Table 1 Ethical guidelines’ argument-based analysis: the final conceptual scheme

Austria

 Management of scarce resource in healthcare in the context of the COVID-19 pandemic 

4 ethical principles;

Equity

equality

Better prognosis

Chronic short-term diseases

Survival probability

Severity of the disease

Status of other previous pathologies

Physical conditions

Score system

Age

Social status

Personal relationships with decision makers

Ethics support service/ethical consultation services

Promoting Advance care planning (ACP)

Reducing to the minimum the damages/sufferings resulting from the treatment, both for the patient and for the staff

Offering the best, though not optimal, care for the patient and palliative care when is not possible to treat

Apply a fair decision making

Assistance to all people without distinctions based on non-medical criteria

Provide those who need it with more resources to be able to exercise their rights (e.g. physical or mental/cognitive impairment)

Belgium

Ethical principles concerning proportionality of critical care during the COVID-19 pandemic: advice by the Belgian Society of IC medicine

Avoid disproportionate treatment

apply the triage criteria fairly

Priority to urgencies

Apply ‘first come, first served’ approach to those with the same urgency

Patient’s Advance Directives

Presence of fragility/comorbidity

Clinical Frailty Score

Cognitive disorders in elderly patients

Terminal onchological diseases

Presence of severe chronic co-morbidities

Age

Team discussion

Transparency and evaluation of decisions (using a triage decisions register)

Psychological and ethical support for professionals

Promoting ACP

Applying triage criteria to all patients

Consider age with other clinical parameters (fragility and cognitive ability)

Council of Europe

COMMITTEE ON BIOETHICS (DH-BIO) DH-BIO Statement on human rights considerations relevant to the COVID-19 pandemic

Respect for human dignity and human right

Apply the principle of equity of access to health care system

Considering human right in the field of medicine (Oviedo Convention)

Solidarity and responsibility

Medical criteria

Protection of the most vulnerable people (persons with disabilities, older persons, refugees and migrants)

The access to existing resources should be guided by medical criteria, to ensure namely that vulnerabilities do not lead to discrimination in the access to healthcare

Estonia

Recommendations on clinical ethics for Estonian hospitals for distribution of limited health care resources during the COVID-19 pandemic

Equal treatment

4 principles of medical ethics

Avoid the greater damage and promote the maximum benefit

honest and transparent distribution of limited resources

Prognosis regarding the treatment’s success

The patient’s future quality of life

The current patient’s clinical status

Presence of comorbidities

The general patient’s health-related status

Presence of other relevant indicators related to prognosis

Patient’s will

effectiveness of medical services

Age

Gender

Ethnicity

Social status

Additional resources (psychologists, consultants..)

Treat all patients equally

Save as many lives as possible

equal distribution of existing resources

ensure that the protection of health workers becomes increasingly essential

EGE

Statement on European Solidarity and the Protection of Fundamental Rights in the COVID-19 Pandemic

Derogations of human rights, albeit in the interests of the public good, must be temporary, and critically.  There must be clear, transparent criteria

France

COVID-19 Contribution from the French National Consultative Ethics Committee. Ethical issues in the face of a pandemic

Respect for the dignity of the person

Principle of equity

definition of priorities requires criteria which are always questionable

Unit of ethics support for health care professionals

Provide assistance based on the patient's needs

Guarantee continuity of care for other patients who do not accede to intensive treatments

Germany

Solidarity and Responsibility during the Coronavirus Crisis

Dignity

Absolute value of life

Constitutional principles

The law does not identify any criteria by which to identify the patients to be denied the treatment

Gender

Ethnicity

Age

Social role, value or presumed life-span

Considerations regarding allocation resources should be weighted, justified, transparent, and criteria should be applied uniformly

Equal access for all to health care

The state must refrain from norms with which lives are categorized on the basis of gender/ethnicity/age/social role/presumed value or duration of life;

The measures required to save as many lives as possible must not go beyond the constitutional framework and the safeguard of the legal system must be considered.

Ireland

Ethical Framework for Decision-Making in a Pandemic

Fairness, minimising harm, solidarity and reciprocity

Patients with a greater chance of benefitting from the intervention;

Some groups at risk and those essential for the management of a pandemic

Patient’s health status before the virus

Patient’s will

Presence of comorbidities

Frailty (regardless of age)

Estimation on

total number of lives saved; total life years saved

how long patients could live in the long term

Age

Social status

Social value

Ethnicity

Gender

Reasonableness

Openness and Transparency

Incusiveness

Responsiveness

Accountability

Maximize the benefits obtained with scarce resources

Distribute benefits and risks equally through a multi-principled approach

Italy

 Clinical Ethics Reccomendations for the Allocation of Intensive Care Treatments in Exceptiona, resource-limited circumstances 

