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https://doi.org/10.1177/22799036221106659
Journal of Public Health Research
2022, Vol. 11(2), 1 –6
© The Author(s) 2022
DOI: 10.1177/22799036221106659
journals.sagepub.com/home/phj
Journal o
f
Public Health Research
Perspectives and Debates
Introduction
The increase in cases of patients needing to be admitted to
intensive care, due to Covid-19 infection, has led to a
strong imbalance between available resources and health-
care requirements. Therefore, the determination of addi-
tional criteria, apart from those of clinical appropriateness
and proportionality of care, to define the allocation of the
limited resources available was deemed necessary.
For these reasons, in March 2020, the SIAARTI (Italian
Society of Anaesthesia, Analgesia, Resuscitation and
Intensive Care) published a document containing the
Clinical Ethics Recommendations for the Allocation of
Intensive Care Treatments, under exceptional resource-
limited circumstances,1 “to relieve clinicians from a part of
the responsibility in the decisions making process, which
can be emotionally burdensome, carried out in individual
cases” and “to make the allocation criteria for healthcare
resources explicit in a condition of their own extraordinary
scarcity.”
The extraordinary and emergency nature of the situa-
tion, in which the availability of resources and their
allocation become components of the decision-making
process, has made it necessary to identify criteria that can
guide choices. Application of this criteria can only be jus-
tifiable once all possible efforts have been made, by all
parties involved, to increase the availability of allocable
resources and once any possibility of transferring patients
to treatment centers with greater availability of resources
has been evaluated.2
1106659PHJXXX10.1177/22799036221106659Journal of Public Health ResearchDelbon et al.
research-article2022
1 Department of Medical and Surgical Specialties, Radiological Sciences,
and Public Health – Centre of Bioethics Research, University of
Brescia, Brescia, Italy
2 Forensic Medicine Unit, Department of Medical and Surgical
Specialties, Radiological Sciences and Public Health, University of
Brescia, Brescia, Italy
3 Department of Medical and Surgical Specialties, Radiological Sciences,
and Public Health, University of Brescia, Brescia, Italy
Corresponding author:
Francesca Maghin, Forensic Medicine Unit, Department of Medical and
Surgical Specialties, Radiological Sciences and Public Health, University
of Brescia, Piazzale Spedali Civili 1, Brescia 25123, Italy.
Email: francesca.maghin@gmail.com
Resource scarcity and allocation criteria
during the Covid-19 pandemic: Ethical
issues
Paola Delbon1, Francesca Maghin2, Bruno Falconi3 and
Adelaide Conti1
Abstract
The increase in cases of patients needing to be admitted to intensive care, due to Covid-19 infection, has led to a
strong imbalance between available resources and healthcare requirements. Therefore, the determination of further
criteria, in addition to those of clinical appropriateness and proportionality of care, to define the allocation of the
limited resources available was necessary. For these reasons, in March 2020, the SIAARTI (Italian Society of Anesthesia,
Analgesia, Resuscitation and Intensive Care) published a document containing the “Clinical Ethics Recommendations for
the Allocation of Intensive Care Treatments, in exceptional, resource-limited circumstances,” to relieve clinicians from a
part of the responsibility in the decision-making process, which can be emotionally burdensome, carried out in individual
cases and to make the allocation criteria for healthcare resources explicit in a condition of their own extraordinary
scarcity.
Keywords
Resource allocation, allocation criteria, bioethics, equity, decision-making process, pandemic
Date received: 18 May 2022; accepted: 23 May 2022
2 Journal of Public Health Research
Resource scarcity and healthcare
requirements during the Covid-19
pandemic: Principles of medical ethics
and allocation criteria
Within this context, there is an emphasis in the document
about what “criteria for access to intensive care and dis-
charge may be needed, not only in strictly clinical appropri-
ateness and proportionality of care, but also in distributive
justice and appropriate allocation of limited healthcare
resources.”1 The document published by SIAARTI indi-
cates that “the underlying principle would be to save lim-
ited resources which may become extremely scarce for
those who have a much greater probability of survival and
life expectancy, to maximize the benefits for the largest
number of people. In the worst-case scenario of complete
saturation of Intensive Care Unit (ICU) resources, keeping
a “first come, first served” criterion would ultimately result
in withholding ICU care by limiting ICU admission for any
subsequently presenting patient” and that “together with
age, the comorbidities and functional status of any criti-
cally ill patient presenting in these exceptional circum-
stances should carefully be evaluated. A longer and, hence,
more “resource-consuming” clinical course may be antici-
pated in frail elderly patients with severe comorbidities, as
compared to a relatively shorter, and potentially more
benign course in healthy young subjects.”
