COVID-19 Ethics Resources

COVID-19 ACIP Vaccine Recommendations from the Advisory Committee on Immunization Practices, updated December 3 - March 2, 2021

The Advisory Committee on Immunization Practices’ Ethical Principles for Allocating Initial Supplies of COVID-19 Vaccine — United States, 2020 from the CDC, November 23, 2020

EtR Framework: Values, Acceptability and Feasibility Domains, the PowerPoint by the Ethics Subcommittee to the Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention

Framework for Equitable Allocation of COVID-19 Vaccine from the National Academies of Sciences, Engineering, and Medicine (NASEM), 2020, is available to read online or for free download

September 24  Response from the Catholic Health Association of the United States to the discussion draft of  the National Academies Framework for Equitable Allocation of COVID-19 Vaccine, reflecting its own Vaccine Equity and Catholic Principles for the Common Good, disseminated July 27, 2020

COVID-19 Vaccines: Resources for [Roman Catholic] Church Leaders from the Vatican COVID-19, March 2, 2021

Enhancing the WHO’s Proposed Framework for Distributing COVID-19 Vaccines Among Countries by Zeke Emanuel et al. suggests that adopting a “fair priority model” would make the WHO approach better achieve its own ethical goals, American Journal of Public Health, March 2021

An ethical framework for global vaccine allocation articulates the “fair priority model,” in Science, September 2020

ASHP principles for COVID-19 Vaccine Distribution, Allocation, and Mass Immunization from the American Society of Health-System Pharmacists, 2020

Interactive Vaccine Allocation Map, launched February 1, 2021, comparing 4 vaccine allocation scenarios county-by-county and demonstrating no allocation strategy is value neutral, from Columbia and Yale Mapping the New Politics of Care collaborative project

See How the Vaccine Rollout Is Going in Your County and State from the New York Times shows county-level vaccination levels based on data from the CDC, lists state eligibility requirements, and provides access to the Times other data-based graphics and maps (e.g., tracking cases, deaths, vaccines in stages of development)

CDC data on COVID-19, including vaccine distribution by manufacturer and jurisdiction, updated each Tuesday

The Ethics of Crossing State Lines For A COVID-19 Vaccine, quoting Center faculty member Michael Deem, NPR-WESA, March 29, 2021

Undocumented Immigrants and Covid-19 Vaccination by Mark A. Rothstein and Christine N. Coughlin, arguing that everyone’s self-interest supports universal vaccination including undocumented immigrants, March 8, 2021

Working Around the System: Vaccine Navigators and Vaccine Equity by Nancy Berlinger and Jeanne Marie Mirabella, March 5, 2021

Whose Underlying Conditions Count for Priority in Getting a Covid Vaccine? by Liz Bowen in Scientific American, arguing that rare diseases have been neglected in CDC guidelines, February 6, 2021

Weighted Lotteries and the Allocation of Scarce Medications for Covid‐19 by Lynn A. Jansen and Steven Wall, The Hastings Center Report, February 25, 2021

Should Covid Vaccination Schedules Deviate from the Status Quo–as a Last Resort? by Nina Shevzov-Zebrun, Arthur Caplan and Brendan Parent, February 1, 2021

Ethics Supports Seeking Population Immunity, Not Immunizing Priority Groups by Michael DeVita and Lisa S. Parker, January 26, 2021

Ethical Challenges in the Middle Tier f Covid-19 Vaccine Allocation: Guidance for Organizational Decision-Making from The Hastings Center, focused on the ethics of vaccine distribution to those in the 1b and 1c categories, also considers vaccination and health justice, January 15, 2021

Recommendations for Prioritization and Distribution of COVID-19 Vaccine in Prisons and Jails, a brief white paper issued December 16, 2020

Prioritizing the 1a: Ethically Allocating Scarce Covid Vaccines to Health Care Workers addresses how to allocate vaccine among healthcare workers given that hospitals will not receive a sufficient allotment for all, December 16, 2020

On December 6, 2020, The New York Times, reported on the challenge the CDC faced in determining who should receive the second round of vaccine doses; see The Elderly vs. Essential Workers: Who Should Get the Coronavirus Vaccine First?. The Times is collecting its reporting on the vaccines here.

