COVID-19 Ethics Resources

An Executive Summary of a Model Hospital Policy for Fair Allocation of Medications to Treat COVID-19 from contributing authors at the University of Pittsburgh/UPMC Health System, Boston College, MIT, University of Denver, and Harvard University, May 18, with the full policy to be posted soon thereafter

Fair Allocation of Scarce Medical Resources in the Time of Covid-19 by Zeke Emanuel et al. with arguments supporting six recommendations, including that “prioritization guidelines should differ by intervention and should respond to changing scientific evidence,” that priority should be given to “front-line health care workers and others who care for ill patients and who keep critical infrastructure operating, particularly workers who face a high risk of infection and whose training makes them difficult to replace” and that some priority should be given to those “who participate in research to prove the safety and effectiveness of vaccines and therapeutics, NEJM, May 21  

Covid-19 Crisis Triage — Optimizing Health Outcomes and Disability Rights, arguing that “crisis triage protocols should focus on identifying the patients who are most likely to die without a ventilator yet most likely to survive with one, using the best available clinical survivability scores,” particularly immediate and near-term survival, by Mildred Solomon, Matthew Wynia, and Larry Gostin, May 19

Respecting Disability Rights — Toward Improved Crisis Standards of Care, arguing for the inclusion of near-term survival, but not long-term life expectancy in policies, among triage criteria in policies regarding allocation of scarce resources like ventilators and ICU, including some comment on some state policies, and recommending four substantive and two process considerations for such policies, by Michell Mello, Govind Persad, and University of Pittsburgh faculty member, Doug White, May 19

AGS Position Statement: Resource Allocation Strategies and Age-Related Considerations in the COVID-19 Era and Beyond, from the American Geriatrics Society, arguing against use of criteria such as “life-years saved” and “long-term predicted life expectancy” that might disadvantage older people in the allocation of scarce resources like ventilators, May 6

Is It Ethical to Unilaterally Withdraw Life-Sustaining Treatment in Triage Circumstances?, analyzing from a Roman Catholic perspective, employing the doctrine of double effect, the question of “whether mechanical ventilation may be unilaterally withdrawn from one patient, who has a relatively poor expected outcome, to benefit another who is predicted to survive to discharge,” May 15

Ventilator Triage Policies During the COVID-19 Pandemic at U.S. Hospitals Associated with Members of the Association of Bioethics Program Directors, characterizing development of ventilator triage policies and comparing policy content, by a Task Force of the Association, April 28

The Way We Ration Ventilators Is Biased: Not every patient has a fair chance, a New York Times  opinion piece by Harald Schmidt, April 15, prior to the April 15, 2020 revision of the policy discussed

When Medical Resources Are Scarce, Doug White’s Letter to the Editor in response, published April 28 (scroll to the bottom of the letters)

Allocation of Scarce Critical Care Resources During a Public Health Emergency: A Model Hospital Policy for Allocating Scarce Critical Care Resources, by Doug White, UPMC Endowed Chair for Ethics in Critical Care Medicine, with Scott D. Halpern of the University of Pennsylvania (Original version)

A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic by UPMC Endowed Chair for Ethics in Critical Care Medicine Douglas B. White and UCSF’s Bernard Lo, published in JAMA March 27, with a related JAMA podcast on March 28

Interim Pennsylvania Crisis Standards of Care for Pandemic Guidelines, developed by the Pennsylvania Department of Health and The Hospital & Healthsystem Association of Pennsylvania, April 10 (March 22 version)

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

Ventilator Allocation Guidelines—New York State Task Force on Life and the Law, 2015

• ‘I Will Not Apologize for My Needs’, a March 23 New York Times opinion piece by Ari Ne’eman, disability rights activist and co-founder of the Autistic Self Advocacy Network, who appointed to the National Council on Disability in 2009 by President Obama

• Disabusing the Disability Critique of the New York State Task Force Report on Ventilator Allocation, by Joseph J. Fins, who is a member of the New York State Task Force on Life and the Law and helped write its 2015 guidelines on the allocation of ventilators during a public health emergency, April 1

• Do New York State’s Ventilator Allocation Guidelines Place Chronic Ventilator Users at Risk? Clarification Needed, by Ari Ne’eman, April 3