The SIAARTI Working Group underlines the fact that
no numerical threshold has been made explicit, precisely
to make sure that the criterion for evaluation and the con-
sequent prognostic orientation adapt to a concept of func-
tional limits that can be seized only by taking into account
both individual biological variability and the treatment set-
ting. This choice should be interpreted as an evaluation of
the patient’s age, which is made as carefully as possible, as
an expression of the functional reserve that the patient
should be able to put into play in order to face not only the
challenge of the disease, but also the impact of intensive
treatment (chronological age in the absence of comorbidi-
ties, biological age in the presence of comorbidities).2
According to the Swiss Academy of Medical Sciences,3
where resources are not sufficient to treat all patients in an
optimal manner, the fundamental principles of medical
ethics (beneficence, non-maleficence, autonomy, and jus-
tice) must be applied following a fair, objectively moti-
vated, and transparent allocation procedure, with no
discrimination, and with a view toward limiting as far as
possible the number of patients becoming seriously ill as
well as that of deaths. In that context, according to the
Swiss Academy of Medical Sciences “If ICU capacity is
exhausted and not all patients who require intensive care
can be admitted, the short-term prognosis is decisive for
purposes of triage. For ICU admission, highest priority is
to be accorded to those patients whose prognosis with
regard to hospital discharge is good with intensive care,
but poor without it – i.e., the patients who will benefit most
from intensive care.” “Age in itself,” it is pointed out in the
document, “is not to be applied as a criterion, as this would
be to accord less value to older than to younger people,
thus infringing the constitutional prohibition on discrimi-
nation. Age is, however, indirectly taken into account
under the main criterion «short-term prognosis», since
older people more frequently suffer from comorbidity. In
connection with COVID-19, age is a risk factor for mortal-
ity and must therefore be considered.” As for the evalua-
tion of additional criteria, the Swiss Academy of Medical
Sciences believes that criteria such as lotteries, “first come,
first served” and prioritization according to social useful-
ness must not be considered.
In the document “Bioethical guidelines for equal access
to healthcare,”4 the National Bioethical Committee points
out that in the context of resource allocation issues,
thoughts regarding ethics play a fundamental role in plac-
ing guidelines and methodologies within boundaries of
just and shared criteria for the reduction of the traumatic
consequences that allocative choices can often involve.
More specifically, the same Committee, in a recent doc-
ument on clinical decisions made under conditions of
scarce resources and the criterion of “triage in pandemic
emergency,”5 examines the ethical problem of patient
access to treatment under conditions of limited health
resources, or in relation to the scenario that has recently
emerged as a result of the Covid-19 emergency. Clearly,
this problem makes it necessary to mitigate the application
of various principles, including the protection of life and
health, freedom, responsibility, justice, fairness, solidarity,
and transparency, in relation to the totality of those people
in need of treatment, whether infected by the current epi-
demic, or affected by other pathologies.
The National Committee for Bioethics has assessed
clinical criteria as the most appropriate point of reference
for the allocation of healthcare resources, deeming any
other selection criteria such as age, sex, social condition
and role, ethnicity, disability, costs, and responsibility with
respect to behaviors that have induced the disease, ethi-
cally unacceptable.
Secondly, the Committee, considering the exceptional
nature of the moment, believe that the method of selecting
patients according to the degree of urgency (triage) should
be redefined. Triage during a pandemic emergency is
based on the concepts of preparedness, clinical appropri-
ateness, and topicality, in order to avoid a priori choices
regarding access to care. The concept of “preparedness”
can be explained, for example, as the preparation of action
strategies in the field of public healthcare, in view of
exceptional conditions with respect to emergencies caused
by pandemics. The term “clinical appropriateness” means
the medical evaluation of the efficacy of the treatment with
respect to the clinical need of each individual patient, seen
in the entirety of his/her clinical situation, whilst taking all
Delbon et al. 3
the necessary factors of evaluation into consideration.
