Article Text

Download PDFPDF
Revisiting the equity debate in COVID-19: ICU is no panacea
  1. Angela Ballantyne1,2,
  2. Wendy A Rogers3,
  3. Vikki Entwistle4,
  4. Cindy Towns5
  1. 1 Primary Health Care and General Practice, University of Otago Wellington, Wellington, New Zealand
  2. 2 Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University Singapore, Singapore
  3. 3 Philosophy and Medicine, Macquarie University, Sydney, New South Wales, Australia
  4. 4 Health Services Research Unit and Philosophy, University of Aberdeen, Aberdeen, UK
  5. 5 Department of Medicine, University of Otago, Wellington, New Zealand
  1. Correspondence to Dr Angela Ballantyne, Primary Health Care and General Practice and the Bioethics Centre, University of Otago Wellington, Wellington 6242, New Zealand; angela.ballantyne{at}


Throughout March and April 2020, debate raged about how best to allocate limited intensive care unit (ICU) resources in the face of a growing COVID-19 pandemic. The debate was dominated by utility-based arguments for saving the most lives or life-years. These arguments were tempered by equity-based concerns that triage based solely on prognosis would exacerbate existing health inequities, leaving disadvantaged patients worse off. Central to this debate was the assumption that ICU admission is a valuable but scarce resource in the pandemic context.

In this paper, we argue that the concern about achieving equity in ICU triage is problematic for two reasons. First, ICU can be futile and prolong or exacerbate suffering rather than ameliorate it. This may be especially true in patients with COVID-19 with emerging data showing that most who receive access to a ventilator will still die. There is no value in admitting patients with poor prognostic indicators to ICU to meet an equity target when intensive critical care is contrary to their best interests. Second, the focus on ICU admission shifts focus away from important aspects of COVID-19 care where there is greater opportunity for mitigating suffering and enhancing equitable care.

We propose that the focus on equity concerns during the pandemic should broaden to include providing all people who need it with access to the highest possible standard of end-of-life care. This requires attention to culturally safe care in the following interlinked areas: palliative care, communication and decision support and advanced care planning.

  • living wills/advance directives
  • clinical ethics
  • end-of-life care
  • distributive justice
  • palliative care

This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Twitter @entwistlev

  • Contributors AB initiated the project, undertook the research and was primarily responsible for drafting the manuscript. WAR, VE and CT contributed key ideas and themes for the manuscript, undertook research for specific sections of the paper and contributed to drafting and editing the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.

Other content recommended for you