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Ethical decision making during a healthcare crisis: a resource allocation framework and tool
  1. Keegan Guidolin1,2,3,
  2. Jennifer Catton4,
  3. Barry Rubin1,4,5,
  4. Jennifer Bell3,6,
  5. Jessica Marangos4,
  6. Ann Munro-Heesters4,6,7,
  7. Terri Stuart-McEwan4,
  8. Fayez Quereshy1,3,8
  1. 1 Department of Surgery, University of Toronto, Toronto, Ontario, Canada
  2. 2 Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
  3. 3 Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
  4. 4 University Health Network, Toronto, Ontario, Canada
  5. 5 Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
  6. 6 Joint Centre for Bioethics, University of Toronto, Toronto, Ontario, Canada
  7. 7 The Institute for Education Research (TIER), University Health Network, Toronto, Ontario, Canada
  8. 8 Department of Surgery, University Health Network, Toronto, Ontario, Canada
  1. Correspondence to Dr Fayez Quereshy, Department of Surgery, University Health Network, Toronto, Canada; fayez.quereshy{at}


The COVID-19 pandemic has strained healthcare resources the world over, requiring healthcare providers to make resource allocation decisions under extraordinary pressures. A year later, our understanding of COVID-19 has advanced, but our process for making ethical decisions surrounding resource allocation has not. During the first wave of the pandemic, our institution uniformly ramped-down clinical activity to accommodate the anticipated demands of COVID-19, resulting in resource waste and inefficiency. In preparation for the second wave, we sought to make such ramp down decisions more prudently and ethically. We report the development of a tool that can be used to make fair and ethical decisions in times of resource scarcity. We formed an interprofessional team to develop and use this tool to ensure that a diverse range of stakeholder perspectives were represented in this development process. This team, called the clinical activity recovery team, established institutional objectives that were combined with well-established procedural values, substantive ethical principles and decision-making criteria by using a variation on the well-known accountability for reasonableness ethical framework. The result of this is a stepwise, semiquantitative, ethical decision tool that can be applied to resource allocation challenges in order to reach fair and ethically defensible decisions. This ethical decision tool can be applied in various contexts and may prove useful at both the institutional and the departmental level; indeed this is how it is applied at our centre. As the second wave of COVID-19 strains healthcare resources, this tool can help clinical leaders to make fair decisions.

  • allocation of health care resources
  • clinical ethics
  • COVID-19
  • decision-making
  • surgery

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  • Twitter @keeganguidolin, @quereshymd

  • KG and JC contributed equally.

  • Collaborators CART Working Group.

  • Contributors KG synthesised and drafted the manuscript. JC, BR, JB, JM, AM-H, TS-M and FQ led and supported development of the work and reviewed and revised the manuscript. All authors met criteria for inclusion.

  • 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.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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