COVID-19 Ethics Resources

Resources on crisis standards of care, resource allocation, and triage decision making in the COVID-19 pandemic

Triage

University of Pittsburgh: Allocation of Scarce Critical Care Resources During a Public Health Emergency  

Fair Allocation of Scarce Medical Resources in the Time of COVID-19 by Ezekiel Emanuel et al. in NEJM, March 23

The Toughest Triage — Allocating Ventilators in a Pandemic by  Robert Truog, Christine Mitchell, and George Daley in NEJM, March 23

Matthew Wynia & John 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?

Minnesota Department of Health clinical guidance on triage: Patient Care Strategies for Scarce Resource Situations. This includes specific guidance for shortages of oxygen (section 1), hemodynamic support (section 5), ventilators (Section 6), and ECMO (section 12) among other resources

From the CDC: Strategies for Optimizing the Supply of N95 Respirators, updated February 29, 2020

Guidance on ventilator allocation from the New York State Task Force on Life and the Law, New York State Department of Health (2015): Ventilator Allocation Guidelines

Guidance on pandemic influenza from the Pandemic Influenza Ethics Initiative Work Group of the Veteran’s Health Administration’s National Center for Ethics in Health Care (2010): Meeting the Challenge of Pandemic Influenza:  Ethical Guidance for Leaders and Health Care Professionals in the Veterans Health Administration

HHS Assistant Secretary for Preparedness and Response (ASPR) Technical Resources, Assistance Center, and Information Exchange (TRACIE) resource page on crisis standards of care

Ethical Guidance for Disaster Response, Specifically Around Crisis Standards of Care: A Systematic Review  (2017)

Care of the Critically Ill and Injured During Pandemics and Disasters: Chest Consensus Statement (2014)

Who Should Receive Life Support During a Public Health Emergency?  Using Ethical Principles to Improve Allocation Decisions (2009)

Institutional/hospital planning

Hasting Center Ethical Framework for Health Care Institutions and Guidelines for Institutional Ethics Services Responding to the Novel Coronavirus Pandemic

John Hick, Dan Hanfling, Matthew Wynia, & Andrew Pavia National Academies of Sciences, Engineering, and Medicine (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

Guidance on hospital preparation from the Johns Hopkins Center for Health Security: What US Hospitals Should Do Now to Prepare for a COVID-19 Pandemic

Optimizing Surge Capacity: Hospital Assessment and Planning This AHRQ issue brief discusses tools that can assist hospitals and other healthcare facilities with an assessment of their current capacity and develop a plan to achieve optimal surge capacity

Altered Standards of Care in Mass Casualty Events This AHRQ report is a summary of findings that emerged from experts’ discussion of the provision of health and medical care in a mass casualty event. It also includes recommendations for action that could be undertaken to support planning an effective response to a mass casualty event

CDC page on clinical guidance for state and local readiness

Guidance on pandemic influenza from the Pandemic Influenza Ethics Initiative Work Group of the Veteran’s Health Administration’s National Center for Ethics in Health Care (2010): Meeting the Challenge of Pandemic Influenza: Ethical Guidance for Leaders and Health Care Professionals in the Veterans Health Administration

ASPR TRACIE resource page on crisis standards of care

Kaiser Health News article on the state-by-state nature of pandemic preparedness and response, with quotes from Matthew Wynia, John Hick, & James Hodge: During A Pandemic, States’ Patchwork Of Crisis Strategies Could Mean Uneven Care

Clinical care, prognosis, research

DoD COVID-19 Practice Management Guide – Clinical management of COVID-19

Clinical research paper suggesting that older age, higher D-Dimer and higher SOFA score are correlated with higher mortality in COVID19 patients: Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Some special issues related to pediatrics are described in this 2011 paper: Ethical issues in pediatric emergency mass critical care

University of Washington resources, on its public site, including protocols regarding personal protective equipment, staff precautions, patient care, and autopsy

The COVID-19 Open Research Dataset (CORD-19)

Various issues (including those listed above)

AMA Journal of Ethics COVID-19 Ethics Resource Center

Hastings Center COVID Resources

Pandemic Ethics Literature, a Google Drive repository for Covid-19 resources, developed by Thomas Cunningham, Bioethics Director, Kaiser Permanente, West Los Angeles (and a graduate of Pitt’s MA Program in Bioethics), with the resources categorized as ‘academic’, ‘government’, and ‘other’ (guides, templates, news)

