A Real-World Ethical Analysis of Contingency Measures Enacted for Crisis Standards of Care during the COVID-19 Pandemic

Abstract

The Nuclear Threat Initiative (NTI) focuses on preventing catastrophes related to weapons of mass destruction, with a wide range of attacks including nuclear, biologic, radiologic, chemical and cyber threats. In response to the COVID-19 pandemic, the NTI published A Frontline Guide for Local Decisionmakers. The guide contains a seven-step checklist: (1) activating an emergency operations center, (2) understanding the real-time spread of COVID-19 in a given community, (3) slowing and reducing transmission, (4) focusing protection on high-risk groups, (5) expanding surge capacity to sustain operations and reduce mortality, (6) expanding community engagement including communicating risk, and (7) mitigating economic and social consequences of the pandemic (Cameron et al. 2020). In their article Between Usual and Crisis Phases of Public Health Emergency: the Mediating Role of Contingency Measures, Alfandre et al. focus on step 5, the point at which the healthcare system becomes overburdened and tips into surge capacity with its attendant shift to crisis standards of care. The authors modified an existing ethical framework developed for SARS to apply it to the current COVID-19 pandemic. They utilized three specific cases (telehealth expansion, use of nasogastric feeding in lieu of hand feeding and use of peritoneal dialysis in lieu of hemodialysis) and applied the framework to the examples to see if they withstood the requirements of efficacy in attaining the stated goal, their functional equivalence to usual practice, their ability to augment capacity, and the potential to disproportionately burden or exclude certain groups so as to proactively address that potential inequality (Alfandre et al. 2021). In this commentary, we explore these specific cases through the lens of our work in New York City at one of the hospitals treating the largest number of COVID-19 patients during the peak of the COVID-19 pandemic.