• New York State Task Force on Life and the Law Ventilator Allocation Guidelines: How Our Views on Disability Evolved, a response by Joseph Fins, April 7

• Allocate ventilators, other Covid-19 resources based on evidence, not political hunches—an opinion piece by Susie A. Han and Valerie Gutmann Koch, who worked on the New York State Task Force on Life and the Law and the project chair of the Ventilator Allocation Guidelines, March 17 

Diversity and Solidarity in Response to Covid-19, responding to arguments presented by Ne’eman (April 13) and others, Govind Persad and David Wasserman argue there “are better ways to address disparities than abandoning the goal of saving more lives,” May 13

When It Comes to Rationing, Disability Rights Law Prohibits More than Prejudice, by Ari Ne’eman, April 10

Preventing Discrimination in the Treatment of COVID-19 Patients: The Illegality of Medical Rationing on the Basis of Disability, Disability Rights Education & Defense Fund, March 25

If Covid-19 gets bad, triage will be needed. Are we ready for that?, a STAT First Opinion, by Matthew Wynia & John Hick providing an overview of ethical principles and considerations in making triage decisions for COVID19, March 10

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 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)

Ethics, Pandemics, and the Duty to Treat—a critical examination of the grounds claimed for asserting that healthcare workers have a duty to treat in the context of an infectious disease pandemic, by Heidi Malm, Thomas May, Leslie Francis, et al., 2008

Ethical Dimensions of COVID-19 for Frontline Staff—published by the Royal College of Physicians, this short document identifies issues such as physicians working outside their specialty and physicians over the age of 70 and/or with co-morbid conditions, as well as the need to have advance care planning with patients in light of the pandemic; the document will be updated with specialty-specific guidance and is available for download here

In a Pandemic, Do Doctors Still Have a Duty to Treat?—a New York Times opinion piece by Sandeep Jauhar, author of Heart: A History and Doctored: The Disillusionment of an American Physician

Doctors Need Room to Make the Wrenching Decisions They Face-- Robert Klitzman urges other states to join New York’s Gov. Cuomo who issues an executive order granting healthcare providers immunity from criminal and civil liability during this pandemic

Protect the Doctors and Nurses Who Are Protecting Us—New York Times opinion piece by Doug White, UPMC Endowed Chair for Ethics in Critical Care Medicine, with Harvard Law School professors Glenn Cohen and Andrew M. Crespo, April 2

Potential Legal Liability for Withdrawing or Withholding Ventilators During COVID-19Assessing the Risks and Identifying Needed Reforms by I. Glenn Cohen, Andrew M. Crespo, and Douglas B. White, JAMA, April 1

COVID-19 and Health Data Privacy—from The Network for Public Health Law, this FAQ addresses HIPAA compliance and disclosures to various entities (e.g., housing authorities, law enforcement, media)

Limited Waiver of HIPAA Sanctions and Penalties During a Nationwide Public Health Emergency—from the Department of Health and Human Services, March 2020

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

Addressing Ethical Issues in Pandemic Influenza Planning, World Health Organization, 2007

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

During A Pandemic, States’ Patchwork Of Crisis Strategies Could Mean Uneven 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

Life After COVID-19: The Road to Recovery, May 14, surveying the wide range of symptoms and immediate and longer-term outcomes observed thus far

ICU Delirium’ is Leaving COVID-19 Patients Scared and Confused—In “regular” times, delirium has been infrequently discussed with patients entering or likely to enter the ICU; this brief article from The Atlantic (May 5) can help to prepare patients and families during this pandemic. See also The Atlantic’s June 7 article The Overlooked Danger of Delirium in Hospitals (not part of its free COVID-19 coverage).