The Medical Ethics of the Coronavirus Crisis, an article by Isaac Chotiner in The New Yorker with quotes from Christine Mitchell

Resources about conducting research during the COVID-19 pandemic

University of Pittsburgh’s Human Research Protections Office (HRPO) COVID-19 webpage provides guidance on continuing/ceasing research operations and other resources and communications from University leadership

Johns Hopkins Hub on COVID-19 and Research Preparedness: Human Subjects

Ohio State provides guidance to investigators regarding current human subjects research procedures, communication with enrolled participants about COVID-19, and other issues

UC-Davis provides guidance, including some scripts, for human subjects researchers

The COVID-19 Webinar Series (including panelist Art Caplan) from the WCG Institute, which focuses on clinical research

'It's Quite Painful': Research Labs Shut Down Non-Coronavirus Work Amid Outbreak, a report from Boston’s NPR station, WBUR

Pacific University Oregon halts all non-essential human subjects research

Resources for explaining the pandemic

Naming the New Coronavirus – Why Taking Wuhan out of the Picture Matters by the Center affiliated faculty member Mari Webel from the Department of History, writing for The Conversation

Johns Hopkins Corona Virus Resource Center, including its Coronavirus COVID-19 Global Cases map

How Coronavirus Hijacks Your Cells, a New York Times article by Jonathan Corum & Carl Zimmer with helpful graphics

Why outbreaks like coronavirus spread exponentially, and how to “flatten the curve,” an article in the Washington Post by Harry Stevens with a simulation of virus spread

Why the [UK] Government changed tack on COVID-19, Saloni Dattani’s analysis of the UK’s approach—and change in approach—to the pandemic, published by UnHeard

While older patients with COVID-19 are the most likely to be hospitalized, to be admitted to ICU, and to die of COVID-19, 20% of US COVID-19 Deaths Were Aged 20-64, as reported March 19, 2020, in Medscape

Quarantined Italians’ messages to their earlier (10 days ago) selves and, by extension, to the rest of the world

Resources to meet the psychosocial & emotional demands of the pandemic

Soothing:

Monterey Bay Aquarium Webcams:  Jellyfish (1:00 pm – midnight EDT), Kelp Forrest (1:00 pm – 1:00 am EDT), Moon Jelly (1:00 pm – 1:00 am EDT); brief prerecorded clips are available at all times

Pittsburgh Zoo Penguins Webcam

Some museums are sharing their most “Zen like” works: #MuseumMomentofZen.

Art:

The Metropolitan Opera is streaming its video broadcasts—one per day, available on demand beginning at 7:30 pm. These are the Live in HD Broadcasts available (for >$25/ticket) in movie theaters over the past few years. March 23 – 26 will be Wagner’s Ring cycle. Nightly Met Opera Streams.

Twelve museums offer virtual tours of their collections, including the Cleveland Museum of Art, which is an open access museum permitting the public to share, remix, and reuse images for more than 30,000 artworks in the public domain from the museum's collection for both commercial and noncommercial purposes.

Beginning Wednesday, March 25, visit the Center’s Medical Humanities page for MedHum resources related to the COVID-19 pandemic.

How Not To Be A Coronavirus Jerk,  an article from Vice.com, quoting Center faculty member from CMU, Alex London, on how concepts like patience and empathy, can be helpful during these anxious times

Headspace is offering free subscriptions to all US healthcare workers in 2020, given the circumstances. This is a mindfulness meditation app that comes highly recommended, though not usually inexpensive. To redeem a free subscription, one must provide his/her state and NPI, name, and email address.

Ten Percent Happier is another program/app offering free access for health care workers, with a PROMO Code of HEALTHCARE (in ALL CAPS). One needs to download the app onto a mobile device—a desktop computer will not work—and must log into the app using the same method used to redeem access on the website. The company asks that no one create more than one account and cautions that the website has been overwhelmed, thus necessitating multiple attempts to redeem access.

Year of Wonders: A Novel of the Plague by Geraldine Brooks, described as “a tale of fragile hope pitted against overwhelming disaster” (by a review in the The Guardian) and based on the historical fact that in 1665, villagers in the Derbyshire town of Eyam, afflicted by the plague, voted to quarantine themselves so as not to spread the disease. Support a local independent bookstore that delivers and has curbside pick-up: The White Whale, including on-line bookshop.

