Between Usual and Crisis Phases of a Public Health Emergency: The Mediating Role of Contingency Measures

Abstract

Much of the sustained attention on pandemic preparedness has focused on the ethical justification for plans for the “crisis” phase of a surge when, despite augmentation efforts, the demand for life-saving resources outstrips supply. The ethical frameworks that should guide planning and implementation of the “contingency” phase of a public health emergency are less well described. The contingency phase is when strategies to augment staff, space, and supplies are systematically deployed to forestall critical resource scarcity, reduce disproportionate harm to patients and health care providers, and provide patient care that remains functionally equivalent to conventional practice. We describe an ethical framework to inform planning and implementation for COVID-19 contingency surge responses and apply this framework to 3 use cases. Examining the unique ethical challenges of this mediating phase will facilitate proactive ethics conversations about healthcare operations during the contingency phase and ideally lead to ethically stronger health care practices.

Keywords:

• Health care delivery
• public health
• rationing/resource allocation

This article is referred to by:

Ethically Navigating the Murky Waters of “Contingency Standards of Care”

The Divided Principle of Justice: Ethical Decision-Making at Surge Capacity

Ethics Frameworks and Beyond—Advancing Our Understanding of the Contingency Phase to Improve Health Care Quality During Public Health Emergencies

Supporting Real-Time Ethical Deliberation in Contingency Capacity During the COVID-19 Pandemic

Limitations to Contingency Measures: Reflections from COVID-19 Surges in the UK

Addressing a Missing Link in Emergency Preparedness: New Insights on the Ethics of Care in Contingency Conditions from the Minnesota COVID Ethics Collaborative

Contingency Measures During the COVID-19 Pandemic in China: An Analysis Based on a New Ethical Framework

Insights from Blood Products Management for Pre-Crisis Ethical Resource Allocation

The Need for an Ethics of Care in the Contingency Response to Public Health Emergencies

Neither ‘Crisis Light’ nor ‘Business as Usual’: Considering the Distinctive Ethical Issues Raised by the Contingency and Reset Phases of a Pandemic

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

DISCLOSURE STATEMENT

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the U.S. Department of Veterans Affairs, the U.S. Government, or the VHA National Center for Ethics in Health Care.

Notes

1 Here we specifically focus on the ethical considerations specific to this public health emergency, including its mechanisms of transmission and morbidity and mortality estimates. We will not cover broader ethical or legal issues that have been addressed in the emergency preparedness literature.

2 We acknowledge that this is not an inescapable outcome. One might establish a rule that the optimal outcome—say, preserving life and health—can only be achieved if the least well off (in terms of that outcome) are prioritized. Yet most approaches, under the auspices of “equity,” simply calculate preserving the greatest number of life-years or similar metrics (Institute of Medicine 2012; Emanuel et al. 2020) using a streamlined version of act utilitarianism/benefit maximizing calculus rather than a more nuanced rule utilitarian/harm minimization approach. It is to these frameworks that we are responding.