Saudi Critical Care Journal

: 2022  |  Volume : 6  |  Issue : 3  |  Page : 61--67

Awareness, opinion, attitude of intensive care unit specialists about the ethical guidelines for dealing with clinical decisions regarding the allocation of scarce resources during the COVID-19 pandemic

Faisal A Al-Suwaidan1, Jamal S AlJarallah2, Nada A Alyousefi2, Ghaiath Hussein3,  
1 Division of Neurology, Department of Medicine, Security Force Hospital; Clinical Excellence Administration, Riyadh Second Health Cluster, King Fahad Medical City; Clinical Assistant Professor, Collage of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
2 Department of Family and Community Medicine, College of Medicine; King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
3 Assistant Professor in Medical Ethics and Law, School of Medicine, Trinity College Dublin, Dublin 2, Ireland, Europe

Correspondence Address:
Faisal A Al-Suwaidan
Department of Medicine, Division of Neurology, Security Force Hospital, Riyadh
Saudi Arabia


Background: With the escalation of the coronavirus disease (COVID-19) pandemic, critical care specialists have been challenged by ethical issues related to the distribution of scarce resources. Many relevant guidelines have been published worldwide. The Saudi Critical Care Society included a local framework for ethics in its first clinical guidelines for clinical decisions regarding the allocation of scarce resources during the COVID-19 pandemic for COVID-19 patients in intensive care units (ICUs). This study aimed to assess the awareness, opinions, and attitudes of ICU specialists concerning these ethical guidelines and the proposed definitions. Methods: A descriptive cross-sectional study using a self-administered questionnaire was conducted. The study population included 300 ICU physicians in Saudi Arabia who were members of the Saudi Critical Care Society. Results: A total of 70 participants (23.3%) responded to the questionnaire. Most were male, non-Saudi, and Muslim. Professionally, they were mostly intensivists with 10 or more years of experience. The most agreed-upon suggested definitions were “health crisis,” “salvageable patients” category, and the “necessity scale” (32; 45.7%, 37; 52.9%, 52; 74.3%, and 34; 48.6%, respectively). Less agreement was observed for the definitions of “de-escalation without omission” and “primary triage scale” (20; 28.6%, and 21; 3%, respectively). The most agreed-upon statements were those requiring healthcare providers to receive training on contagious diseases and calling for providing them with housing if a situation requires them to leave their homes (56; 80%), while the least agreed-upon statements concerned withholding mechanical ventilation from patients (29; 41.4%). Conclusion: During epidemics, health-care workers provide services in unusual, challenging situations. Doing so necessitates support in social, psychological, and professional areas. A decision-making framework is needed that endorses the cultural and religious contexts, as well as the lived experiences of frontline clinicians, including a clear de-escalation plan and a primary triage system during the pandemic.

How to cite this article:
Al-Suwaidan FA, AlJarallah JS, Alyousefi NA, Hussein G. Awareness, opinion, attitude of intensive care unit specialists about the ethical guidelines for dealing with clinical decisions regarding the allocation of scarce resources during the COVID-19 pandemic.Saudi Crit Care J 2022;6:61-67

How to cite this URL:
Al-Suwaidan FA, AlJarallah JS, Alyousefi NA, Hussein G. Awareness, opinion, attitude of intensive care unit specialists about the ethical guidelines for dealing with clinical decisions regarding the allocation of scarce resources during the COVID-19 pandemic. Saudi Crit Care J [serial online] 2022 [cited 2023 Feb 8 ];6:61-67
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Full Text


With the escalation of the coronavirus disease (COVID-19) pandemic and hundreds of thousands of deaths, critical care specialists have been challenged by a scarcity of resources. During pandemics, health-care providers may face a challenging work environment that mandates altered standards of care, such as triaging patients based on criteria such as the likelihood of survival or being a member of the healthcare team.

Although most COVID-19 patients have minor symptoms, 4.7% of patients in Saudi Arabia required intensive care unit (ICU) admission and ventilator assistance.[1] Internationally, the rate of ICU admission among hospitalized patients with COVID-19 was about 20%.[2],[3],[4],[5] The length of stay in the ICU was reported to be over 7 days.[6] The currently limited data on the mortality of COVID-19 leads to challenging uncertainty in making decisions and prioritizing care. A cohort study found that pressure on critical care capacity was linked to increased COVID-19 ICU mortality.[7]

Italian COVID-19 crisis data showed an average case fatality rate of 7.5%, and an average ICU admission rate of 21.4%, with an association between mortality and the absence of treatment in ICUs.[8] That is why most countries have initiated lockdown regulations and implemented restrictions to avoid going into extreme crises in which care initiation or withdrawal may be practiced when healthcare resources surpass abilities.

These successive events cause concerns for all countries, which began to consider drafting ethical frameworks for protocols when health-care systems could not provide adequate care for COVID-19 patients with respiratory failure. Many guidelines have been published on how to distribute scarce resources in crisis times, notably a limited number of ventilators and ICU resources.