According to the National Bioethics Committee, without
prejudice to the priority of treatment according to the
degree of urgency, other factors include the severity of the
ongoing clinical situation, the comorbidity, and the situa-
tion of imminent termination of life. Age is also a param-
eter that is taken into consideration due to the correlation
with the current clinical and prognostic evaluation, but it is
neither the only nor the main parameter. According to the
National Bioethics Committee, the priority should be
established by evaluating, based on the indicators men-
tioned, the patients for whom the treatment can reasonably
be most effective, in the sense of ensuring the greatest
chance of survival. In other words, a criterion should not
be adopted, according to which the sick person would be
excluded because he/she belongs to a category established
a priori. Lastly, “topicality” because during triage, in a
pandemic emergency, in addition to the patients who are
“physically present,” we consider those who have been
evaluated and observed from a clinical point of view,
whose critical conditions we are already aware of, always
keeping in mind the objective of avoiding the formation of
categories of people who would then be disadvantaged and
discriminated against.
Some authors6 underline the “prospective” character of
the very serious situation of scarce resources: the emer-
gency, though not concentrated in a given space and time
with a defined number of patients, is a crisis of the system
and is on-going. That is to say, the crisis is destined to
spread, to last for an unpredictable period of time and is
characterized by the rapid and progressive increase in the
number of the sick, for whom it is necessary to apply
extraordinary rationing criteria.
The German Ethics Council, in its Ad hoc Recommen-
dation on “Solidarity and Responsibility during the
Coronavirus Crisis,”7 distinguished two basic scenarios in
emergency situations, when fewer ventilators are available
than are acutely needed. “Triage in ex ante situations”
refers to “cases where the number of unoccupied ventila-
tors is smaller than the number of patients who have an
acute need for them.” In these situations, “patients who are
subsequently denied treatment (. . .) are simply not saved
from disease-related death for reasons of tragic impossibil-
ity” and “from an ethical point of view, the decision should
be based on well-considered, justified, transparent and as
far as possible, uniformly applied criteria.” In “Triage in
ex post situations,” where all ventilators are occupied “the
life-sustaining treatment of one patient would have to be
discontinued to save the life of another patient by reassign-
ing the medical device”: in these situations, the decisions
are “far more problematic.”
On the other hand, other Authors8 have emphasized
how we must start from the full awareness that extraordi-
nary circumstances cannot overturn fundamental ethical
values that normally regulate our social life. Healthcare
needs, even if they are deficient, cannot assume such a
preponderant weight as to compress the irreducible core of
the right to healthcare, an indispensable element of human
dignity. In this context, it remains necessary to use the
decision-making criterion of clinical and scientific appro-
priateness to evaluate the efficacy and proportionality of
the treatment (which must not be wasted). Treatment
choices must be evaluated case by case and based on the
informed consent of the patient, on the refusal or interrup-
tion of medical treatment, on the prohibition of clinical
obstinacy given the real health conditions of the patient, on
treatment planning, and on any advance declarations con-
cerning treatment. To ensure the necessary and continuous
adaptation of the adopted criteria, in the various phases of
the emergency, it would be appropriate to hold a collegial
bioethical discussion within the healthcare professions and
to set up specific, multidisciplinary bodies, equipped with
the necessary knowledge, skills, and abilities.8
Within this exceptional context, therefore, problematic
situations are created that effectively prevent the principle
of favor vitae from being fully respected, precluding the
ethical, deontological, and legal duty of providing neces-
sary assistance.6 In this situation, in which, given the insuf-
ficiency of available resources, healthcare professionals
may no longer be able to distribute treatment and assis-
tance equitably, the identification of criteria aimed at guid-
ing the decision-making process, albeit with awareness of
the extraordinary, necessarily flexible and adaptable nature
it must encompass, in relation to the availability of
resources, the concrete possibility of transferring patients
and the number of accesses currently underway or planned,
and temporary, of these criteria must be provided for.