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

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)

LitCovid is a literature hub for tracking up-to-date scientific information about the 2019 novel Coronavirus, curated by the NIH National Library of Medicine (NLM)

COVID-19 – ethical issues. A guidance note—British Medical Association, March 2020

AMA Code of Medical Ethics: Guidance in a pandemic

Adapting Standards of Care Under Extreme Conditions, American Nurses Association, 2008

Responding to COVID‐19: How to Navigate a Public Health Emergency Legally and Ethically, an overview by public health law and ethics scholar Larry Gostin with Eric Friedman and Sarah Wetter

New England Journal of Medicine’s collection of articles and other resources on the Coronavirus (Covid-19) outbreak, including clinical reports, management guidelines, and commentary

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

The New York Times is making its COVID-19 coverage available for free, as is the Coronavirus archive at The Atlantic

Science Friday produced a ~35 minute podcast The Many Ways COVID-19 Exacerbates Pre-existing Inequality. Among the resources it recommends are these:

• COVID-19 exacerbating inequalities in the US, The Lancet, April 18
• 'A Terrible Price': The Deadly Racial Disparities of Covid-19 in America, by L. Kasimu Harris for The New York Times, detailing how African Americans have been affected by the pandemic, April 29
• African Americans Bear the Brunt of Covid-19's Economic Impact, The Guardian, April 28

In How Racism Is Shaping the Coronavirus Pandemic, Evelynn Hammonds, Chair of Harvard’s Department of History of Science, is interviewed by Isaac Chotiner for The New Yorker, May 7

The Catholic Health Association of the United States has collected articles reporting on COVID-19 and health disparities

African Americans are disproportionately represented among those infected and among those dying:

• Early Data Shows African Americans Have Contracted, Died of Coronavirus at an Alarming Rate, ProPublica, April 2
• What COVID-19 Means for the American South, NPR’s The Takeaway, April 6 (minutes 2:00-37:30)—at minute 2:00, the report begins by relating COVID-19 to chronic health conditions and lack of health insurance, with comments from New Orleans which has the highest COVID-19 death rate and Mississippi which lacked Medicaid expansion ; at minute 21:10, the report shifts to the prevention of bias in the allocation of scarce healthcare resources, with commentary from Doug White, UPMC Endowed Chair for Ethics in Critical Care Medicine and co-author of the University of Pittsburgh’s: Allocation of Scarce Critical Care Resources During a Public Health Emergency
• COVID-19: Detroit's Black Community is Disproportionately Falling Ill and Dying, The Takeaway, April 7 (minutes 1:00 – 20:30)—from Detroit, Michigan, one of the few states tracking the racial breakdown of COVID-19 infection, this report connects difficulty preventing the spread of COVID-19 with economic and infrastructure issues, as well as long-standing social and racial inequities
• Coronavirus Is Devastating Communities Of Color, Exposing Underlying Health Inequities, Here and Now, April 7—ProPublica reports on the racial pattern of COVID-19 repeating in Milwaukee, Detroit, New Orleans, and New York’s largely low-income black and Latino neighborhoods
• Albany, Georgia, is an Unlikely Hotspot for COVID-19, The Takeaway, March 31 (minutes 1:06 – 13:58)—examining COVID-19 in one of Georgia’s most impoverished small towns

Coronavirus Exposes Public Health Inequities in Indigenous Communities, The Takeaway, April 2 (minutes 1:04 – 13:20)—a report about challenges of COVID-19 facing indigenous people living in both urban and reservation locations

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

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

Flattening the Curve for Incarcerated Populations — Covid-19 in Jails and Prisons—elaborating arguments supporting measures to protect incarcerated and nonincarcerated communities— NEJM, April 2

Older adults are at increased risk

• Why Covid-19 is so dangerous for older adults, a basic explanation from Vox, March 13
• 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
• 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

New Zealand has sought to eliminate the virus within its borders.

• New Zealand’s United against COVID-19 issues frequent updates.
• Wikipedia’s account of the COVID-19 pandemic in New Zealand
• Vanquish the Virus? Australia and New Zealand Aim to Show the Way, The New York Times, April 24
• How New Zealand 'eliminated' Covid-19 after weeks of lockdown, April 28
• Why New Zealand’s Coronavirus Elimination Strategy Is Unlikely to Work in Most Other Places, April 28

A Tale of Two Cities: Seattle And New York’s Response To The Pandemic, a 12 minute, April 27 segment of 1A, explores the view of former CDC director Tom Frieden that if New York had learned from Seattle’s experience and implemented stay-at-home orders “ten days earlier than it did, it might have reduced COVID-19 deaths by 50 to 80 percent”

