination-during-the-pandemic/
• COVID-19 Triage and Disability: What NOT To Do by Joe Stramondo:  http://www.bioethics.net/2020/03/covid-19-triage-and-disability-what-not-to-do/?fbclid=IwAR1bWRFHA58cveNO4SBvQXEca_sLQSAeRLFOUIz6MIM5pjaH2uwRfkqPvsQ
• Denver Post, Fair coronavirus triage guidelines – not business as usual – will save more patients with disabilities
• Disablism In a Time of Pandemic: Some Things Don’t Change by Jackie Leach Scully: https://www.ijfab.org/blog/2020/04/disablism-in-a-time-of-pandemic-some-things-dont-change/
• Disabusing the Disability Critique of the New York State Task Force Report on Ventilator Allocation by Joe Fins: https://www.thehastingscenter.org/disabusing-the-disability-critique-of-the-new-york-state-task-force-report-on-ventilator-allocation
• The Hastings Center, When It Comes to Rationing, Disability Rights Law Prohibits More than Prejudice
• National Council on Disability, Medical Futility and Disability Bias
• Research-to-Policy Collaboration, COVID-19 and Special Education
• United Nations, Convention on the Rights of Persons with Disabilities

Role of Students

• Should medical students continue clinical rotations during a pandemic?

Patient Resources

• Center to Advance Palliative Care, CAPC COVID-19 Response Resources
• Colorado Program for Patient Centered Decisions, decision aid for patients 
• Vital Talk consortium, COVID-ready communication skills: A playbook of VitalTalk Tips 

Faith and Religion

• Association of Professional Chaplains, COVID-19 Resources
• Bioethical Framework of Monotheist Religions on the Occasion of Covid-19, Spanish
• National Catholic Bioethics Center, Points to Consider: Triage in the Perspective of Catholic Bioethics
• The Rabbinical Assembly, statements on triage
• Rabbi Jason Weiner, Proposed Emergency/ICU Triage Protocol Based on Jewish Values

Law and Liability

• Akerman LLP, Taking Triage to Trial
• Barrett Law, COVID-19 and Resource Allocation: Planning for Times of Scarce Medical Resources
• Institute of Medicine, Ethical and Legal Considerations in Mitigating Pandemic Disease: Workshop Summary (2007)
• New York Network for Public Health Law, Emergency Legal Preparedness and Response and COVID-19: Public and Global Health Law and Ethics Across Diverse Systems, Populations and Workforces
• POLITICO Magazine, Nurses lawsuit: New York failed to protect health care workers and the public, April 20, 2020
• University of Ottawa, Vulnerable: The Law, Policy and Ethics of COVID-19, 2020

Privacy, HIPAA

• U.S. Department of Health and Human Services, HIPAA and Public Health
• HHS Office of Civil Rights, HIPAA Privacy and Novel Coronavirus Bulletin (February 2020); Bulletin on Civil Rights Laws and HIPAA Flexibilities That Apply During the COVID-19 Emergency (March 2020)

Data, Evidence, Informatics

• AMIA (American Medical Informatics Association), Coronavirus Resource Center
• Association of Public Health Laboratories, sample HL7 messages and coding guidelines for public health labs sending COVID-19 results to CDC; and a coding spreadsheet with specific LOINC and SNOMED codes.
• COVID-19 Interoperability Alliance, collection of value sets for clinical, demographic, and administrative concepts 
• National Academies of Sciences, Engineering, and Medicine's Societal Experts Action Network (SEAN), COVID-19 Response Support
• National Center for Advancing Translational Sciences, National COVID Cohort Collaborative (N3C)
• National Library of Medicine and others, COVID-19 Open Research Dataset (CORD-19) of scholarly literature about COVID-19, SARS-CoV-2, and the coronavirus group (2020)
• University of Michigan, COVID-19 Best Evidence Front Door
• Omaha System Guidelines
• Regenstrief Institute's LOINC, pre-release codes