Many proposed ethical frameworks were introduced based on societies' cultural and legal backgrounds, which mainly highlighted either egalitarian or utilitarian principles.[9],[10] Practically, these were interpreted as considering a fair lottery or the likelihood of survival. Other ethical principles and approaches have been suggested, mostly based on the lessons learned from previous pandemics, such as SARS, Ebola, and H1N1.[11],[12],[13]

Compared to other countries that delayed introducing restrictive measures, Saudi Arabia took early, extreme measures to control the spread of COVID-19, and thus did not face a severe shortage of resources during the pandemic. Considering the cultural and legal factors influencing healthcare providers in Saudi Arabia, the Saudi Critical Care Society announced a local ethical framework to guide health-care providers in clinical decision-making regarding the allocation of scarce resources during the COVID-19 pandemic.[14]

Given the rarity of such pandemics on a large scale and the likelihood that similar pandemics might still occur, it was a timely opportunity to assess the awareness, opinions, and attitudes of ICU specialists concerning the ethical guidelines for clinical decision-making regarding the allocation of scarce resources during the COVID-19 pandemic.

The current study was carried out to assess ICU specialists' awareness, opinions, and attitudes concerning these ethical guidelines and the proposed definitions therein.


A descriptive, cross-sectional, questionnaire-based study was conducted between October and December 2020 using an electronic self-administered questionnaire. This e-questionnaire was designed using Google Forms and then posted on selected professional social media platforms: Twitter, LinkedIn, and WhatsApp groups dedicated to ICU physicians working in Saudi Arabia. The questionnaire comprised three main sections that asked questions about the physicians' demographics, clinical experience, and opinions on the main statement and definitions used in the ethical framework. It was revised and pretested on seven physicians who were not included in the sample.

The physician's opinions were assessed using an agreement scoring system of 3 or 5 points to rate their agreement with predesigned statements related to clinical practice and ethical issues concerning the COVID-19 pandemic. The statements included definitions of terminology for use in the context of epidemics. The questionnaire also included statements related to what facilities should be provided for health-care workers and how they could provide healthcare during the epidemic. Finally, there were statements concerning resource allocation during the crisis. The first section of the questionnaire contained statements to assure the participants that their participation was voluntary, that their responses would remain anonymous, and that only the research team would have access to the data, which would only be used for research purposes. Ethical approval was obtained from the King Fahad Medical City Institutional Review Board (20-547).

All the data collected through Google Forms was exported as a Microsoft Excel spreadsheet and then exported to IBM SPSS Statistics for Windows, version 24.0 (IBM Corp., Armonk, NY, USA) for further analysis. Frequencies and percentages were reported for the categorical variables.


Characteristics of participants

A total of 70 respondents responded to the questionnaire, with a response rate of 23.3%. [Table 1] shows the participants' demographics characteristics. Most of the respondents were male (62; 88.6%), non-Saudi (53; 75.7%), and Muslim (66; 94.3%). Most were intensivists (53; 75.7%), and almost half had 10 or more years of experience (34; 48.6%).{Table 1}

Opinions on healthcare during the COVID-19 crisis

[Table 2] summarizes the opinions of health-care providers on definitions of terminology to be used in the context, namely a “health crisis,” “salvageable patients” category, the “necessity scale,” “escalation without omission,” and “the primary triage scale.” When both “agree” and “strongly agree” options were added, there was strong agreement with the suggested definitions of “health crisis,” “salvageable patients” category, and the “necessity scale” (32; 45.7%, 37; 52.9%, 52; 74.3%, 34; and 48.6%). Lesser levels of agreement were observed regarding the definitions of “de-escalation without omission” and “primary triage scale” (20; 28.6% and 21; 30%).{Table 2}

Opinions of health-care providers on their needs and the measures to be taken during a health crisis

The ethical framework included statements [Table 3] on what should be provided for healthcare workers during a health crisis. Most respondents agreed with all the statements. The highest agreement was with the statements that “security services are capable of managing crowd control during a crisis or clash” and the “assurance of healthcare workers” stress management skills and psychological support for them during and after the pandemic (65; 92.9% and 66; 94.3%).{Table 3}

Most of the participants (56; 80%) agreed on statements requiring health-care providers to receive training in contagious diseases and to provide them with housing if the situation requires them to leave their homes.

In contrast, only 3 (4.3%) participants disagreed with the following statement: “It is forbidden to refuse to provide clinical care by a specialist in infectious or epidemic diseases (directly or indirectly) for suspect infected patients as long as he/she is equipped with required personal protective equipment.”

Regarding the measures taken in response to an extreme surge level and shortage of medical resources, most participants (55; 78.6%) agreed that all health-care workers must provide clinical care under policies and regulations supplied by an authorized pandemic committee. Fifty-two participants (74.3%) agreed that the authorized pandemic committee could mandate all health-care providers to care only for emergency cases at direct and immediate risk if not treated.

Opinions of health-care providers on the allocation of resources during the COVID-19 crisis

Most participants (47; 67.1%) agreed that the authorized pandemic committee could withhold access to medical care for nonsalvageable patients. About 9% of participants disagreed that access to medical care should be withheld from patients with a suspected poor response to treatment based on similar cases. About 23% of the participants were neutral in this regard.