Clinical appropriateness and

Proportionality of care;

Distributive justice and

Appropriate allocation of resources

Age threshold: priority for those patients who are most likely to survive

and who’ll have several years of life saved

Presence of comorbidities

Evaluation of patient’s functional status

Presence of patient’s Advance Directives or Advance Care Planning

‘Inappropriateness’ is justified by the extraordinary nature of the situation

Shared decision making process among multiple clinicians

Use a ideal list of patients

Daily reassessment of appropriateness/care objectives/proportionality

Support to health care professionals

Maximizing benefits for most people

Palliative care (also sedation)

Evaluation of the situation’s implications on family members

Republic of San Marino

Statement on ethical issues regarding to the use of invasive assisted ventilation in patient s all age with serious disabilities in relation to Covid-19 pandemic

Respect for human dignity and human rights

Equality and non-discrimination (due to disability)

Equal opportunities to access

Clinical appropriateness

Proportionality of care

Age,

Gender

Social status, ethnicity, disability

The only parameter for the allocation decisions consists in a correct application of the triage which is based on:

(a) the respect for every human life

(b) criteria of clinical appropriateness and proportionality of the treatments

Portugal

CNECV statement: Covid-19 key consideration

Value of life, dignity and integrity of individuals

Principle of necessity

Principle of solidarity

The evaluation of the clinical criteria and the technical and scientific recommendations must be accompanied by a careful ethical reflection based on the case studies

Permanent support from the members of the local ethics committees to help professionals in the decision-making process

Protect the health of each citizen

Mitigate asymmetries and inequalities

 Public health emergency situation due to the COVID-19 pandemic - Relevant ethical aspects

Principle of necessity

Precautionary principle

Proportionality principle

Transparency

Solidarity

Subsidiarity

Medical criteria

Evaluation of the respective clinical criteria, including the technical and scientific recommendations issued by the health authorities, professional bodies and scientific societies

Support for decision-making through members of the health institution not directly involved in intensive care (hospital ethics committees)

Principle of decision-making process:

reasonableness, transparency, inclusion, reactivity and institutional responsibility

Decisions regarding the allocation resources are based on medical criteria which is based on solid ethical principles (proportionality, reciprocity, equity, trust and solidarity); careful ethical consideration is required on a case-by-case basis

Spain

Report of the Ministry of Health on ethical aspects in pandemic situations: SARS-CoV-2

Equity and non discrimination

Solidarity

Justice

Proportionality

Transparency

A hierarchy of priorities must be established

Gravity of the patient's condition

Objective expectations on the patient’s short-term recovery to his previous state of health

Date of arrival (not as the only criterion)

Existence or absence of serious concomitant pathologies that would indicate a fatal prognosis (such as a terminal disease with a prognosis of irreversibility or irreversible coma), even if this could lead to further clinical assistance

Age

Disability

Vulnerable children

It is recommended that guidelines are requested and received, for example, by the hospital's ethics and health committee, within the time available

Priorities’definition will be based on objective, generalizable, transparent, public and consensus-based criteria, despite the possibility of evaluating the unique and individual characteristics of each person who has contracted the virus

The maximum benefit in saving lives, which must be made compatible with the continuation of the treatment started with each individual patient)

Consider alternative treatments to invasive mechanical ventilation provided in intensive care, even in cases where this does not seem to be indicated

Switzerland

Pandemic Covid-19: triage of intensive care treatments in case of scarcity of resources Indications for the implementation of chapter 9.3 of the directives of the ASSM "Measures of intensive care" (2013), updated version of March 24, 2020

4 Principles of medical ethics

equity

Save as many lifes as possible

Protection of the health care professionals involved

Patients who can benefit most from the hospitalization

It also indirectly includes the patient’s age (even if is not considered as a valid criterion itself)

The patient's age

 ≪ first principle such as, first served ≫ , priority to people with

A high social value etc

Early identification of patients' wishes

If ICU treatments are denied, adequate palliative care must be ensured

Determining criterion for triage and short-term prognosis

Further criteria such as first come, first served and, priority to persons with

A high social value etc. should be avoided

The Holy See

Pandemic and universal Brotherhood: Note on the Covid-19 emergency

Equal value of human life and the dignity of the person (they are always the same and priceless)

Justice

Patient’s need

patient’s prognosis

The severity of patient’s illness and his need for treatment

The evaluation of the clinical benefits obtained by the treatment, in terms of prognosis

Age cannot be taken as a single and automatic choice criterion

The allocation criteria should be shared and reasonably founded, to avoid arbitrariness or improvisation in emergency situations

Provide treatments in the best possible way based on the patient's needs

The sick person should be never abandoned, even when there are no more treatments available: palliative care, pain treatment and accompaniment should never be overlooked