Resource scarcity and healthcare
required during the Covid-19
pandemic: Reallocation of resources
and protection of health
According to the Council of Europe - Committee on
Bioethics (DH-BIO)9 it is essential that decisions and prac-
tices in this context “meet the fundamental requirement of
respect for human dignity and that human rights are
upheld.” The DH-BIO highlights some of the principles of
human rights laid down in the Oviedo Convention which
require vigilance in their application in the current pan-
demic. The principle of equity of access to health care laid
down in Article 3 of the Oviedo Convention says “that
access to existing resources be guided by medical criteria,
to ensure namely that vulnerabilities do not lead to dis-
crimination in the access to healthcare. This is certainly
relevant for the care of COVID-19 patients, but also for
any other type of care potentially made more difficult with
confinement measures and the reallocation of medical
resources to fight the pandemic.”
The ISTAT 2020 Annual Report10 shows how the pan-
demic had a significant impact on the quantity and type of
supply of the health system, being able to influence its
4 Journal of Public Health Research
dynamics and organization also in the future. The redistri-
bution of resources, in consideration of Covid-19, has
resulted in a limitation of the ordinary supply, postponing
the deferred scheduled interventions, and discouraging
non-urgent demand. Furthermore, the fear of contagion
would have played an important role in limiting demand.
It should be remembered that in Italy, during the lock-
down period (March–May 2020), outpatient and hospital-
ization services defined as “non-urgent” (i.e. those that can
be scheduled or deferred) were suspended as per provi-
sions issued by the Government (DPCM of 08/03/202011
and DPCM of 09/03/202012 for the contrast and contain-
ment of the spread of the SARS-Cov-2 virus. During the
lockdown period, only the booking lists for urgent and
cancer patients remained active, as indicated by the
Ministry of Health circulars no. 7422 of 16/03/202013 and
n. 8076 of 30/03/2020.14
A huge number of specialist visits and diagnostic test-
ing services (CT, MRI, ultrasound, PET, etc.) were frozen,
awaiting reopening and the return to normal in the country.
Patients with other diseases, the so-called “non-Covid,”
had to wait for the requested though postponed services,
de facto losing, though temporarily, their rights to health
care. In many cases urgent or short-term services saturated
the waiting lists and, therefore, the reopening following
the lockdown did not involve the automatic resumption
and recovery of services, not performed during this period.
The reopening of those hospitals not identified as “Covid
Centers” to the entire population also required the imposi-
tion of new rules for maintaining social distancing, with
the reduction of available beds and the number of outpa-
tient visits that could be performed.
In order to promptly respond to requests for outpatient,
screening and hospitalization services not provided during
the emergency period and to reduce waiting lists, with
Article 29 of Decree-Law no. 104 of 14/08/2020,15 con-
verted into Law no. 126 of 13/10/2020,16 containing
“urgent measures to support and relaunch the economy,”
the Government ordered an increase in spending for
healthcare personnel, in terms of new hires and an increase
in their hourly rate, in attempt to mitigate the effects of the
health emergency and the scarcity of resources. Despite
the current recovery attempts, we might expect an even
more serious delay than in the past in the new bookings,
due to a further extension of the waiting lists, disregarding
the legitimate expectations of patients who would be
forced to wait even longer before receiving treatment.
Conclusions
As is evident from the documents taken into consideration,
in the context outlined, we may be faced with the choice of
who to include and who to exclude from intensive treat-
ment. Considerations on who is to make the choice and the
possible criteria to be used for that selection further high-
light the tragic nature of the situation, in which as some17
have underlined, the “random lottery” as a criterion for
solving the dilemma of distribution seems to be entirely
unacceptable, even though, at times, when faced with an
apparently impossible decision, it seems to be the only
solution. On the other hand, these same Authors underline
the fact that the criterion of age or preference of a life less
lived and open to the future with respect to the life most
lived, the quality of probable life, financial availability,
social role, disability or dependence, productive capacity
or efficiency, social cost, responsibility with respect to the
pathology, nationality and ethnicity are unacceptable crite-
ria as they are extra-medical, which arbitrarily and extrin-
sically establish inequalities among human individuals,
representing an evident deviation from the logic based on
the criterion of objective medical evaluation of the case in
question. If the scarcity of available resources does not
make it possible to treat all patients, the criterion for access
to treatment should be defined only using objective (medi-
cal) criteria, that is, based on the patient’s clinical condi-
tion. In the context of the pandemic, it has therefore been
made very clear that scarce resources must not be misused
or wasted. Instead, they must be used as effectively as pos-
sible. That is to say, they must be used to save human lives.