Prioritizing COVID-19 vaccination for people with severe mental illness, a perspective from an interdisciplinary group in Belgium, November 1, 2020

Is It Lawful and Ethical to Prioritize Racial Minorities for COVID-19 Vaccines? concludes that a “vaccine distribution formula, therefore, could lawfully prioritize populations based on factors like geography, socioeconomic status, and housing density that would favor racial minorities de facto, but not explicitly include race,” in JAMA, October 2020

Rationing of civilian COVID-19 vaccines while supplies are limited by University of Pittsburgh Department of Family Medicine faculty Richard Zimmerman and Jeanette South-Paul, with co-author Gregory Poland, September 7, 2020

Why COVID-19 vaccines need to prioritize ‘superspreaders’, by two economists and a data scientist, writing for the Conversation, September 3, 2020

Who Gets the Covid-19 Vaccine First? Here’s One Idea, by Gina Kolata, quotes UPMC Endowed Chair for Ethics in Critical Care Medicine Doug White and presents proposals for a weighted lottery to allocate scarce vaccine, New York Times, July 23, 2020

The line is forming for a COVID-19 vaccine. Who should be at the front? Discusses scientific and ethical considerations in the future allocation of scarce COVID-19 vaccines, Science, June 29, 2020

Vaccine Rationing and the Urgency of Social Justice in the Covid‐19 Response, by Harald Schmidt in The Hastings Center Report, argues that “ethical, epidemiological, and economic reasons demand that rationing approaches give priority to groups who have been structurally and historically disadvantaged, even if this means that overall life years gained may be lower,” May 28, 2020

Vaccine Update: Development, Approval, Allocation and Distribution in the US, an archived webinar presented by the National Academy of Medicine and the American Public Health Association, first presented November 18, 2020

Walid Gellad, Director of Pitt’s Center for Pharmaceutical Policy and Prescribing wrote More Safety Data Would Be Nice, But We Need a Vaccine Now for Wired, November 11, 2020

The unequal scramble for coronavirus vaccines — by the numbers, a news report in Nature documenting wealthy countries’ pre-ordering of vaccines in development, August 24, 2020

How Herd Immunity Works — And What Stands In Its Way, a simulation from NPR, February 18, 2021

In Good reasons to vaccinate: mandatory or payment for risk? Julian Savulescu defends mandating vaccination and paying individuals for assumption of risk, in Journal of Medical Ethics, February 2021

Susan Pennings and Xavier Symons respond that Persuasion, not coercion or incentivisation, is the best means of promoting COVID-19 vaccination

Mandating COVID-19 Vaccines by Larry Gostin et al. advocates “limited vaccine mandates with public support, in special high-risk or high-value settings,” in JAMA, February 2021

US Public Attitudes Toward COVID-19 Vaccine Mandates by Largent EA, et al., in JAMA Network Open, December 2020

Let Employers Mandate Vaccines by Art Caplan, February 12, 2021

Time to mandate influenza vaccination in health-care workers by Art Caplan, July 23, 2011

Coronavirus Variants and Mutations by Jonathan Corum and Carl Zimmer, an updated archive of recent information, March 22, 2021

How do coronavirus variants form and will the current vaccines work against them? Pitt faculty Ghady Haidar and Paul Duprex appeared on 60 Minutes on March 14, 2021, to explain their study (published in Science) of mutations in the coronavirus; also appearing are David Ho and Francis Collins discussing emerging variants and vaccine effectiveness

A Dose Of Reality, a four-part episode of On the Media from WNYC-NPR, discussing vaccine hesitancy and including Rev. Paul Abernathy’s efforts in Pittsburgh to address concerns of members of Black communities, December 4, 2020

COVID-19 vaccine hesitancy in the UK: the Oxford coronavirus explanations, attitudes, and narratives survey (Oceans) II reports on development and use of a vaccine hesitancy scale with rather unsurprising results, December 2020

In Mitigating Inequities and Saving Lives with ICU Triage During the COVID-19 Pandemic, Doug White, UPMC Endowed Chair for Ethics in Critical Care Medicine and UCSF’s Bernie Lo, address the concern that “use of existing ICU triage protocols to allocate scarce ventilators and critical care resources—most of which are designed to save as many lives as possible—would compound” the inequitable burdens of COVID-19 that have disproportionately fallen on already disadvantaged groups, American Journal of Respiratory and Critical Care Medicine, December 2, 2020.