UNESCO International Bioethics Committee (IBC)and theUNESCO World Commission on the Ethics of Scientific Knowledge and Technology (COMEST)

 Statement on COVID-19: Ethical considerations from a global perspective

Principle of justice, beneficence

Equity

Respect for human dignity

Human rights framework recognize the protection of health as a right of each human being

right to health can be guaranteed only by our duty to health

Recognition of a collective responsibilities for the protection of vulnerable persons and the need to avoid any form of stigmatization and discrimination

Procedures need to be transparent and should respect human dignity

The highest attainable standard of health is a fundamental right of every human being, which means the access to the highest available healthcare

UK

Guidance: Responding to COVID-19: the ethical framework for adult social care

Respect

Reasonabless

Minimising harm

Inclusiveness

Flexibility

Proportionality

Communty

Justification of the decision-making process, considering alternative courses of action, clear, transparent decision-making process

Be transparent about why certain decisions are made

Patient’s informed consent

Minimize inequalities

Ethical considerations in responding to the COVID-19 pandemic

Proportionality, Interventon’s effectiveness and necessity

Fair and respectful treatment

Solidariety

All the people should be treated as moral equals, worthy of respect

Interventions should be evidence-based and proportionate

People should be treated as moral equals, worthy of respect

COVID-19—ethical issues. A guidance note

maximising the overall reduction of mortality and morbidity

Need to maintain vital social functions

Clinically relevant elements about each patient

Patient’s possibilities to benefiting

From available resources (younger patients will not automatically have priority over older ones)

The presence of comorbidities

Decisions regarding treatments of those who lack decision-making capacity should be made in the same way as all the others

Patients requiring treatment

It would not be ethical

apply these limits in health care access differently to patients with or without appointed or surrogate decision makers, or those with or without particular religious opinions

The decision making process should be based on the best available clinical data and opinions; consistent with ethical principles and reasoning

Agreed in advance where possible, while recognizing that decisions may need to be made quickly

Revised in changing circumstances

as far as possible coherent between Different professionals

Communicated openly and transparently

Subjected to change and review as the situation develops

Provide adequate support, including support from the clinical ethics committee and psychologists to health care professionals

Prioritisation policies:

Refuse someone potentially life-saving treatment where someone else is expected to benefit more from the available treatment

No automatic priority

Patients whose treatment is suspended or withdrawn must receive compassionate care and dedicated medical assistance

Ethical dimension of COVID-19 for front-line staff

Ensuring fair and equitable care

Caring for COVID-19 and non-COVID-19 patients

There will be some patients (with or without confirmed COVID-19) for whom admission to ICU would be inappropriate (proportionality)

Assessment and prioritisation decisions are carried out by more than one clinician colleague (multidisciplinary team)

Treatment should be provided, independently of the individual’s background (e.g. disability), where it is considered that it will help the patient survive and not harm their long-term health and wellbeing.

Many front-line staff will already be caring for patients for whom any escalation of care, regardless of the current pandemic, would be inappropriate, and must be properly managed. All front-line staff should have discussions with those relevant patients for whom an advance care plan is appropriate

Covid-19 Guidance: Ethical Advice and Support Framework

Respect

Fairness

Minimising harm

Working toghether

Flexibility

Reciprocity

Capacity and consent

Where there is a decision that a treatment is not clinically appropriate there is not an obligation to provide it

No active steps should be taken to shorten or end the life of an individual, however the appropriate clinical decision may be to withdraw life prolonging or life sustaining treatment

Clinicians should act with honesty and integrity in their communication with patients and should communicate clinical decisions and the reasoning behind them transparently. This should be documented appropriately

Ethical advice and support groups will be established as a priority.

There must be immediate access to ethical advice if this occurs, to offer an independent view and support in difficult circumstances

All patients should be offered good quality and compassionate care

Patients should be treated as individuals, and not discriminated.

Where there are resource constraints, patients should receive the best care possible, while recognising that there may be a competing obligation to the wider population

Coronavirus: Your frequently asked questions

React responsibly and reasonably to the circumstances

Take account of current local and national policies that set out agreed criteria for access to treatment

Take account of patient wishes and expectations

Be confident that decisions are based on clinical need and the likely effectiveness of treatments

Don’t unfairly discriminate against particular groups

Be open and honest with patients and the rest of the healthcare team about the decision-making process and the criteria for setting priorities in individual cases.

Keep a record

Discussion with colleagues and, if possible, with input from local ethics committees.

Recognise the significant emotional distress

Provide the best service possible within the resources available.

Where decisions are made to withhold or withdraw some forms of treatment from patients, doctors should still take all possible steps to alleviate the patient’s symptoms and distress and respect their dignity