Respondents showed disagreement over certain statements [Table 4]. The most disagreed-upon statement concerned the withdrawal of care, for which 35 (50.0%) of respondents were neutral, and 6 (8.6%) respondents disagreed. These percentages did not change significantly, even when conditions were added.{Table 4}

The respondents' opinions on the withdrawal of care were unequivocal when one consultant and two other physicians determined that a patient was nonsalvageable (84% agreed, and only 14% disagreed). Most participants agreed that a fair lottery could be used when all the parameters among patients are equal and under inevitability (47; 67.1%).


During epidemics, health-care workers provide services in unusual, difficult situations. They are overburdened by an excessive workload, longer working hours, physical exhaustion, and psychological stress.[15],[16] They are also at risk of contracting the disease, and they may lack personal protective equipment. Such situations necessitate support in various social, psychological, and professional areas, as reflected by the high proportion of physicians in the current study who agreed with the need for it. Nevertheless, health workers, especially physicians and nurses, were found to be willing and able to make sacrifices and work in difficult circumstances.[17] The current study reflects this, with most respondents advocating for the continuation of care in accordance with the policies mandated by the authorized committee and rejecting the refusal to provide care if adequate personal protection is available.

At the beginning of the COVID-19 pandemic in 2019, the health-care system faced an enormous strain beyond its already overstretched health-care resources. For example, the scarcity of intensive care beds and equipment due to the massive influx of patients in desperate need of intensive care facilities affected the care provided to them.

Statistics have shown a clear disparity between the demand for medical resources and the capacity of any health system worldwide, even health-care systems with significant resources.[18] This situation is difficult and thus challenging.

Health-care systems are obligated to decide who should receive care and who should be denied it. This obligation raises at least two fundamental ethical questions: On what basis should these decisions be made? and How can medical resources be fairly allocated during an epidemic?

Ethical principles central to these questions include beneficence, nonmaleficence, autonomy, and justice. Maximizing benefits and minimizing harm are of paramount importance during an epidemic. Respecting the principle that everyone matters equally is also pivotal. Justice, in particular, distributive justice, must be observed in situations when resources are distributed among patients, such as straightforward first come, first served decisions. However, such principles guiding ethically acceptable decisions could conflict with usual standards of care when resources are scarce. An objective allocation system should thus be developed.

Several allocation systems and strategies were suggested,[19] but they were unsatisfactory. For instance, after conducting an extensive review of triage protocols and ethical frameworks, Fiest et al.[20] were unable to identify a single protocol or framework that could be applied. At best, they believed a particular protocol or framework would assist health-care decision-makers to determine the best solution for a particular situation.[20]

Cao and Huang investigated four principles to guide resource allocation in disasters: first come, first served; random selection; most serious first; and least serious first. They discovered that the most serious first principle performed the worst, while the least serious first principle performed the best.[21] This finding can be problematic from an ethical standpoint.

It is worth noting that ICU physicians were divided over whether it is permissible to withdraw medical care from one patient in favor of another based on changing priorities. About half of the participants agreed, and 40% were neutral. This is unsurprising because physicians usually have reservations about discontinuing care for a patient.[22] Nevertheless, we believe that such viewpoints may change with time and that experience with current and future epidemics and disasters could be an important factor leading to this change.

Similarly, physicians were divided over withholding mechanical ventilation during a crisis, even if the patient survived or the ventilator could be reused. Given the clinical and ethical uncertainty in such situations, this finding is unsurprising. However, it presents a quandary in which the simple first come, first served rule no longer applies, and a new decision-making system must be developed, which should include a clear de-escalation plan and primary triage system that healthcare providers must be oriented in before using.

In extreme situations with a large influx of patients and severe resource constraints, two-thirds of the respondents would accept a fair lottery. This, in our opinion, is a balanced stance, because a fair lottery, while contentious, is acceptable and even recommended as an option in a time of severe scarcity of resources if everything else is equal among patients.[23],[24]


Two caveats must be noted in the present study. First, the low response rate (23%) could be explained by the targeted physicians' uncertainty over how to deal with this exceptional situation and their busyness due to the peak of the COVID-19 pandemic at the time of the survey. Second, the draft framework was not published or officially distributed among clinicians; consequently, they may not have had enough opportunity to critically consider the framework's statements in their practice.

Despite the low response rate, there is a general agreement among Saudi ICU clinicians about a set of ethical principles and criteria outlining what should be provided to them and what resources should be allocated to their patients during the pandemic. A decision-making framework is needed that endorses the cultural and religious contexts as well as the lived experiences of the frontline clinicians that include a clear de-escalation plan and a primary triage system during the pandemic.


The authors report no conflicts of interest in this work.


Not funded.

Availability of data and materials

The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.

Authors' contributions

All the authors made a significant contribution to the work reported, whether in the conception, study design, execution, acquisition of data, analysis, and interpretation, or in all of these areas. They have drafted, revised, or critically reviewed the article, and read and approved the final manuscript.

Ethics approval and consent to participate

Ethical approval was obtained from the King Fahad Medical City Institutional Review Board.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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