Access to Therapeutic and Palliative Drugs in the Context of Covid-19: Justice and the Relief of Suffering from The Hastings Center, July 14, 2020

Volume 20, Issue 7 of The American Journal of Bioethics, is a special issue on COVID-19 and allocation of scarce resources, with articles by Center faculty members Lisa Parker, Doug White, and Mark Wicclair, July 8, 2020, contact bioethics@pitt.edu regarding AJOB’s limited article access

Ethical Challenges Arising in the COVID-19 Pandemic: An Overview from the Association of Bioethics Program Directors (ABPD) Task Force, July 8, 2020, contact bioethics@pitt.edu regarding AJOB’s limited article access

Contingency and Crisis Standards of Care – Palliative Care and Hospice Services, issued by Colorado’s Governor’s Expert Emergency Epidemic Response Committee, was updated to take into consideration the challenges presented by COVID-19, and join the Colorado Crisis Standards of Care documents the Committee approved on April 5, 2020

Ethical Allocation Framework for Emerging Treatments of COVID-19, from the Commonwealth of Pennsylvania, articulates an allocation framework embracing the public health goal of redressing inequities that make health and safety less accessible to disadvantaged groups and, within this broader framework, provides an example of how somewhat increased chances to receive treatment for COVID-19 may be given to members of disadvantaged communities

Model Hospital Policy for Fair Allocation of Scarce 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 28, 2020 draft

A Conversation about Allocating Scarce COVID-19 Medications: The Case for Increasing Disadvantaged Groups’ Access, with University of Pittsburgh Professor of Medicine Mark Schmidhofer, part of the Pandemic Policies & Practices series co-sponsored by the Mid-Atlantic Regional Public Health Training Center and the Center for Bioethics & Health Law, July 7, 2020

A Proposed Lottery System to Allocate Scarce COVID-19 Medications: Promoting Fairness and Generating Knowledge, by Doug White and Derek Angus,  JAMA, June 24, 2020

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, 2020 

On Being an Elder in a Pandemic, by Larry Churchill, discuss the special obligations he believes elders have during this pandemic, not as a matter of policy, but as the result of embracing a lifespan approach to ethics, April 13, 2020

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, 2020

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 Michelle Mello, Govind Persad, and University of Pittsburgh faculty member, Doug White, May 19, 2020

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, 2020

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, 2020

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, 2020

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, 2020, 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, 2020 (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, April 15, 2020, by Doug White, UPMC Endowed Chair for Ethics in Critical Care Medicine, with Scott D. Halpern of the University of Pennsylvania (Original version)

A Conversation about Allocating Scarce Resources, with Doug White, as part of the Pandemic Policies & Practices series co-sponsored by the Mid-Atlantic Regional Public Health Training Center and the Center for Bioethics & Health Law, May 12, 2020; the presentation begins at minute 7

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, 2020, with a related JAMA podcast on March 28, 2020

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, 2020 (March 22, 2020 version)

Fair Allocation of Scarce Medical Resources in the Time of COVID-19 by Ezekiel Emanuel et al. in NEJM, March 23, 2020

The Toughest Triage — Allocating Ventilators in a Pandemic by Robert Truog, Christine Mitchell, and George Daley in NEJM, March 23, 2020

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

• ‘I Will Not Apologize for My Needs’, a March 23, 2020 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, 2020
• Do New York State’s Ventilator Allocation Guidelines Place Chronic Ventilator Users at Risk? Clarification Needed, by Ari Ne’eman, April 3, 2020
• 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, 2020
• 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, 2020 

Diversity and Solidarity in Response to Covid-19, responding to arguments presented by Ne’eman (April 13, 2020) 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, 2020

When It Comes to Rationing, Disability Rights Law Prohibits More than Prejudice, by Ari Ne’eman, April 10, 2020

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, 2020

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, 2020

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)

Allocating Ventilators During the COVID-19 Pandemic and Conscientious Objection, by Center faculty member Mark Wicclair, July 27, 2020

“We Signed Up for This!” — Student and Trainee Responses to the Covid-19 Pandemic—a NEJM perspective piece reflecting on a survey of ~300 trainees, June 18, 2020

A Conversation about Providers’ Liability and Immunity for Providing COVID-19 Care with Diane Hoffman, Professor of Law at the University of Maryland, part of the Pandemic Policies & Practices series co-sponsored by the Mid-Atlantic Regional Public Health Training Center and the Center for Bioethics & Health Law, May 26, 2020

