approaches to critical care resource allocation and triage during the covid-19 pandemic: an examination from a developing world perspective

The distribution of scarce critical care resources during public health emergencies in an ethically justified manner has been widely acknowledged as a major bioethics concern (1, 2). The Center for Disease Control (CDC) recommends that critical care allocation during a pandemic emergency should uphold basic biomedical principles through maintenance of procedural justice which requires decision-making that is consistent, impartial, neutral, and nondiscriminatory (3). During the current COVID-19 pandemic, health systems, even in developed countries with robust existing health infrastructure, have experienced sustained demands that have compelled the rationing of critical medical infrastructure, especially ventilators and intensive care beds (4, 5). Conventionally, triage prioritizes medical utility by sorting and allocating the limited available care to patients based on their disease severity and favoring those whom the critical care intervention would give the highest survival chances (6, 7). During a public health emergency such as a pandemic, the overarching utilitarian goal of achieving the greatest good for the greatest number usually attains paramountcy. This dominant mainstream ethical view unequivocally advocates maximizing medical outcomes in terms of either lives saved or life-years gained when allocating scarce medical resources during pandemics (8, 9). Equity considerations and unresolved concerns pertaining to social justice are usually deemed secondary and may be disregarded, especially when in conflict with the utility view. However, Reid has strongly emphasized the need to firmly integrate justice-related concerns in resource allocation by elevating the ideals related to egalitarianism, non-discrimination and social justice (10).