Boris Johnson and COVID-19: A Timeline, Medscape News UK, April 7

Covid-19 and the Stiff Upper Lip — The Pandemic Response in the United Kingdom, NEJM, March 20

Lessons from Italy’s Response to Coronavirus from Harvard Business Review writers applying management decisionmaking, in retrospect, to Italy’s response, March 27

Why Germany's Coronavirus Death Rate Is Far Lower Than In Other Countries, NPR, March 25

Estimates of the prevalence of COVID-19 infection and predictions about the course of the current pandemic play a major role in public health and public policy responses to it. Differing views of epidemiologists and philosophers of science reveal the roles played by models and evidence. See, for example:

• Models v. Evidence by University of Pittsburgh’s Jonathan Fuller, Assistant Professor of History and Philosophy of Science, May 5
• On COVID-19, a Respected Science Watchdog Raises Eyebrows reports on controversy stirred by epidemiologist John Ioannidis, May 4
• Good Science Is Good Science by epidemiologist Marc Lipsitch, May 12
• COVID-19 Prevalence: John Ioannidis Responds to His Critics in this May 16 Medscape interview

Anatomy of a Coronavirus - An Interview with Virologist Barbara Sherry, who explains basic issues—e.g., what is a virus, what is the ACE2 receptor, how soap stops the spread of the virus—in an interview with science communicator Brian Malow on April 8

This 3-D Simulation Shows Why Social [sic. Physical] Distancing Is So Important; it augments the spread of coronavirus from a cough, sneeze, or conversation. A video at the end demonstrates through augmented reality technology what physical distancing looks like as one moves through a supermarket; the augmented reality technology may be downloaded for personal use in one’s own space.

Cannonsburg-based Ansys is also developing 3D simulations to encourage physical distancing, such as this comparison of the difference between 3 feet and 6 feet distancing in the presence of a cough.

Embracing the Uncertainties—While the unknowns about coronavirus abound, a new study finds we ‘can handle the truth’, New York Times, April 7

Dr. David Price of Weill Cornell Medical Center in New York City shares information in a Zoom call with family and friends on empowering and protecting families during the COVID-19 pandemic. Note that this was produced March 22; nevertheless, the advice and explanation remains relevant, and its practical, measured approach seems both empowering and comforting.  Further note: Since this video was made, all individuals are now being asked to cover their nose and mouth—using a nonmedical face mask or scarf—when they leave their homes, to avoid unknowingly transmitting the coronavirus. See:

• How NOT to Wear a Mask, with diagrams, New York Times, April 8
• How to Protect Yourself & Others, CDC, April 4

This recent directive reflects emerging evidence that the virus may be transmitted in ways not previously appreciated; see these articles:

• Coronavirus Is Aerosolized Through Talking, Exhalation, New Report Says, Medscape, April 4
• Turbulent Gas Clouds and Respiratory Pathogen Emissions Potential Implications for Reducing Transmission of COVID-19, JAMA, March 26, suggesting that “although no studies have directly evaluated the biophysics of droplets and gas cloud formation for patients infected with the SARS-CoV-2 virus, several properties of the exhaled gas cloud and respiratory transmission may apply to this pathogen,” which may warrant alteration of the 3 foot, now 6 foot physical distancing guidelines, to include covering nose and mouth as well when outside of one’s home.
• Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1, NEJM, March 17, reporting results, in a letter to the editor, indicating “that aerosol and fomite transmission of SARS-CoV-2 is plausible, since the virus can remain viable and infectious in aerosols for hours and on surfaces up to days (depending on the inoculum shed).”
• Transmission Potential of SARS-CoV-2 in Viral Shedding Observed at the University of Nebraska Medical Center, indicating that disease spread through both direct (droplet and person-to-person) as well as indirect contact (contaminated objects and airborne transmission) and supporting the use of airborne isolation precautions

Saving Your Health, One Mask at a Time—an accessible explanation of how the combination of hand washing, face non-touching, physical distancing, and mask wearing can help stop the spread of coronavirus and keep an individual more safe from infection, by Peter Tippett, MD, PhD, CEO careMESH. Note that the numbers he uses in his risk calculations are only estimates and/or mere examples.