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, 2020

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, 2020

Responding to Covid-19 as a Regional Public Health Challenge, guidance from The Hastings Center regarding collaboration among hospitals within a region, April 29, 2020

Ethical Framework for Health Care Institutions & Guidelines for Institutional Ethics Services Responding to the Coronavirus Pandemic from The Hastings Center, March 16, 2020

COVID-19 and Underinvestment in the Public Health Infrastructure of the United States and COVID-19 and Underinvestment in the Health of the US Population in The Millbank Quarterly discuss features of US policy that made it more susceptible to COVID-19 and its lingering effects, June 2020

Lessons from Covid-19: Why Treating Sick Patients is Bad Business for Hospitals places in the broader context of the US health insurance system the economic challenges of caring for COVID-19 patients faced by healthcare institutions and society

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

Communication Skills in the Age of COVID-19, co-authored by Center faculty member Robert Arnold, Chief of the Department of Medicine’s Section of Palliative Care and Medical Ethics, and Director of the Institute for Doctor-Patient Communication, presenting a “talking-map” to discuss care planning with critically ill patients and their families during the pandemic, April 2020

A Conversation about Ethical Issues Arising with Use of Telemedicine during This Pandemic, with Gary Fischer, Professor of Medicine and Biomedical Informatics, and Medical Director, Clinical Decision-Support and Analytics, Ambulatory eRecord at the University of Pittsburgh, part of the Pandemic Policies & Practices series co-sponsored by the Mid-Atlantic Regional Public Health Training Center and the Center for Bioethics & Health Law, June 23, 2020

ICU and Palliative Care services have been profoundly affected during the pandemic in ways that raise ethical questions for care during the pandemic and in general:

• "You Can See Your Loved One Now." Can Visitor Restrictions During Covid Unduly Influence End-of-Life Decisions? considers whether visitation restrictions not only made for gut-wrenching experiences for patients and families, but also unduly influenced end-of-life decisions, even being perceived as coercive, June 18, 2020 
• Not Dying Alone — Modern Compassionate Care in the Covid-19 Pandemic, a NEJM perspective piece considering how technologies may be employed to ease the pain of patients and their families at the end of life, June 11, 2020
• The Hastings Center has collected articles on the relief of suffering during the pandemic, access to palliative drugs, and considerations of justice

Life After COVID-19: The Road to Recovery, May 14, 2020, 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, 2020) can help to prepare patients and families during this pandemic. See also The Atlantic’s June 7, 2020 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)

Structural Racism in the COVID-19 Pandemic: Moving Forward, an American Journal of Bioethics article with a series of commentaries, by Maya Sabatello et al. March 2021

The COVID Racial Data Tracker from The Atlantic’s COVID Tracking Project, updated regularly

What Young, Healthy People Have to Fear From COVID-19, by Atlantic staff writer Derek Thompson, explains that COVID-19 is not quite benign for younger people and why seeking to establish herd immunity is an inappropriate strategy to combat it, September 6, 2020

In Why Some People Get Terribly Sick from COVID-19 science journalist Claudia Wallace analyzes some findings about variation in the severity of COVID-19, Scientific American, August 20, 2020

A Conversation about the Ethical Concerns of People with Disabilities, with Mary Crossley, Professor of Law at the University of Pittsburgh, part of the Pandemic Policies & Practices series co-sponsored by the Mid-Atlantic Regional Public Health Training Center and the Center for Bioethics & Health Law, June 9, 2020

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, 2020
• '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, 2020
• African Americans Bear the Brunt of Covid-19's Economic Impact, The Guardian, April 28, 2020

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, 2020

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, 2020
• 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, 2020 (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, 2020—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, 2020 (minutes 1:06 – 13:58)—examining COVID-19 in one of Georgia’s most impoverished small towns

Rural communities face particular challenges during the pandemic:

