The final product of the Summit is a set of 10 principles to guide allocation decisions involving scarce resources in public health emergencies (). The principles are grouped into three broad categories: obligations to community; balancing personal autonomy and community well-being/benefit; and good preparedness practice. The principles could also be organized as substantive and procedural in nature. Substantive principles supported by Summit participants included that allocation decisions should be (1) driven and supported by good data, (2) nondiscriminatory and sensitive to the needs of vulnerable populations, and (3) revisable. Procedural principles included the need for (1) transparency to all stakeholders, (2) public participation to the greatest extent possible, and (3) accountability. The narratives provided with each principle in the subsequent sections are based on comments from the Summit attendees, supplemented by the authors, and are organized in narrative form.
The order of the principles, as listed in the and as discussed in the narrative summaries that follow, does not reflect any attempt to prioritize their importance. As well, some common legal and ethical norms may not be fully stated or captured in these principles, largely because their relevance is clear. For example, any decision maker needs to be knowledgeable of changing legal requirements at the federal, state, and local levels that arise during the declared emergencies to make good choices about allocating scarce resources.
Obligations to community
1. Maintain transparency (e.g., openness and public accessibility) in the decision-making process at the state and local levels. One potential outcome of transparency is public trust. Public trust is a key to compliance with directives announced during a public health crisis. The process and outcomes must reflect public values and priorities and, therefore, should include representatives from the general public, including those whose cultural norms are different from the majority. Bringing appropriate stakeholders into the process in which finite resources will be allocated can enhance the quality of the process as well as increase the likelihood that the public will trust the outcomes of such processes. In addition, a transparent decision-making process promotes accountability among local and state institutions responsible for acting on the decisions made.
2. Conduct public health education and outreach (to the extent possible) to encourage, facilitate, and promote community participation or input into deliberation about allocation decisions. To engage the community in the decision-making process, the relevant local and state institutions need to make a commitment to quality public education and outreach efforts. For community engagement to be effective, clear communication and open discourse must be operative. Effective communication and community engagement during the decision-making process set a standard for what the community can expect from local and state institutions during a public health crisis. Setting a precedent for transparency and truth-telling in the planning process can be invaluable when managing community expectations during a public health crisis.
Balancing personal autonomy and community well-being/benefit
3. Balance individual and communal needs to maximize the public health benefits to the populations being served while respecting individual rights (to the extent possible), including providing mitigation for such infringements (e.g., provide fair compensation for volunteers who are injured while rendering emergency care or services for the benefit of the community). A particular challenge in the development of policy related to resource allocation is the answer to the question of when, if ever, is it appropriate to restrict the actions an individual can take in the name of community well-being? Put another way, when does acting in the best interest of the community take precedence over acting in the best interest of any particular individual? In the context of allocating finite resources during a public health crisis, the answer to this question may vary depending on the resource under consideration. During public deliberations about plans for a public health crisis, local and state officials should solicit feedback on the development of a reasonable, acceptable threshold at which the well-being of the community takes precedence. In addition, local and state institutions should consider if and how groups or individuals will be compensated when they are prevented from taking actions they believe to be in their best interest but considered not in the best interest of the larger community.
4. Consider the public health needs of individuals or groups without regard for their human condition (e.g., race/ethnicity, nationality, religious beliefs, sexual orientation, residency status, or ability to pay). The principle of distributive justice requires that public health crisis response plans take into consideration the social, economic, and cultural barriers that may limit the effectiveness of proposed interventions. Local and state institutions should avoid, as much as possible, the development of policy that treats individuals or groups of people differently according to morally irrelevant characteristics when it comes to allocating a finite resource during a public health crisis. In addition, policy makers should avoid the adoption of policy that exacerbates preexisting disparities in the community.
Good preparedness practice
5. Adhere to and communicate applicable standard-of-care guidelines (e.g., triage procedures), absent an express directive by a governmental authority that suggests adherence to differing standards. Applicable standard-of-care guidelines, including medical triage, should be the default setting for public health practitioners, absent explicit alternate directions from a governmental authority. In large-scale emergencies, postponement or cancellation of elective medical procedures and efficient, targeted physical examination may be critical when the surge capacity of the health-care system is reached. In dealing with natural or manmade crises, public health practitioners should be on the frontline of clearly communicating these emergent standards of care to patients and providers alike.
6. Identify public health priorities based on modern, scientifically sound evidence that supports the provision of resources to identified people. Just as evidence-based medicine has become an increasingly established part of routine health-care practice, so too must evidence-based decision-making become a cornerstone of disaster-response resource prioritization. Building the evidence for resource triage in controlled nonemergent clinical settings is inherently much easier than in the fluid context of large-scale emergencies. However, a growing evidence base for the latter has emerged in a variety of forms, including modeling studies based on past disasters (e.g., pandemic influenza), and published after-action reports from emergency exercises and drills. Public health practitioners and leaders should apply this growing evidence base toward establishing priorities in an all-hazards framework.
7. Implement initiatives in a prioritized, coordinated fashion that are well-targeted to accomplishing essential public health services and core public health functions.
The 10 essential services of public health are applicable in both emergent and nonemergent contexts.26
Public health crisis resource allocation decision-making should be consistent with provision of these essential services. In a crisis, public health providers must not only address the urgent health-care needs of those immediately affected by the disease- or injury-causing agent (e.g., pandemic flu or a bioterrorism agent), but also those with unrelated acute and chronic health needs (e.g., dialysis patients or drug treatment patients) whose access to appropriate care may be compromised as the health-care system is stretched to its limits.
8. Assess (to the extent possible) the public health outcomes following a specific allocation decision, acknowledging that the process is iterative. Disaster response is by nature an imperfect process fraught with unpredictable dynamics and countless decisions. This complexity, however, does not waive the need for assessing and evaluating the outcomes of the process. While it is difficult to completely anticipate every second- and third-order effect of a public health emergency decision, such downstream effects must be factored into crisis public health decision-making and should become a standard part of pre-event agency planning to the extent possible.
9. Ensure accountability (e.g., documentation) pertaining to the specific duties and liabilities of people in the execution of the allocation decision. Legal and ethical principles support the need for the individuals who are making critical choices in the allocation of limited resources during emergencies to be accountable for their decisions. This may entail procedures to ensure that the underlying rationale for their decisions is documented and preserved for current and future reference. The goal of ensuring accountability is not to create a record to sustain future criticisms or support potential legal claims. Rather, the objective is to provide assurances to the community that the individuals vested with making critical choices (1) are authorized to make the decisions, (2) have gathered data or input to support their decisions, and (3) have based their decisions on available information and existing legal requirements or ethical norms.
10. Share personally identifiable health information—with the patients' consent where possible—solely to promote the health or safety of patients and other people. Personally identifiable health information is routinely exchanged during public health emergencies to facilitate the allocation of scarce resources. Acquiring, using, or disclosing identifiable health data with specific informed consent of patients is ideal. During emergencies, however, the need for such data is compelling. Clinicians performing medical triage need rapid access to patients' records. Disaster managers operating emergency response clinics may need to know the patient-specific health information to better coordinate the delivery of care. Public health officials have equal claims to needing identifiable health data to ensure community health efforts. Use or disclosure of identifiable health data in each of these examples is legally and ethically justifiable (even without informed consent) only when the overriding goal is protecting individual and public health. However, other data exchanges for nonhealth purposes may be not be permissible without patient consent. These may include, for example, disclosures to employers, law enforcement, commercial entities, researchers, and emergency responders whose efforts do not include providing health or public services to patients.