How To Test A Country—Planet Money Episode 981 explaining why testing has taken so long to become available in the US

How the Virus Got Out—a New York Times online graphic from March 22

COVID19 in numbers—R0, the case fatality rate and why we need to flatten the curve—In this video, three computational biologists explain in accessible terms how contagious this coronavirus is, how many people it may infect, how virulent it is, and what it means to “flatten the curve.”

How the Pandemic Will End: The US may end up with the worst COVID-19 outbreak in the industrialized world. This is how it’s going to play out.—by Ed Yong in The Atlantic, March 25

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

The Imperial College COVID-19 Response Team modeling report that helped to persuade the UK to change its approach, March 16

Two commentaries in tension:

• A fiasco in the making? As the coronavirus pandemic takes hold, we are making decisions without reliable data by John P.A. Ioannidis, March 17
• We know enough now to act decisively against Covid-19. Social distancing is a good place to start by Marc Lipsitch, March 18

Mitigating Economic Impacts of the COVID-19 Pandemic and Preserving U.S. Strategic Competitiveness in AI, from the National Security Commission on Artificial Intelligence, “offers recommendations for using AI to mitigate the economic impact of COVID-19, and for protcting AI and other emerging technologies as strategic assets and sources of US and allied economic strength.”

When to Reopen the Nation is an Ethics Question—Not Only a Scientific One elaborates the normative dimensions of the decision about relaxing shelter at home orders, April 28.

COVID-19 Why We Can’t Test Our Way Out of This describes types of testing available and argues that testing is not the panacea it is purported to be, May 6.

What the Proponents of ‘Natural’ Herd Immunity Don’t Say—a May 1 New York Times opinion piece arguing that in the absence of a vaccine attempting to achieve herd immunity would involve “catastrophic loss of lives”

Grappling with the Ethics of Social Distancing: A Framework for Evaluating Social Distancing Policies and Reopening Plans—Plans for “reopening” society by relaxing, replacing, or eliminating at least some social distancing policies raise difficult ethical questions, as well as theoretical questions about modeling and empirical questions with answers that remain uncertain. This article provides a framework for evaluating various plans, and provides a step-by-step process for their evaluation. It also provides a table displaying key features of different plans.

When Can We Go Out? Evaluating Policy Paradigms for Responding to the COVID-19 Threat—this white paper from Harvard’s Edmond J. Safra Center for Ethics is in the Center’s repository containing all of its pandemic-related white papers and opinion pieces by faculty member Danielle Allen

Roadmap to Pandemic Resilience is the product of a bipartisan group of experts in economics, public health, technology, and ethics from across the country gathered by the Edmond J. Safra Center for Ethics with support from The Rockefeller Foundation

The Four Rules of Pandemic Economics—The Atlantic staff writer Derek Thompson discusses four key points and notes that saving the economy or saving lives is a false choice, along with his opinion piece, The Economy Is Ruined: It Didn’t Have to Be This Way, both on April 2

Angela Merkel explains the risks of loosening social distancing too rapidly in this video clip with subtitles

Scientific and Ethical Basis for Social-Distancing Interventions Against COVID-1—a March 23 article from The Lancet Infectious Diseases that foretold many of the consequences experiences, while providing the rationale for the policies pursued

Show Me Your Passport: Ethical Concerns About Covid-19 Antibody Testing as Key to Reopening Public Life discusses the scientific limitations of currently available antibody testing and ethical concerns associated with uses of proof of immunity

Disease Control, Civil Liberties, and Mass Testing — Calibrating Restrictions during the Covid-19 Pandemic, by David M. Studdert and Mark A. Hall (from, respectively Stanford’s and Wake Forest’s Schools of Law and Medicine)

Restarting America Means People Will Die. So When Do We Do It?—in this April 10 issue of The New York Times Magazine, five public scholars, including Ezekiel Emanuel and Peter Singer, discuss “reopening”

Inequality During a Pandemic, Part I: Shared Suffering and Self-Quarantine, by Robert L. Tsai, author of Practical Equality: Forging Justice in a Divided Nation, writing in the Harvard Law Review Blog, April 9

In When Will the Pandemic Cure Be Worse Than the Disease? Peter Singer and Michael Plant argue that directly focusing on well-being enables comparison of physical distancing policies and “reopening,”  April 6