• A Conversation about Creating Fair Opportunity for Rural Americans, with Valerie B. Satkoske, part of the Pandemic Policies & Practices series co-sponsored by the Mid-Atlantic Regional Public Health Training Center and the Center for Bioethics & Health Law, August 18, 2020
• Rural America is more vulnerable to COVID-19 than cities are, and it’s starting to show, by David Peters at Iowa State University, in The Conversation series about the pandemic, June 18, 2020
• On The Brink, Rural Hospitals Brace For New Surge In COVID-19 Cases is a July 3, 2020 NPR report.
• As Coronavirus Slams Houston Hospitals, It’s Like New York ‘All Over Again’, a New York Times report detailing similarities and differences in the current pandemic response, July 4, 2020
• Case Study: Managing COVID-19 in a Rural Community: St. James Parish Hospital, Lutcher, Louisiana—Details how St. James Parish Hospital in Lutcher, Louisiana, worked with local government community partners to prepare for COVID-19
• COVID-19 And The Financial Viability Of US Rural Hospitals—Examines the financial pressures on rural hospitals and how the COVID-19 pandemic is impacting hospital finances and identifies potential policy options to help rural hospitals and maintain rural healthcare access

Coronavirus Exposes Public Health Inequities in Indigenous Communities, The Takeaway, April 2, 2020 (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, which includes an interactive map tracking the spread and mitigation of COVID-19 in Pennsylvania prisons and jails

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, 2020

Older adults are at increased risk:

• Why Covid-19 is so dangerous for older adults, a basic explanation from Vox, March 13, 2020
• 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

Pregnant women face particular health- and healthcare-related concerns during the pandemic:

• The Birth of Injustice: COVID-19 Hospital Infection Control Policy on Latinx Birth Experience by Pitt faculty member Marielle Gross and Alexandra Norton in AJOB, February 2021
• A Conversation about Ethical Challenges for Evidence-Based Obstetrics during COVID-19, with Marielle Gross, MD, MBE, Assistant Professor of Obstetrics, Gynecology and Reproductive Services University of Pittsburgh, part of the Pandemic Policies & Practices series co-sponsored by the Mid-Atlantic Regional Public Health Training Center and the Center for Bioethics & Health Law, July 21, 2020
• The Legal and Medical Necessity of Abortion Care Amid the COVID-19 Pandemic, by Center faculty members Greer Donley and Sonya Borrero, with Beatrice Chen, argues that no public health interest is served by classifying abortion as nonessential healthcare, April 2020
• COVID-19 amplifies racial disparities in maternal health, May 14, 2020
• COVID-19 Is No Reason to Abandon Pregnant People, a Scientific American blog criticizing early policies barring spouses and doulas during labor and delivery, March 26, 2020

COVID-19 Timeline: Critical Moments in the First Year produced by information designer Lydia Hooper, Jan 29, 2021

The Code: How Genetic Science Helped Expose a Secret Coronavirus Outbreak, by Sarah Kaplan et al., The Washington Post, September 24, 2020

The Mayo Clinic provides accurate, up-to-date, patient-focused explanation of the symptoms, cause, diagnosis, and treatment of COVID-19, as it does for many medical conditions

A Primer on R0 for Infectious Diseases from 2U, a company providing digital learning technology

COVID-101: Doctor-reviewed answers to all your COVID-19 questions. This website states “Our consortium of public health experts, medical doctors, and experts-in-training rapidly review the scientific literature and tell you what you need to know. Each post is reviewed for accuracy by our doctors.”

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, 2020
• On COVID-19, a Respected Science Watchdog Raises Eyebrows reports on controversy stirred by epidemiologist John Ioannidis, May 4, 2020
• Good Science Is Good Science by epidemiologist Marc Lipsitch, May 12, 2020
• COVID-19 Prevalence: John Ioannidis Responds to His Critics in this May 16, 2020 Medscape interview

History and Symptoms of the Coronavirus Illness, from Pacific Medical Training, provides some basic information and context for understanding COVID-19, accessed November 20, 2020

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, 2020

Embracing the Uncertainties—While the unknowns about coronavirus abound, a new study finds we ‘can handle the truth’, New York Times, April 7, 2020

How To Test A Country—Planet Money Episode 981, from March 18, 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, 2020

Measuring the basic reproduction rate (R0), dispersion (k), and case fatality rate of coronavirus:

• 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.”

