When the Going Gets Tough, the Tough Must Be Ethical

I have a confession to make. I sometimes publish papers in journals other than JPHMP. I know, for shame.

One of these papers is on Crisis Standards of Care, and was recently made freely available as a COVID-19 resource from the American Journal of Public Health. The premise of this manuscript is that it is a follow-on to the 2012 Institute of Medicine report on Crisis Standards of Care (CSC), focusing especially on the ethical considerations around CSC. A CSC framework acknowledges that there will be times when normal operations aren’t possible due to resource and other constraint or limitations. It is clear that some localities are now here, some have been for a while, and many of the rest of the states and counties in the US may follow – especially if strict social distancing is not implemented. And maintained. There are a lot of great and important planning tools out there, many of which were developed years ago, and more in development.

In my view, a CSC plan is not just about the science of how you respond to this disease, or how you triage patients, but the moral justifications and approaches to doing so. In the state of Minnesota, I was fortunate to support the efforts of the Minnesota Pandemic Ethics Project, which created an ethics framework to respond to a pandemic. This was waaaaay back when the world was worried about Bird Flu. It was informed by expert and community stakeholder input, and the project team took the plan out to Minnesotans for feedback. This guidance was updated and operationalized in recent years in the Minnesota Crisis Standards of Care Ethical Considerations plan.

So why am I talking about a paper from another journal, and one that’s about ethics? Frankly, because even though things could get much, much worse if we don’t maintain good social distancing approaches, allocating scarce resources like ventilators or ECMO is going to be challenging regardless -– and it sounds like many folks are already there. In this paper, after reviewing dozens of articles and state plans (though the latter was not part of the published manuscript but you can see them here), we made a few recommendations –- which I think bear repeating. I just wanted to quickly share something from this paper with JPHMP Direct readership; I hope it can be useful in the hard work ahead.

Issues that need to be addressed in ethical frameworks/guidance for CSC:


  • Include commitments to achieve highest standard of care within contextual constraints and duty to plan.
  • Identify ethical process for planning and response, including considerations of transparency, public engagement, and communicating information to the public.
  • Establish fundamental norms governing the establishment and implementation of CSC — includes overarching mission, goals, values, etc. This includes not only the role of utilitarianism but also the importance of fairness and equity, which relate, in part, to protection of vulnerable populations, addressing access barriers, and expectations about culturally sensitive planning and response.


  • Different types of Mass Casualty Events (sudden impact vs. extended impact, terrorism vs. naturally developing infectious threats) raise distinctive ethical issues that must be addressed,


  • Clarify duty to care and corresponding duties to care givers, including obligations to patients, as well as ethical significance of types of care covered by CSC plans: mental health care and palliative care, respectful handling of dead bodies.
  • Clarify obligations to care givers, which may encompass reciprocity, moral distress interventions/support, and ethically appropriate liability protections.


  • Establish norms governing triage/stewardship of resources, including which criteria to use or not to use for resource allocation. These might include eg, social worth, age, first-come first served.
  • Create appropriate processes by which to employ triage, expectations concerning repeated triage, and consideration of due process for triage — reviews, appeals.


  • Ethical considerations involved in technical components of CSC — scope of work, ratios, shutting down intensive interventions — also provide guidance about ethically appropriate stewardship of resources. Also address ethical considerations for liberty limiting considerations such as isolation, quarantine, other social distancing methods.

Source and copyright: Leider et al, American Journal of Public Health

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Author Profile

JP Leider
Jonathon P. (JP) Leider, PhD, is an independent consultant in the public health and health policy space, as well as a Senior Lecturer at the University of Minnesota and Associate Faculty at the Johns Hopkins Bloomberg School of Public Health. He has active projects and collaborations with foundations, national public health organizations, public health researchers and academics, and public health practitioners. His current projects focus on public health systems, the public health workforce, and public health finance. He holds a PhD in Health Policy and Management from the Johns Hopkins Bloomberg School of Public Health.