However, at the same time we must not forget that the
needs of each person must be placed at the center and that
this criterion must be applied to all patients indiscrimi-
nately. Selection must not lead to differentiated treatment
between infected patients and patients with other patholo-
gies, since vigilance is ethically due to the continuity of
taking care of other patients.17
The importance of sharing rigorous and transparent cri-
teria, and medical-clinical parameters, the application of
which takes place in compliance with constitutional and
ethical principles and within the framework of the appro-
priateness of care, to guide health professionals in the dis-
tribution of resources when guaranteeing intensive care to
all patients has proved to not be possible, which has led to
the adoption of documents containing such indications
by scientific societies. A recent joint document, drawn
up by SIAARTI and the FNOMCeO (National Federation
of Orders of Physicians and Dentists) on “Therapeutic
choices in extraordinary conditions,”18 intends to establish
these criteria, being coherent with ethical and professional
principles, in support of the doctor who is faced with tragic
choices, due to the imbalance between needs and available
resources.
In these situations of absolutely urgent necessity, under
exceptional conditions of imbalance between needs and
available resources, access to intensive treatment would be
guaranteed with priority given to those who might receive
a concrete, acceptable and lasting benefit. Therefore, the
following concurrent and integrated criteria, always evalu-
ated case by case will be applied: the severity of the clini-
cal case, any comorbidities, the previous functional state,
the impact of the potential side effects of intensive care,
the knowledge of previous expressions of will, as well as
Delbon et al. 5
the patient’s biological age, which should never be preva-
lent. The document specifies that if providing a specific
medical treatment in exceptional conditions of imbalance
between needs and available resources is impossible, ther-
apeutic abandonment must not follow. In consideration of
his or her position as guarantor, the doctor must always
carry out the necessary assessments for the progression of
the pathology, causing as little pain as possible, whilst
safeguarding the dignity of each person, through suitable
support in an attempt to alleviate physical, mental, and
spiritual suffering.
Following the aforementioned SIAARTI Recommenda-
tions and the SIAARTI – FNOMCeO agreement docu-
ment, the Italian National Institute of Health (ISS) invited
SIAARTI and the Italian Society of Legal and Insurance
Medicine (SIMLA) to prepare draft guidelines for triage in
relation to decisions for intensive care in the event of dis-
proportion between healthcare requirements and resources
available during the Covid-19 pandemic. After public con-
sultation, the final version of the document was published
on the ISS National Center for Clinical Excellence, quality
and safety of care (CNEC) website on 13 January 2021.19
Specifically, the document emphasizes that “the
increase in demand for health care (. . .), due to a situation
such as the pandemic, does not reduce the necessary adher-
ence, as regards the protection of health, to the constitu-
tional and founding principles of the National Health
Service and to deontological principles, particularly uni-
versality, equality (non-discrimination), solidarity and
self-determination”; “at every level of intensity of care,
should care resources become saturated, making it impos-
sible to guarantee each sick person the recommended treat-
ment, it is necessary to resort to triage rather than to a ‘first
come, first served’ or random (lottery) criterion,” in order
to ensure life-sustaining treatments to as many patients as
possible who may benefit from them.
Triage must be based on a global evaluation of patients,
through clinical-prognostic parameters such as: number
and type of comorbidities, previous functional status and
frailty relevant to the response to care, severity of the cur-
rent clinical condition, presumable impact of intensive
treatment, also in consideration of the patient’s age (it
should be noted that age should be considered as part of
the global assessment of the patient and not on the basis of
pre-set cut-offs), patient’s wishes with regard to intensive
care, which should be investigated at an early stage of the
assessment, or, in the event of the person’s incapacity, by
verifying any wishes previously expressed through
advanced treatment provisions or through shared care
planning. These proposed criteria do not have a predefined
hierarchy and should not be viewed as absolute but should
be “balanced and viewed in the light of each clinical con-
dition, where one criterion or more may become more
important and thus predominate in the clinical decision.”