• This Overlooked Variable Is the Key to the Pandemic. It’s not R.—Zeynep Tufekci, a University of North Carolina faculty member writing in The Atlantic, explains attempts to measure dispersion of the virus and the “superspreader” phenomenon, September 30, 2020

Here’s How the Pandemic Finally Ends gathers comments from 11 experts, including Paul Offit and Zeke Emanuel, on the next one to three years, Politico, September 25, 2020

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, 2020

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, 2020

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, 2020
• We know enough now to act decisively against Covid-19. Social distancing is a good place to start by Marc Lipsitch, March 18, 2020

The Plan That Could Give Us Our Lives Back, by Atlantic staff writers Robinson Meyer and Alexis C. Madrigal, report on a plan that doesn’t depend on a vaccine, but emphasizes testing, August 14, 2020

Justin Bernstein, PhD, provides  A Conversation about Lives and Livelihoods: Evaluating What’s at Stake in Reopening in a one-hour webinar co-sponsored by the Mid-Atlantic Regional Public Health Training Center and the Center for Bioethics & Health Law, August 4, 2020

America Is Giving Up on the Pandemic discusses the risk of a resurgence of COVID-19 in the current contest of both venues reopening and responses to police abuse of power, and points to both the role of luck and the role of injustices in the cases and patterns of infection that will result, The Atlantic, June 7, 2020

Democracy and Pandemics is a series of essays by social scientists investigating “the implications of Covid-19, pandemics, and major crises more generally, for democratic governance” as “public safety concerns are weighed against foundational freedoms and the norms and expectations of a democratic citizenry.”

Society after Pandemic, by Alondra Nelson, President of the Social Science Research Council, poses this question for social scientists: “how do the social conditions exposed, exacerbated, and created by the novel coronavirus demand that we substantively rethink our ideas of society and, therefore, some of the prevailing assumptions, methods, and theories of social science?”

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 protecting 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, 2020.

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, 2020.

What the Proponents of ‘Natural’ Herd Immunity Don’t Say—a May 1, 2020 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, 2020.

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, 2020 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, 2020

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, 2020

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, 2020

Isolated By The Law is the Wake Forest Journal of Law and Policy archive of two webinar series it hosted: one from 2018 on the legal and ethical implications surrounding quarantine during public health emergencies, and the second, a set of 2020 responses to the issues presented in 2018, in light of COVID-19

Building Solidarity: Challenges, Options, and Implications for COVID-19 Responses, a white paper from the Edmond J. Safra Center for Ethics discussing why social solidarity is a prerequisite for the success of more technical interventions during the pandemic and providing some strategies for fostering solidarity, March 30, 2020

In What Values Should Guide Us? on April 21, 2020 Zeke Emanuel and Danielle Allen discussed values like public health, economic well-being, and respect for civil liberties that must be balanced in maintaining the economy and public health. Allen advocated massively ramped up testing is a key ingredient of re-opening, and panelists noted that the Centers for Disease Control and Prevention guidelines, which called for testing those with symptoms, were wrong-headed. Instead, asymptomatic people needed to be tested to identify those who are spreading it and ask them to isolate themselves. On December 9, 2020, The New York Times explained different types and methods of testing and their goals; see What You Need to Know about Getting Tested for Coronavirus.

The Unequal Cost of Social Distancing discusses the disparate impact of social distancing on already disadvantaged individuals and households.

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, 2020

Center faculty member Alan Meisel is quoted in this USA Today Fact check: No mask? You can ask why — it isn’t against HIPAA or the Fourth or Fifth Amendments, July 20, 2020

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, 2020 article from The Lancet Infectious Diseases that foretold many of the consequences experiences, while providing the rationale for the policies pursued

This 3-D Simulation Shows Why Social [sic. Physical] Distancing Is So Important; it 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.

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, 2020; nevertheless, much of 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, and in many cases required, 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:

• A User's Guide To Masks: What's Best At Protecting Others (And Yourself), NPR, July 1, 2020

• How NOT to Wear a Mask, with diagrams, New York Times, April 8, 2020

• How to Protect Yourself & Others, CDC, April 4, 2020

The evolution of advice regarding mask-wearing reflects evolving evidence that the virus is transmitted in ways not initially appreciated; see these articles and a two-day workshop from the National Academies:

• Airborne Transmission of SARS-CoV-2: A Virtual Workshop, video of the workshop held on August 26-27, 2020, which had this agenda
• 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.
• Coronavirus Is Aerosolized Through Talking, Exhalation, New Report Says, Medscape, April 4, 2020
• Turbulent Gas Clouds and Respiratory Pathogen Emissions Potential Implications for Reducing Transmission of COVID-19, JAMA, March 26, 2020, 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, 2020, 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

