Table 1 Ethical recommendations for clinical triage and guidelines

1. Frameworks of justice and utility underlying the COVID-19 triage protocols must be explicitly defined and explored

Vague and nonspecific terms such as “utility” and “fairness” must be clearly defined and operationalized into concrete metrics (e.g., utility through maximizing life-years saved, fairness through prioritizing the worst off)

2. Principles of transparency, openness, and procedural justice must be followed in developing clinical decision- making documents. An explicit commitment to diversity and inclusion must be incorporated into procedural justice considerations

The development of protocols should be done in the public sphere, with public stakeholders and input from members of disability communities to ensure procedural justice. Recommendations should be made with guidance from disabled individuals and their advocates, including caretakers and disability rights groups

3. Triage policies must adhere to human rights standards and explicitly condemn bias and discrimination

Ableist biases which categorically exclude individuals with certain disabilities (e.g., advanced neurocognitive disorder) must be prohibited. Clinical biases surrounding quality-of-life assessments which negatively affect individuals with disabilities must be recognized and explicitly condemned

4. Reasonable accommodations must be made in consideration of disability status, and how an individual’s underlying conditions may influence their COVID-19 care needs

Policies should be written and revised to provide reasonable accommodations for individuals with disabilities. These may include allocating greater time on ventilator support for equal chances of survival, or providing communication assistance for those who are Deaf or Deaf-blind

5. Clinical scores and prognostic instruments must be carefully examined to exclude factors such as functional status that may not accurately represent prognosis in people with disabilities

Clinical criteria that are value-neutral at face value but disproportionately affect individuals with disabilities (e.g., evaluation of long-term survival, triage based on co-morbidities) should be reconsidered. Proper adjustments should be considered in the application of these clinical criteria to disabled individuals

6. COVID-19 care and triage must not be seen in isolation but must be seen within the broader context of justice for people with disabilities

Protocols surrounding scarce resource allocation carry a powerful symbolic meaning: one which embodies the value judgements that are made by society in critical times. Since these policies touch on fundamental human rights—such as the right to life, to health care, and equality—they must be drafted and treated as such