In Pandemic Ethics: Infectious Pathogen Control Measures and Moral Philosophy, Jonathan Pugh and Tom Douglas, Senior Research Fellows at the Oxford Uehiro Centre for Practical Ethics, succinctly discuss utilitarian considerations, “the least restrictive alternative,” and the constraint of proportionality  in developing a pluralist justification for interventions, March 16

COVID-19 ‘Immunity Passports’ and Dystopian Segregation: A Few Concerns, by Daniel Tigard of the Institute for History & Ethics of Medicine at the Technical University of Munich, in an April 6 bioethics.net post

A Harm Reduction Approach to Physical Distancing, by Daniel Weinstock suggests thinking about space and time more creatively to make maintaining distance more plausible in the longer term, April 21

Cleanliness and good hygiene are vested with multiple meanings in this time of pandemic: some focus on caring for others; some are used to label and pressure others as sources of contagion. Clean in Times of Covid-19: on Hygiene and Pollution also addresses the impact on our environment of our ways of being clean to be safe from COVID-19

Privacy and Ethics Recommendations for Computing Applications Developed to Mitigate COVID-19, from the National Security Commission on Artificial Intelligence, “offers recommendations to put civil liberties at the center of contact tracing methods, and to ensure that federally funded AI tools used in pandemic response account for potential bias and avoid introducing additional unfairness into healthcare delivery and outcomes.”

Transcript: Re-Opening the Nation: Privacy, Surveillance and Digital Tools for Contact Tracing, the transcript of The Hasting Center’s May 18 discussion focused on digital tools and the ethical considerations they raise

A National COVID-19 Surveillance System: Achieving Containment, an April 7 policy report from Duke University’s Margolis Center for Health Policy describing features of a national surveillance system to mitigate the current pandemic wave and to limit and suppress future outbreaks

The European Data Protection Board’s Statement on the Processing of Personal Data in the Context of the COVID-19 Outbreak, adopted March 19

The Value and Ethics of Using Technology to Contain the COVID-19 Epidemic surveys ethical issues presented by some countries’ uses of technology to support nonpharmaceutical interventions in the pandemic, including digital contact tracing and use of geolocation data, April 23

The Value and Ethics of Using Phone Data to Monitor Covid-19, a March 30 analysis in Wired

Ethics and the Conduct of Public Health Surveillance by Amy Fairchild and Ronald Bayer addresses the question of whether the collection and analysis of data should always be considered research and thus be subject to ethical oversight, and whether this oversight should be welcomed or regarded as an impediment, 2004

Ethical Issues in Public Health Surveillance: A Systematic Qualitative Review, 2017 

With more students taking courses online due to the pandemic, an additional form of surveillance is unnerving some: remote proctoring of them taking examinations, as Monica Chin reports in Exam Anxiety: How Remote Test-proctoring Is Creeping Students Out—As Schools Go Remote, So Do Tests and So Does Surveillance, April 29

Cancer Research Ethics and COVID-19—This brief editorial in The Oncologist describes the need to balance responsibilities to oncology trial participants, particularly those in studies that may provide them direct therapeutic benefit, and the constraints imposed by the pandemic.

Covid-19 Changed How the World Does Science, Together—Reporting that “while political leaders have locked their borders, scientists have been shattering theirs, creating a global collaboration unlike any in history. Never before, researchers say, have so many experts in so many countries focused simultaneously on a single topic and with such urgency. Nearly all other research has ground to a halt.”—NYTimes, April 1

Preserving Clinical Trial Integrity During the Coronavirus Pandemic by Mary M. McDermott and Anne B. Newman, Chair and Professor of Epidemiology at Pitt

Office of Human Research Protections Guidance on COVID-19, April 8

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

Pacific University Oregon halts all non-essential human subjects research, March 17

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

The race for coronavirus vaccines: a graphical guide—Eight ways in which scientists hope to provide immunity to SARS-CoV-2—this graphical guide in Nature explains different vaccine designs.