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, 2020 discussion focused on digital tools and the ethical considerations they raise

A National COVID-19 Surveillance System: Achieving Containment, an April 7, 2020 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, 2020

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, 2020

The Value and Ethics of Using Phone Data to Monitor Covid-19, a March 30, 2020 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, 2020

COVID-19 vaccine research and the trouble with clinical equipoise argues that “a more fine-grained analysis of clinical equipoise is needed to account for cases in which uncertainty in the medical community exists for some outcomes [of COVID-19 research] and not for others,” in Lancet, February 2021

A Politics-free Path to a COVID-19 Vaccine outlined by Physicians for Human Rights Advisory Council members, October 30, 2020

Ethics of Placebo Controls in Coronavirus Vaccine Trials, by Franklin G. Miller, who argues that even after some vaccines receive Emergency Use Authorization by the FDA, it will remain ethical to enroll participants in other coronavirus trials that randomize half of them to a placebo, October 27, 2020

Fair Compensation for Rare [COVID-19] Vaccine Harms, by Art Caplan and Dorit Reiss, advocates expansion of the National Childhood Vaccine Injury Compensation Program, rather than limiting manufacturers’ liability and providing claimants compensation under the Public Readiness and Emergency Preparedness Act, September 9, 2020

How the race for a Covid-19 vaccine is getting dirty by Laura Spinney, author of Pale Rider: The Spanish Flu of 1918 and How It Changed the World, reports on global competition to develop a COVID-19 vaccine, The Guardian, August 30, 2020

In Pregnant Women in Trials of Covid-19: A Critical Time to Consider Ethical Frameworks of Inclusion in Clinical Trials Ruth Farrell, Marsha Michie, and Rachel Pope argue that the pandemic demands reconsidering inclusion of pregnant women in treatment and vaccine trials, July 2020

Center faculty member Alex John London was quoted in We can’t skip steps on the road to a COVID-19 vaccine, arguing that emergency conditions should be allowed to rush vaccine research and undermine rigorous scientific standards, The Verge, August 4, 2020

Researchers Debate Infecting People on Purpose to Test Coronavirus Vaccines; bioethicists Art Caplan (NYU) and Jeff Kahn (Johns Hopkins) comment on the ethics of human challenge trials for a COVID-19 vaccine, New York Times, July 7, 2020

Decades-Old Soviet Studies Hint at Coronavirus Strategy reports on the potential repurposing of polio vaccine to confer protection against the coronavirus, and ethical considerations associated with testing such repurposing, New York Times, June 25, 2020

Can a Vaccine for Covid-19 Be Developed in Record Time?—a discussion moderated by Siddhartha Mukherjee, New York Times Magazine, June 14, 2020

Human Challenge Studies for Covid-19 Vaccine: Questions about Benefits and Risks, by Ruth Macklin, concludes that it is ethically unjustifiable to begin human challenge trials for a COVID-19 vaccine, a “grave disease lacking an effective treatment,” June 15, 2020

Human Challenge Studies to Accelerate Coronavirus Vaccine Licensure argues that by accelerating vaccine evaluation, such studies could reduce the global burden of coronavirus-related mortality and morbidity, and that volunteers could autonomously authorize the risks to themselves and such risks could be acceptable under particular conditions and eligibility criteria, March 31, 2020

What risks should be permissible in controlled human infection model studies? evaluates proposals for different risk thresholds for human challenge studies, March 1, 2020

Challenge studies of human volunteers: ethical issues argues that such studies are not necessarily unethical, but that the level of risk is critical to ethical assessment of them, 2004

In Compensation for cures: Why we should pay a premium for participation in ‘challenge studies’ Jonathan Anomaly and Julian Savulescu argue that standard worries about paying for participation in risky research, including challenge studies, are reducible to concerns that can be addressed with appropriate screening mechanisms, 2018

The Road to Immunity During COVID-19 — Developing and Distributing a Vaccine—From the American Public Health Association and the National Academy of Medicine, this recorded panel discussion outlines types of vaccines and process of their development and testing, with attention to the manufacture and supply chain, as well as challenges of distribution of what will be an initially short supply of vaccines against COVID-19 (recorded June 10, 2020, posted with video and transcript)

Addressing the Coronavirus Challenge, and hour-long talk describing the process of creating vaccines against a previously unknown virus, by Michael Farzan, PhD, Professor and Co-Chair of the Department of Immunology and Microbiology at Scripps Research, April 22, 2020, with the talk beginning at minute 6:14

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, 2020

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 Hastings Center has collected articles from the medical and bioethics literatures regarding COVID-19 vaccine and treatment research

The Washington Post offers two, frequently updated primers on vaccines in development and under FDA review:
These are the top coronavirus vaccines to watch
What you need to know about the AstraZeneca, Moderna and Pfizer vaccines

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.

