Scope of the review
A rapid systematic review methodology was selected given the time-sensitive nature of this project. As described by Tricco and colleagues, ‘Rapid reviews are a form of knowledge synthesis in which the components of the systematic review process are simplified or omitted to produce information in a timely manner’ (14). Rapid reviews have emerged as a streamlined approach to knowledge synthesis, usually to inform urgent decisions faced by decision-makers in a healthcare setting (15, 16). Although the review team were required to respond to the time-sensitive needs of the ethics committee, they simultaneously had to ensure that the scientific imperative of methodological rigour was satisfied.
The research team consisted of a core team of three researchers who performed the database searching, screening and data extraction, and a broader steering group including a medical ethicist, an academic medical consultant and a clinical psychologist. This team set and refined the review question, eligibility criteria, and the outcomes of interest.
The review protocol was developed in line with the PICO evidence-based approach (Problem, Intervention, Comparator, Outcome) which was used to frame the research question (17) as follows –
- Problem: In a context of acute resource limitations in healthcare system, how should limited resources be rationed or allocated fairly in the healthcare setting?
- Intervention: ethical values or principles to guide allocation of resources
- Comparator: not applicable for this review
- Outcome: maximise the protection of a person’s rights to healthcare, minimise the risk for treatment withdrawal based on unethical reasoning, and support for practitioners, administrators and managers making difficult decisions regarding resource allocation.
The protocol was published on the Open Science Framework and is available at https://osf.io/krgsn/
The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance and checklist (18) – see Appendix A.
The search strategy was informed and refined with advice from an information specialist (health sciences liaison librarian). The search is described with reference to the PRISMA-S checklist (19) – see Appendix B.
A comprehensive literature review search of multiple bibliographic databases including MEDLINE, EMBASE and Google Scholar was conducted. Google Scholar was selected as an effective tool to identify grey literature (20, 21). A search of references lists of relevant systematic reviews, government and non-governmental organisation reports, opinion pieces, included articles and other relevant grey literature, including LitCOVID was also undertaken. National and International Ethical Frameworks already familiar to the authors were also included. References in identified articles were also reviewed (backwards citation screening).
The search terms used for the MEDLINE search within the title or abstract are shown in Table 1.
Table 1: Search terms used in MEDLINE
(“Coronavirus” OR “COVID19” OR “epidemic” OR “outbreak” OR “pandemic” OR “humanitarian emergency” OR “catastrophes” OR “disaster”)
(“Resources” OR “Resource Allocation” OR “Rationing” OR “Shortage” OR “Personal Protective Equipment” “Ventilator” OR “Triage” OR “Withholding”)
(“Ethics” OR “Morality” OR “Ethical framework” OR “Health equity” OR “Decision making”).
1 AND 2 AND 3
Limit Jan 2000 to 6th April 2020
A list of the EMTREE (EMBASE) search terms can be found in Appendix C. No limits with regard to language were applied.
For MEDLINE and EMBASE, the following limits were applied:
• Human studies
• Time period January 2000 to 6th April 2020
Within Google Scholar, the search was performed in incognito mode – this ensures that any previous searches will not influence Google’s algorithm when searching for new material/ The first 200 entries were included, as recommended by Haddaway and colleagues (20).
All identified papers were exported to Zotero, and duplicates excluded. All remaining papers were imported to Rayaan for review (22). Two members of the team (LOS and AOB) independently and blindly screened Titles and Abstracts of all papers in accordance with the Inclusion and Exclusion Criteria detailed below. Additionally, the scope of this rapid review was limited to public health threats, such as pandemics. For this reason, disasters such as plane crashes or hurricane aftermath, where the triage of casualties would be required, were excluded.
Articles were included if they met the following Inclusion/Exclusion Criteria.
Inclusion Criteria – selected papers including at least two of the following three concepts:
- Acute Resource Limitation or similar
- Rationing / Allocation / Decision-making or similar
- Ethical perspective
Exclusion Criteria – papers with no abstract or with a focus on the following were excluded:
- Accident and Emergency Services
- In-flight emergencies
- Clinical research taking place during humanitarian emergencies
- Ethics in clinical research
- Communication strategies
- Informed consent
- Other clinical emergencies which are not outbreaks/disasters/pandemics
Once Title/Abstract screening was complete, a third member of the research team (EA) resolved any conflicts.
Authors of individual papers were not contacted to collect additional information or to request the full text of inaccessible papers, due to time constraints.
Full text Screening
All three team members (EA, LOS, AOB) each reviewed a portion of the full texts. Papers were excluded if:
- The full text was not available
- They did not contain principles or values relevant to an ethical framework which could be used to support decision-making about the allocation of resources
- The topic related solely to triage procedures in pandemics/disasters e.g., operational medical or nursing triage procedures
- The topic related to legal aspects, rather than ethical ones
- They contained only a clinical case study/case studies i.e., summary of a patient or patients’ clinical condition and outcome
- They only gave a brief summary of the main ethical approaches, with no further details
- The topic related only to pandemic planning
Data extraction and analysis
Data extraction was completed by all three reviewers using a customised data extraction form in Microsoft Excel, all three checked for correctness and completeness of extracted data, and one researcher synthesised all data extractions. The following data items were extracted:
- Lead author
- Year of publication
- Ethical values or principles relevant to an ethical framework
- Synonyms of the named ethical value or principle
- Related ethical values or principles
- Example(s) of a scenario where the ethical values or principles apply
The aim of this rapid systematic review was to identify ethical values and principles, rather than quantitatively assess healthcare interventions or to assess the methodological quality of clinical trials. Therefore, the articles were assessed and the extracted themes were synthesised, and no risk of bias assessment was performed. Emphasis was placed on high-quality literature and also key publications identified by the key stakeholders – these included peer-reviewed literature, government reports or publications produced by reputable organisations. Due to differences in nomenclature used in the literature, both the terms ‘ethical value’ and ‘ethical principle’ are used to describe the findings.