International

• Chile: Pontificia Universidad Católica de Chile, Ethical Guidelines for the Care of Patients During a Pandemic, Spanish | English
• Council of Europe Committee on Bioethics, Statement on human rights considerations relevant to the COVID-19 pandemic.
• Germany: Interdisciplinary Association for Intensive Care and Emergency Medicine et al., Deutsche Interdisziplinare Vereinigung Fur Intensiv- und Notfallmedizin (German), Decisions on resource allocation in emergency and intensive care in the context of the COVID-19 pandemic (English) (2019);  Kompetenznetz Public Health–Covid 19, Public Health Ethics and Covid-19
  
• InterAction Council, Pandemic Emergency Response to the Coronavirus, COVID-19
• International Association for Hospice and Palliative Care et al., Briefing Note: Bio-Ethical Principles, Practices, and Recommendations Relevant to the COVID-19 Pandemic
• International Coalition of Medicines Regulatory Authorities, Global regulatory workshop on COVID-19 vaccine development, Summary Report (2020)
• Italy: SIAARTI (Società Italiana di Anestesia, Analgesia, Rianimazione e Terapia Intensiva): Raccomandazioni di etica clinica per l’ammissione a trattamenti intensivi e per la loro sospensione, in condizioni eccezionali di squilibrio tra necessità e risorse disponibili (2020) (Clinical ethics recommendations for admission to intensive treatments and for their suspension, in exceptional conditions of imbalance between needs and available resources SIAARTI translation; Raho translation).
• Pakistan: Centre of Biomedical Ethics and Culture, COVID-19 Pandemic: Guidelines for Ethical Healthcare Decision-Making in Pakistan 
• South Africa: South African Technology Network Position Paper: Priority Setting for Interventions in Pre-and Post-Pandemic Management: The Case of COVID-19 (2020)
• Switzerland: Swiss Academy of Medical Sciences and Society of (2020) Intensive Care, COVID-19 pandemic: triage for intensive-care treatment under resource scarcity (2020)
• United Kingdom: Nuffield Council on Bioethics, Ethical considerations in responding to the COVID-19 pandemic (2020); and Guide to the ethics of surveillance and quarantine for novel coronavirus (2020)
• World Health Organization, Ethics in epidemics, emergencies and disasters: Research, surveillance and patient care (2015); Public Health Emergency Preparedness and Response Ethics Network, Epidemics Ethics

Other Resources  

• COVID 19 Hotspots And Vulnerable Populations Identified By Area Deprivation Index Mapping, University of Michigan
• "Save Other Souls," COVID-19 Advance Directive
• Wynia/Hick STAT First Opinion article providing an overview of ethical principles and considerations in making triage decisions for COVID19: If Covid-19 gets bad, triage will be needed. Are we ready for that?
• Hick/Hanfling/Wynia/Pavia NASEM Perspective article on hospital planning for COVID-19 triage: Duty to Plan: Health Care, Crisis Standards of Care, and Novel Coronavirus SARS-CoV-2
• Helpful guidance on hospital prep from the Johns Hopkins Center for Health Security: What US Hospitals Should Do Now to Prepare for a COVID-19 Pandemic
• Kaiser Health News article on the state-by-state nature of pandemic preparedness and response, with quotes from Wynia, Hick and Hodge: During a Pandemic, States’ Patchwork of Crisis Strategies Could Mean Uneven Care

ACKNOWLEDGEMENTS

Thanks to Matthew Wynia, MD, MPH, FACP, Professor of Medicine and Public Health, Director, Center for Bioethics and Humanities, University of Colorado Anschutz Medical Campus, for valuable contributions; and Joseph A. Raho, PhD, Clinical Ethicist, Ethics Center, UCLA Health, Clinical Instructor, Department of Pediatrics, David Geffen School of Medicine, for permission to share his Italian translation of guidelines by an Italian medical group.

Please send suggestions, corrections, comments, etc. to FBN@med.miami.edu

Revised March 12, 2023