Conducting Research in the COVID-19 Pandemic: Ethics in an Emergency, an archived webinar from the Consortium on Law and Values in Health, Environment & the Life Sciences, University of Minnesota, March 3, 2021; conference/webinar website here

The Hastings Center has collected articles from the medical and bioethics literatures regarding COVID-19 vaccine and treatment research

Where Is America’s Groundbreaking Covid-19 Research? In this New York Times opinion piece, Penn bioethicists Ezekiel J. Emanuel, Cathy Zhang, and Amaya Diana identify 6 lessons from the British COVID-19 research effort which could improve the US effort, September 1, 2020

The Pandemic Claims New Victims: Prestigious Medical Journals, June 15, 2020 New York Times front-page report on the retraction of two studies inadequately vetted by The Lancet and NEJM and the challenges for peer review of detecting fraudulent studies, especially in the face of the pandemic’s pressure

‘It’s Just Everywhere Already’: How Delays in Testing Set Back the U.S. Coronavirus Response reports the effect of federal and state authorities not permitting the repurposing of samples from the Seattle flu study to test for the presence of coronavirus, March 10, 2020 

In her NEJM letter, Early Detection of Covid-19 through a Citywide Pandemic Surveillance Platform, and related supplement, Helen Chu et al. explain how the Seattle flu study was employed to test for coronavirus and report results under a public health surveillance exemption, May 1, 2020

Against pandemic research exceptionalism, by Center faculty member Alex John London from CMU and Jonathan Kimmelman, who argue that rigorous standards for scientific research should not be abandoned in COVID-19 clinical research, April 23, 2020

Three related articles by Alex John London:

• Social value, clinical equipoise, and research in a public health emergency, 2018
• Ethics of randomized trials in a public health emergency, 2018, with co-authors
• Clinical Research in a Public Health Crisis: The Integrative Approach to Managing Uncertainty and Mitigating Conflict, 2009

Also see Placebo use in vaccine trials: Recommendations of a WHO expert panel, 2014, to which he contributed

Companies researching COVID-19 interventions are considering allocation issues regarding the products they are seeking to produce; for example, Johnson & Johnson has issued an Ethical Framework for Decision-Making During the COVID-19 Pandemic.

The Inflated Promise of Genomic Medicine, by Eric Parens, argues that COVID-19 “has laid bare the need to reconsider the hope and money we invest in genetics research,” June 1, 2020

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, May 14, 2020

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, 2020

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, 2020

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, 2020 

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, 2020

UPMC led global trial fast tracks testing of hydroxychloroquine, other COVID-19 therapies—in this April 9, 2020 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, 2020

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”

'It's Quite Painful': Research Labs Shut Down Non-Coronavirus Work Amid Outbreak, a report from Boston’s NPR station, WBUR, March 17, 2020

COVID-19 Conversations is a collection of webinars hosted by the National Academy of Medicine and the American Public Health Association

Pandemic Ethics: 8 Big Questions of COVID-19, is a very readable (and downloadable) discussion of major ethical challenges revealed by the current pandemic by Ben Bramble, a philosopher at the Australian National University.

Democracy and Pandemics is a series of essays by social scientists investigating “the implications of Covid-19, pandemics, and major crises more generally, for democratic governance” as “public safety concerns are weighed against foundational freedoms and the norms and expectations of a democratic citizenry.”

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

COVID-19 Responses & Resources from the National Academies of Sciences, Engineering, and Medicine (NASEM) also makes available for public comment a range of plans, including for example, vaccine allocation plans

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

The UNC Center for Bioethics provides Pandemic Ethics Resources, including webinars, articles, and guidance documents on a range of ethical issues, as well as the field of bioethics and COVID-19