March 26, 2020

EJRC - Resource allocation during COVID-19 pandemic

Fair Allocation of Scarce Medical Resources in the Time of Covid-19: a post -publication review 

COVID-19 is exerting an extensive strain on all healthcare systems. Front line clinicians including intensivists risk physical and psychological burnout taking decisions about withdrawal/withholding and resource allocation. All this raised the need for specific admission/resource allocation guidelines by higher authorities.  A group of 10 authors from four countries (USA, UK, Canada and Brazil) suggested six recommendations as the ethical background for such prioritisation guidelines.

Emanuel et al first reviewed the health impact of COVID-19 on the medical capacity focusing on the USA. Based on previous Influenza models, as well as Chinese and Italian references, severe COVID-19 can result in 5.1 million hospitalisations, 3.8 million ICU admission and 1.9 million deaths in the USA alone.

Comparing this to the medical capacity, they estimated 68,400-85,000 adult ICU bed (20.7-25.7 bed per 100,000 population), and 170,000-180,000 ventilators to be available.

The workforce includes 512,000 ICU nurses and 76,000 respiratory therapists. Despite such numbers looking better than most other countries, the demand is expected to exceed therapeutic, diagnostic and preventive resources.

The article included six recommendations based on four ethical values (Fig (1)). They represent the ethical bases for the highly needed prioritisation guidelines. Consistent and transparent application is necessary to ensure public trust. The guidelines can be ultimately applied by a third party (e.g. triage officers, physicians not caring for the patients, and ethicists) in order to shield front line physicians.

The authors suggested a limited institutional appeal process to protect against procedural mistakes.


Fig (1): Ethical values and recommendations for resource allocation.



  1. Can serve as baseline for future guidelines.
  2. High impact article published in high impact journal addressing a very urgent and important question.
  3. Precise, short article with very good reasoning.


  1. Can be debatable, especially as not all stakeholders participated (the public, politicians, economists and front-line clinicians).
  2. Despite the sound reasoning, cultural, religious and legal factors can affect ethical considerations from country to another. Furthermore, translation and impact can differ significantly in resource limited settings.
  3. Needs to be translated into a more specific guideline to be applicable by frontline physicians.



Emanuel et al addressed the point of resource allocation in the middle of COVID-19 pandemics. They recommended an ethical background to be used for the publication of more specific prioritisation guidelines.


This article review was prepared and submitted by Dr Ashraf Roshdy, Whipps Cross University Hospital – Barts Health NHS Trust, London, United Kingdom, on behalf of the ESICM Journal Review Club.


Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, Zhang C, Boyle C, Smith M, Phillips JP. Fair Allocation of Scarce Medical Resources in the Time of Covid-19.  N Engl J Med. 2020 Mar 23. doi: 10.1056/NEJMsb2005114.


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