The ethical challenge of infection-inducing challenge experiments—by G. Miller Franklin and Christine Grady, writing in Clinical Infectious Diseases in 2001, offer a framework for evaluating the ethical acceptability of infection-inducing challenge experiments that focuses on their “scientific and public health rationale …, the risks that they pose …, the symptoms experienced by healthy volunteers …, the exclusion of vulnerable research subjects, the informed consent process, the payment of volunteers, and the use of isolation of volunteers to prevent infection of others.”

In 2017, an ethics panel convened by the National Institute of Allergy and Infectious Diseases and the Walter Reed Army Institute of Research published its recommendations regarding a proposal to conduct a controlled infection study in healthy human volunteers to develop a vaccine against the Zika virus. Ethical Considerations for Zika Virus Human Challenge Trials contains considerations pertinent to development of a vaccine for COVID-19.

Ebola vaccine development plan: ethics, concerns and proposed measures—Of particular relevance for this pandemic is this paper’s discussion of whether healthcare workers should be prioritized for vaccine research, as well as the need to counter misinformation in order to facilitate research on a vaccine.

Vaccine testing for emerging infections: the case for individual randomization—Focusing on the 2014-2015 Ebola outbreak, authors Nir Eyal and Marc Lipsitch discuss the debate about using individually randomized controlled trials (iRCTs) to test candidate Ebola vaccines, a debate that centered on “statistical efficiency, logistical feasibility and public acceptability,” as well as ethical concerns. They make an ethical case for employing iRCTs based on benefits to non-participants, post-trial benefits to participants (including post-trial access to the study intervention), participants’ prospects before randomization, and the near-inevitable disparity between arms in any RCT.

Are placebo controls necessary in controlled human infection trials for vaccines?—The authors of this 2020 Personal Viewpoint article in The Lancet review considerations supporting the view that data from past studies (historical data) could be used as a valid alternative to a placebo control group.

"We are the heroes because we are ready to die for this country”: Participants' decision-making and grounded ethics in an Ebola vaccine clinical trial—This 2018 paper in Social Science and Medicine reports participant motivations for volunteering for a vaccine trial, in spite of anxieties, rumors and mistrust surrounding the Ebola outbreak.

Ethics and pre-exposure prophylaxis for HIV infection—Although this article focuses on ethical challenges of testing the effectiveness of PrEP in preventing HIV infection, there are relevant parallels to be drawn for testing of a COVID-19 vaccine, because while “providing preventive modalities besides what is being tested in the trial … may protect participants, it may also undermine the ability of the trial to answer the research question at hand.”

Microneedle array delivered recombinant coronavirus vaccines: Immunogenicity and rapid translational development—EbioMedicine publication reporting promising vaccine research, tested in mice, by the University of Pittsburgh (with Erasmus Medical Center Rotterdam), April 1

Coronavirus (COVID-19) Update: Vaccines and Immunity—JAMA audio interview with Mayo Vaccine Research Group Director Gregory Poland, MD, who discusses antibody responses, duration of immunity, vaccine safety, and the prospects for using convalescent serum to passively immunize people unexposed to SARS-CoV-2.

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.

Ethical considerations in post-market-approval monitoring and regulation of vaccines—This 2014 paper provides a framework for evaluating post-approval oversight of vaccines to minimize potential harms, including both direct harms to health and indirect harms resulting from withdrawal of vaccines from the market, and concomitant special harms to vulnerable populations.

The Danger of Rushing Through Clinical Trials During the Coronavirus Pandemic—an interview in The New Yorker with Peter B. Bach, who runs the Center for Health Policy and Outcomes at Memorial Sloan Kettering Cancer Center, and who cautions against relaxing rigorous standards for conducting clinical trials in the search for COVID-19 treatments

Clinical Trials vs. Right to Try: Ethical Use of Chloroquine for Covid-19—Robert Veatch argues that “whether hydroxychloroquine is beneficial or harmful depends not only on the results of trials, but also on the unique value systems of individual patients,” April 29

Ethical Responsibility in Publishing Research Results on Covid-19 Treatments—a brief commentary by Michael Erdek on the risks and ethics of premature publication, April 30

Against pandemic research exceptionalism, by Alex John London and Jonathan Kimmelman, arguing that rigorous standards for scientific research not be abandoned in COVID-19 clinical research, April 23 

