What constitutes an ethically sound crisis standard of care?

From the Guidelines

An ethically sound crisis standard of care is a systematic, transparent framework that guides healthcare resource allocation during disasters or public health emergencies when demand exceeds capacity, prioritizing fairness, equity, and the greatest good for the greatest number while maintaining respect for human dignity. This framework should include clear triggers for implementation, specific protocols for triage and resource allocation, and processes that avoid discrimination based on non-medical factors like race, disability, or socioeconomic status 1. Decision-making should be consistent across facilities and involve multidisciplinary input, including ethics committees. Communication with the public must be transparent about the rationale for difficult choices. Healthcare workers need legal and psychological protection when operating under crisis standards. The framework should also include provisions for palliative care when life-saving interventions cannot be provided to all patients.

Some key considerations for implementing crisis standards of care include:

• Graded staff-to-patient ratios with consideration to experience level, resources, and patient acuity to optimize contingency care and avoid crisis care 1
• Limiting overtime to less than 50% above normal for all healthcare workers to minimize the risk of burn-out and exhaustion 1
• Prioritizing the mental health needs of all healthcare workers to maintain an effective response and staffing capacity 1
• Actively monitoring and determining resource strain level by front line clinical leaders based upon assessment of available resources and conditions 1
• Early transfer of patients before a hospital is overwhelmed to promote the effective conservation of resources and less deviation from routine care standards 1

These standards are ethically justified because they provide a structured approach to impossible choices, minimize arbitrary decisions, and maintain core medical ethics principles even when conventional care is impossible. Regular review and revision based on evolving circumstances ensures the framework remains responsive to changing conditions while preserving essential ethical foundations. As outlined in the Institute of Medicine report, the adoption of contingency or crisis standards of care will be predicated on the exhaustion (or impending exhaustion) of the capability to provide conventional standards of care 1.

From the Research

Ethical Principles in Crisis Standards of Care

• Crisis Standards of Care (CSC) provide a framework for the fair allocation of scarce resources during emergencies, with ethical principles guiding decision-making 2, 3
• Ethical principles such as equity, fairness, and respect for persons are essential in CSC, ensuring that resources are allocated in a way that minimizes harm and promotes the well-being of all individuals 2, 3
• The incorporation of ethical principles in CSC is crucial to prevent disproportionate impact on disadvantaged populations, who may be more vulnerable to the effects of systemic racism and other forms of discrimination 2

Key Components of Ethically Sound Crisis Standards of Care

• Explicit statement of ethical principles and frameworks to guide decision-making 2, 3
• Prioritization strategies that take into account factors such as medical need, likelihood of benefit, and societal value 2, 4
• Consideration of comorbid conditions, expected lifespan, and other factors that may affect an individual's ability to benefit from treatment 2
• Mechanisms for addressing moral distress and other psychological impacts on healthcare providers 4, 3

Implementation and Practical Considerations

• Ethical guidance must be practical and implementable, with clear and justified norms and guidelines 3
• Clinical protocols should be guided by ethical frameworks, with consideration of strategies to honor ethical commitments and achieve ethical objectives 3
• Ongoing evaluation and revision of CSC are necessary to ensure that they remain effective and ethical in responding to emerging challenges and disasters 4, 3