As highlighted by the National Bioethics Committee,
the fundamental lines of triage in a pandemic emergency
should be based on one premise, namely the preparation of
action strategies in the field of public health, in view of
exceptional conditions with respect to emergencies caused
by pandemics. In other words, we must evaluate how to
manage, in exceptional situations, the inevitable conflict
between the collective objectives of public healthcare (to
ensure the maximum benefit for the greatest number of
patients) and the ethical principle of ensuring maximum
protection for the individual patient: a dilemma difficult to
resolve in the concreteness of the choices.5
Finally, it is necessary to emphasize that Italy was only
one of the first countries to experience the rapid increase in
severe COVID-19-cases. Thus, triage recommendations
have been published by several professional associations,
in several countries, in an extremely short time.20 The goal
of the guidance documents drawn up in 2020 was “to
achieve maximum benefit for as many as possible and to
save the maximum number of lives with the resources
available at the time of the decision.” The principle of jus-
tice and equitable access to healthcare was always invoked
and described. Most of the documents included medical
criteria in triage decisions and recommended regular re-
evaluation “in order to continually adapt treatment strate-
gies to current resources and to an individual patient’s
condition.”21
Author contributions
PD drafted the work and revised it. FM revised the work. BF
revised the work. AC made substantial contributions to the con-
ception and design of the work.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Informed consent
The manuscript does not contain any individual person’s data in
any form.
Significance for public health
The spread of Covid-19 infection has led to a strong imbalance
between available resources and healthcare requirements, which
has necessitated the establishment of further criteria, in addition
to those of clinical appropriateness and proportionality of care,
needed to define the allocation of the limited resources available,
primarily considering access to intensive treatments. The redis-
tribution of resources, in relation to the demand related to Covid-
19, resulted in a limitation of the ordinary supply, postponing
planned interventions, and discouraging non-urgent demand. The
National Bioethics Committee has highlighted that “how to deal
in exceptional situations with the inevitable conflict between col-
lective public health objectives (ensuring maximum benefit for
6 Journal of Public Health Research
the largest number of patients) and the ethical principle of ensur-
ing maximum protection for the individual patient: a dilemma
difficult to solve in the concreteness of the choices.”
ORCID iD
Francesca Maghin https://orcid.org/0000-0002-9087-8698
References
1. Italian Society of Anaesthesia, Analgesia, Resuscitation, and
Intensive Care (SIAARTI). Clinical ethics recommendations
for the allocation of intensive care treatments, in excep tional,
resource-limited circumstances, https://www.flipsnack.
com/siaarti/siaarti_-_covid-19_-_clinical_ethics_recco-
mendations/full-view.html (2020, accessed 25 July 2020).
2. Riccioni L, Bertolini G, Giannini A, et al. (Gruppo di Lavoro
SIAARTI – Società Italiana di Anestesia Analgesia
Rianimazione e Terapia Intensiva). Raccomandazioni di etica
clinica per l’ammissione a trattamenti intensivi e per la loro sos-
pensione, in condizioni eccezionali di squilibrio tra necessità e
risorse disponibili. Recenti Prog Med 2020; 111: 207–211.
3. Swiss Academy of Medical Sciences. COVID-19 pandemic:
triage for intensive-care treatment under resource scarcity.
Guidance on the application of Section 9.3 of the SAMS
Guidelines «Intensive-care interventions». https://www.
samw.ch/en/Ethics/Topics-A-to-Z/Intensive-care-medicine.
html (2013, accessed 29 May 2020).
4. Comitato Nazionale per la Bioetica – National Bioethics
Committee. Orientamenti bioetici per l’equità nella salute
– Bioethical guidelines for equal access to healthcare, http://
bioetica.governo.it/media/3585/p49_2001_equita-nella-
salute_it.pdf (2001, accessed 26 May 2020).
5. Comitato Nazionale per la Bioetica – National Bioethics
Committee. Covid-19: la decisione clinica in condizioni
di carenza di risorse e il criterio del “triage in emergenza
pandemica” – Covid-19: clinical decision-making in con-
ditions of resource shortage and the “pandemic emergency
triage” criterion. https://bioetica.governo.it/media/4248/
p136_2020_-covid-19-la-decisione-clinica-in-condizioni-
di-carenza-di-risorse-e-il-criterio-del-triage-in-emergenza-
pandemica.pdf (2020, accessed 26 May 2020).
6. Piccinni M, Aprile A, Benciolini P, et al. Considerazioni
etiche, deontologiche e giuridiche sul Documento SIAARTI
“Raccomandazioni di etica clinica per l’ammissione a trat-
tamenti intensivi e per la loro sospensione, in condizioni
eccezionali di squilibrio tra necessità e risorse disponibili”.
