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  • Identifying ethical values for guiding triage decisions during the COVID-19 pandemic: an Italian ethical committee perspective using Delphi methodology

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Ethics
Original research
Identifying ethical values for guiding triage decisions during the COVID-19 pandemic: an Italian ethical committee perspective using Delphi methodology
  1. Anita Zeneli1,
  2. Giovanni Brandi2,
  3. Giuseppe Di Pasquale3,
  4. Danilo Orlandini3,
  5. Piero De Carolis3,
  6. Francesca Bravi4,
  7. Francesco Pugliese5,
  8. Elisabetta Poluzzi2,
  9. Fausto Catena6,
  10. Filippo Giovanardi7,
  11. Giorgia Valpiani4,
  12. Renato Mantovani3,
  13. Eugenia Magnanimi5,
  14. Primiano Iannone8
  1. 1Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRST IRCCS, Meldola, Italy
  2. 2Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
  3. 3Ethical Committee AVEC, Bologna, Italy
  4. 4Sant'Anna University Hospital of Ferrara, Ferrara, Italy
  5. 5University of Rome La Sapienza, Rome, Italy
  6. 6Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
  7. 7AUSL IRCCS, Reggio Emilia, Italy
  8. 8Higher Institute of Health, Rome, Italy
  1. Correspondence to Dr Francesca Bravi; francesca.bravi{at}auslromagna.it

Abstract

Objectives This study aimed to identify the guiding ethical principles that should be considered for critical resource allocation during pandemic emergency situations, and especially for the COVID-19 outbreak. The secondary objective was to define the priority to be assigned to each principle.

Setting The study was conducted from March to June 2020 within the context of an ethical committee (EC) in Northern Italy.

Participants Eleven EC members and five additional external healthcare and bioethical professionals, forming a multidisciplinary panel, took part in the study.

Primary and secondary outcome measures The compilation of a list of ethical principles (maximum of 10 items) and their priority ranking and application within an emergency pandemic context was established as the expected outcome of this work.

Results A consensus on 10 guiding ethical principles was reached by the multidisciplinary panel. Transparency ranked first on the priority list as the most frequently voted principle, followed by the number of lives saved, life-years saved, respect for individuals’ autonomy and equity. Other principles including life cycle, ‘sickest first’, reciprocity, instrumental value and lottery were also considered appropriate as potential tiebreakers. These principles were discussed and made consistent with the current Italian pandemic context by producing an explanatory document.

Conclusions The identified principles could be used in preparedness plans to guide resource allocation during pandemic events. By combining their rank and relevance in relation to disease, health system organisations, social and economic settings, and critical resources at risk of scarcity, these principles could help to maximise the benefit of resource use for the community, thus reducing inequalities for individuals.

  • COVID-19
  • ethics (see medical ethics)
  • intensive & critical care
  • medical ethics

Data availability statement

All data relevant to the study are included in the article or uploaded as supplemental information. The authors confirm that the data supporting the findings of this study are available within the article (and/or) its supplemental materials.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2020-043239

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplemental information. The authors confirm that the data supporting the findings of this study are available within the article (and/or) its supplemental materials.

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    Footnotes

    • Contributors Study design (Steering Committee)—AZ, GDP, DO, PDC and PI. Literature review and data collection and analysis—AZ, GB, GDP, PDC, DO, FB, FC, FP, EP, FG, RM, GV, EM and PI. Manuscript drafting—AZ, GB, FB, GDP and PI. Critical revision for important intellectual content—AZ, GB, FB, GDP, DO and PI. All authors read and approved the final version of the manuscript for submission.

    • 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.