Recommendations for global responses to the pandemic and for vulnerable populations

Responding to Covid-19 — A Once-in-a-Century Pandemic? by Bill Gates in the NEJM

COVID-19 and the Global Ethics Freefall from The Hastings Center’s Sridhar Venkatapuram

COVID-19: a potential public health problem for homeless populations

Pennsylvania Prison Society supports a COVID-19 resources page related to those incarcerated

Vaccine research

Making Emergency Use of Experimental Vaccines Safer (2020)—Reflecting on the Ebola epidemic, the authors analyze challenges of deploying experimental vaccines and present recommendations of the Pregnancy Research Ethics for Vaccines, Epidemics, and New Technologies (PREVENT) Working Group.

Guidance for Managing Ethical Issues in Infectious Disease Outbreaks (2016), World Health Organization—“Research is an integral part of the public health response—not only to learn about the current epidemic but also to build an evidence base for future epidemics. Research during an epidemic ranges from epidemiological and socio-behavioral to clinical trials and toxicity studies, all of which are crucial.”

Ethical Considerations of Experimental Interventions in the Ebola Outbreak (2014)—Reflecting on the Ebola epidemic, Rid and Emanuel argue that “experimental Ebola treatments or vaccines should only be deployed in clinical trials. If trials are done, they must meet the eight ethical principles for research.”

Ethics and Etiquette in an Emergency Vaccine Trial. The Orchestration of Compliance (2020)—cautioning readers about generalizing from the Ebola vaccine trial reported, the author analyzes “the practices that contributed to very high compliance rates [in an Ebola vaccine trial]. … This analysis uses the notion of bioetiquette—the set of rules specifying “proper” and “improper” trial subjects and behaviours—which runs in the shadow of formal bioethics in trials and requires careful transdisciplinary examination.”

Infectious Disease Research and Dual-Use Risk (2006)—presents general recommendations to address the dual-use risk presented by vaccine and treatment research on infectious

Ethics Review of Studies during Public Health Emergencies: The Experience of the WHO Ethics Review Committee during the Ebola Virus Disease Epidemic (2017)—Based on a review of 24 new and 22 amended protocols for studies reviewed by the WHO ethics review committee during the Ebola epidemic, including vaccine and drugs trials, the authors make 8 recommendations to accelerate study approval in future public health emergencies.

COVID-19 treatment research

Making Emergency Use of Experimental Vaccines Safer (2020)—Reflecting on the Ebola epidemic, the authors analyze challenges of deploying experimental vaccines and present recommendations of the Pregnancy Research Ethics for Vaccines, Epidemics, and New Technologies (PREVENT) Working Group.

Guidance for Managing Ethical Issues in Infectious Disease Outbreaks (2016), World Health Organization—“Research is an integral part of the public health response—not only to learn about the current epidemic but also to build an evidence base for future epidemics. Research during an epidemic ranges from epidemiological and socio-behavioral to clinical trials and toxicity studies, all of which are crucial.”

Ethical Considerations of Experimental Interventions in the Ebola Outbreak (2014)—Reflecting on the Ebola epidemic, Rid and Emanuel argue that “experimental Ebola treatments or vaccines should only be deployed in clinical trials. If trials are done, they must meet the eight ethical principles for research.”

Ethics and Etiquette in an Emergency Vaccine Trial. The Orchestration of Compliance (2020)—cautioning readers about generalizing from the Ebola vaccine trial reported, the author analyzes “the practices that contributed to very high compliance rates [in an Ebola vaccine trial]. … This analysis uses the notion of bioetiquette—the set of rules specifying “proper” and “improper” trial subjects and behaviours—which runs in the shadow of formal bioethics in trials and requires careful transdisciplinary examination.”

Infectious Disease Research and Dual-Use Risk (2006)—presents general recommendations to address the dual-use risk presented by vaccine and treatment research on infectious

Ethics Review of Studies during Public Health Emergencies: The Experience of the WHO Ethics Review Committee during the Ebola Virus Disease Epidemic (2017)—Based on a review of 24 new and 22 amended protocols for studies reviewed by the WHO ethics review committee during the Ebola epidemic, including vaccine and drugs trials, the authors make 8 recommendations to accelerate study approval in future public health emergencies.