Recenti Prog Med 2020; 111: 212–222.
7. Deutscher Ethikrat. Solidarity and responsibility during
the Coronavirus Crisis. Berlin: Ad Hoc Recommendation.
2020. https://www.ethikrat.org/fileadmin/Publikationen/Ad-
hoc-Empfehlungen/englisch/recommendation-coronavirus-
crisis.pdf (2020, accessed 26 April 2022).
8. D’Avak L. Covid-19: criteri etici. Rivista di BioDiritto 2020;
1: 371–378.
9. Council of Europe. Committee on Bioethics (DH-BIO). DH-BIO
Statement on human rights considerations relevant to the
COVID-19 pandemic. Strasbourg: Council of Europe. https://
rm.coe.int/inf-2020-2-statement-covid19-e/16809e2785
(2020, accessed 11 June 2020).
10. Istituto Nazionale di Statistica (ISTAT). Rapporto annuale
2020. La situazione del Paese. Presented in Rome on 3 July
2020. http://www.istat.it (accessed 3 December 2020).
11. Decree of the President of the Council of Ministers. Further
implementing provisions of the decree-law 23 February
2020, n. 6, containing urgent measures regarding the con-
tainment and management of the epidemiological emer-
gency from Covid-19 (20A01522) (G.U. General Series n.
59 of 08-03-2020), 8 March 2020.
12. Decree of the President of the Council of Ministers. Further
implementing provisions of the decree-law 23 February
2020, n. 6, containing urgent measures regarding the con-
tainment and management of the epidemiological emer-
gency from Covid-19, applicable throughout the national
territory. (20A01558) (G.U. General Series n. 62 of 9-03-
2020), 9 March 2020.
13. Italian Ministry of Health. Ministerial circular no. 7422
of 16-03-2020. Guidelines for the reshaping of the sched-
uled activity which can be deferred during an emer-
gency from Covid-19, http://www.prefettura.it/FILES/
AllegatiPag/1221/Circolare_del_Ministero_della_
Salute_n.7422_del_16_marzo_2020.pdf (2020, accessed 21
June 2022).
14. Italian Ministry of Health. Ministerial circular no. 8076 of
30-03-2020. Clarifications: Guidelines for the reshaping
of the scheduled activity that can be deferred during an
emergency from Covid-19. https://www.trovanorme.salute.
gov.it/norme/renderNormsanPdf?anno=2020&codLeg=7
3775&parte=1%20&serie=null (2020, accessed 21 June
2022).
15. President of the Italian Republic. Decree-Law n. 104: Urgent
measures to support and revive the economy. (20G00122)
(G.U. General Series n. 203 of 08-14-2020 - Ordinary Suppl.
N. 30). The measure came into force: 15-08-2020, 14 August
2020.
16. President of the Italian Republic. Law n. 126: Conversion
into law, with amendments, of the decree-law of 14 August
2020, n. 104, containing urgent measures to support and
relaunch the economy. (20G00145) (G.U. General Series n.
253 of 10-13-2020 - Ordinary Suppl. N. 37) notes: The pro-
vision comes into force: 14-10-2020, 13 October 2020.
17. Palazzani L. La pandemia e il dilemma per l’etica quando le
risorse sono limitate: chi curare? BioLaw Journal 2020; 1:
359–370.
18. FNOMCeO – SIAARTI. FNOMCeO – SIAARTI
Document. https://portale.fnomceo.it/wp-content/
uploads/2020/10/DOCUMENTO-FINALE-FNOMCEO_
SIAARTI_22-OTTOBRE-2020_x.pdf (2020, accessed 28
November 2020).
19. Riccioni L, Ingravallo F, Grasselli G, et al. The Italian docu-
ment: decisions for intensive care when there is an imbalance
between care needs and resources during the COVID-19
pandemic. Ann Intensive Care 2021; 11: 100.
20. Ehni HJ, Wiesing U and Ranisch R. Saving the most lives - a
comparison of European triage guidelines in the context of
the COVID-19 pandemic. Bioethics 2021; 35: 125–134.
21. Jöbges S, Vinay R, Luyckx VA, et al. Recommendations
on COVID-19 triage: international comparison and ethical
analysis. Bioethics 2020; 34: 948–959.