Ethics and Evidence in the Search for a Vaccine and Treatments for Covid-19—placing the push to relax scientific standards in the historical context, this brief Hastings Center review recommends against acceding to this pressure, April 15

UPMC led global trial fast tracks testing of hydroxychloroquine, other COVID-19 therapies—in this April 9 news report, Derek Angus, Professor and Chair of Department of Critical Care Medicine at Pitt and UPMC, explains an adaptive clinical trial model that relies on reinforcement learning (a type of artificial intelligence) to identify an evidence-backed therapy for COVID-19 more rapidly than can be achieved through traditional clinical trial approaches

Compassionate Use of Remdesivir for Patients with Severe Covid-19—reporting on a Gilead Sciences funded study of 53 patients, with 36 showing “clinical improvement,” following compassionate use of Remdesivir

FDA Expedites Treatment of Seriously Ill COVID-19 Patients with Experimental Plasma, an NPR news report that includes brief discussion of research risks, March 24

Treating COVID-19—Off-Label Drug Use, Compassionate Use, and Randomized Clinical Trials During Pandemics—Arguing for the importance of RCTs with appropriate control groups, the author states: “The administration of any unproven drug as a “last resort” wrongly assumes that benefit will be more likely than harm. However, when a drug with unknown clinical effects is given to patients who have severe illness from a new disease (like COVID-19), there is no way to know whether the patients had benefited or were harmed if they were not compared to a concurrent control group. A common interpretation of off-label use and compassionate use of drugs is that is that if the patient died, they died from the disease, but if the patient survived, they survived because of the given drug. This is not true.”

Infectious Disease Research and Dual-Use Risk, a brief overview of the dual-use research concern that research on infectious agents, their prevention, and their treatment can be diverted and “weaponized”

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.

Attack Theatre—founded in 1994 “as a collaboration between two dancers and a city”— is a modern dance company using original live music and interdisciplinary art forms. During the pandemic, it is producing Cello Diary, posted here on April 29, International Dance Day.

You can laugh, you can cry, it may be better than Cats:  With stages dark, several theaters and streaming services are making past productions free for the viewing. See Where to Find Drama Now? All the Internet’s a Stage for a listing, including: the National Theater at Home initiative that uploads an archived production on its YouTube channel every Thursday, where it can be seen, for free, for a week; several free Shakespeare’s Globe productions; and The Show Must Go On! that posts Andrew Lloyd Webber musicals.

The Rotterdam Philharmonic teamed up with a Dutch healthcare provider to film the finale of Beethoven’s 9th with all the musicians playing their parts by video from their homes.

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. 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.

For those who like to color between the lines, the New York Times published a COVID-19 Coloring Activity

For those seeking a brief gallery tour, view these works in glass, “an homage to the future generations of Indigenous people” by Preston Singletary

The Carnegie Museum of Art is offering artwork to take you through the week from Monday Motivation and Tour Tuesday to Storyboard Saturday and Self-Care Sunday.

Virtual tours of over 1200 art museums

A 5-Hour, One-Take Cinematic Tour of Russia’s Hermitage Museum, Shot Entirely on an iPhone

Visit the Center’s COVID-19 Medical Humanities Resources page.

Sustaining Clinical Empathy During the Pandemic—recommends strategies of engaged curiosity and self-awareness to avoid empathy depletion

Telehealth and Online Mental Health Resources During COVID-19 Pandemic—resources recommended by Sunshine Behavioral Health, which provides substance abuse treatment services

For some people, identifying a way to help other people helps them address their own anxiety, thereby fueling mutual aid efforts like those described in The New Yorker’s What Mutual Aid Can Do during a Pandemic, May 11

The best thing you can do for your health: sleep well—The Guardian, February 9, and as The Guardian also suggests, make a donation if you can to support journalism, or perhaps the arts, your local bookstore, or your local restaurant worker (Virtual Tip Jar); you may sleep better

Fiction Podcasts to Get Lost In—when screen time is overwhelming and being absorbed in a non-COVID-19 plot desirable, these podcasts recommended by The New York Times may distract

Coursera Together: Free online learning during COVID-19—available through July 31, including courses on mental health and well-being and on understanding public health, as well as courses to make productive use of time at home

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.