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Organizational Ethics

This CQ section will address ethical challenges arising in the actions and decisionsmade by health care institutions or a health care system. Organizational ethics articles shift the focus from individual patients to the broader context of the organization, including its mission, values, financial management and health care delivery practices. Readers are invited to contact Bill Nelson to propose a submission at: [email protected].

Incorporating Stakeholder Perspectives on Scarce Resource Allocation: Lessons Learned from Policymaking in a Time of Crisis

BETHANY BRUNO*, HEATHER MCKEE HURWITZ*, MARYBETH MERCER, HILARY MABEL, LAUREN SANKARY, GEORGINA MORLEY, PAUL J. FORD, CRISTIE COLE HORSBURGH, and SUSANNAH L. ROSE

Abstract: The coronavirus disease (COVID-19) crisis provoked an organizational ethics dilemma: how to develop ethical pandemic policy while upholding our organizational mission to deliver relationship- and patient-centered care. Tasked with producing a recom- mendation about whether healthcare workers and essential personnel should receive priority access to limited medical resources during the pandemic, the bioethics department and survey and interviewmethodologists at our institution implemented a deliberative approach that included the perspectives of healthcare professionals and patient stakeholders in the policy development process. Involving the communitymore, not less, during a crisis required balancing the need to act quickly to garner stakeholder perspectives, uncertainty about the extent and duration of the pandemic, and disagreement among ethicists about the most ethically supportable way to allocate scarce resources. This article explains the process undertaken to garner stakeholder input as it relates to organizational ethics, recounts the stakeholder perspectives shared and how they informed the triage policy developed, and offers suggestions for how other organizations may integrate stakeholder involvement in ethical decision-making as well as directions for future research and public health work.

Keywords: organizational ethics; stakeholder input; scarce resource allocation; pandemic planning

Policies for the allocation of scarce healthcare resources and the potential prioritization of healthcare and other essential workers during the corona- virus disease (COVID-19) pandemic have not routinely incorporated direct patient and community input. Pub- lished recommendations from ethics cohorts highlight the importance of

*Bethany Bruno, Heather Mckee Hurwitz are co-first authors.

Acknowledgments: We thank the following for their contributions: G. Deadwyler, R.C. Langley, M.Michalski, M. Nall, V. Nall, C. Reeves, J. Szabo, D. Easton, R. Field, K. Flowers, J. Gorecki, R. Hosler, C. Leigh, K. Lichman, A. Markert, Y. Mauer, B. O’Neill, J. Ramsey, J. Toski Welsh, C. Turner, J. Jankowski, S. Feldman,A. Boissy, and D. Klein.

Cambridge Quarterly of Healthcare Ethics (2021), 30, 390–402. © The Author(s), 2021. Published by Cambridge University Press. doi:10.1017/S0963180120000924390

transparency with the public about developed policies1,2 but do not emphasize the value of involving the public as stakeholders in the policy development process itself. The inclu- sion of patient and community perspec- tives on pandemic triage is rarely reported in the literature with some exceptions3,4,5,6,7,8,9 and has failed to be comprehensively considered in relation to the COVID-19 pandemic. Similarly, although some healthcare professionals have published recommendations regarding the COVID-19 crisis, the lit- erature is void of a robust exploration of the perspectives of healthcare profes- sionals, collectively or by discip- line.10,11,12,13,14,15,16

In developing recommendations regar- ding healthcare and essential worker pri- oritization as part of a resource allocation policy during COVID-19, the Cleveland Clinic’s ethics department, with support from executive leadership, chose to inte- grate the perspectives of stakeholders, including healthcare professionals with direct care obligations and patients (and their families). Involving stakeholders in ethical decision-making has been coined a “deliberative” approach, defined as “[an] iterative two-way dialogue…[that] engage[s] citizens in a formal process of information exchange and knowledge- making.”17Howapolicy decision ismade significantly impacts trust in an organiza- tion and perceptions of organizational fairness;18 using the deliberative approach identifies collective priorities while also building trust among stakeholders.19

There were several reasons our bio- ethics department chose to pursue this deliberative approach. First, through our internal deliberative process, there were core disagreements among ethi- cists within the bioethics department regarding whether essential workers should receive allocation priority, particularly with respect to critical care resources. Obtaining stakeholder

perspectives was a natural step as part of the next phase of deliberations, which also included continued conversations with other ethicists in the region and an internal survey of our own ethicists. The ethics consultation service at our institu- tion has a history of commitment to actively engaging patients and healthcare professionals in ethical decision-making surrounding care.20,21,22 Seeking stake- holder input on COVID-19 resource allo- cation would be an extension of the department’s disposition toward cultivat- ing a broader moral community in terms of ethical decision-making at the organ- izational level.23

Moreover, recognizing our institu- tion as a moral agent responsible for its actions,24 our hospital leadership encourages stakeholder participation in the policy-making process in alignment with our organizational com- mitment to relationship- and patient- centered care. This viewpoint is reflected in the institution’s mission to treat all patients and healthcare professionals as a collaborative team with crucial per- spectives.25,26,27,28 It also aligns with the organizational ethics concept known as “stakeholder theory,” which posits that members of an organization constitute a moral community who each have obli- gations toward one another.29,30,31

By exploring the perspectives of care- givers, including physicians, nurses, social workers, and law enforcement personnel, as well as patients, this paper fills a gap in knowledge about how an organization may incorporate stake- holder perspectives in formulating responses to organizational ethics issues, even in the middle of a crisis. Several questions are addressed: How should healthcare institutions best involve stakeholders in the midst of an emergency? What are the benefits, limi- tations, and tradeoffs to engaging a wider community in ethical deliber- ations in the midst of a crisis? What are

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the lessons learned and how should processes be modified going forward? And finally, what future efforts are needed to improve organizational ethics practices and engage a range of stake- holders in discussions about responses to organizational ethics issues? To create inclusive pandemic planning, value-laden policy decisions should be informed not only by the perspectives of administrators, senior clinicians, and ethicists, but also by those who will be responsible for this work and live with the decisions made.

The Process

Several organizational constraints spar- ked our modified deliberative approach to involving stakeholders. Our delibera- tive process was engaged when the pandemic first began to escalate in the United States. The traditional public health strategy of involving the public in town hall meetings to gather commu- nity feedback, teach about public health crises, and share policies was not feasible.32,33 The unprecedented nature of the pandemicmade large-scalemeet- ings impossible due to required social distancing, and, at the beginning of the pandemic, video conferencing capaci- ties were still limited. There was an urgent need to act quickly to develop new practices and policies, but health- care institutions were also directing efforts to transform their hospitals and workforces. In response to these con- straints and with a goal to involve stake- holders, the deliberative approach was modified.

A series of short conversations were held between 21 stakeholders andmem- bers of the bioethics department and the research team. While the ethicists were directly involved in the conversations with stakeholders, survey and inter- view methodologists on the research team provided practical support to

develop conversation guides and to quickly identify themes in these conver- sations.34 The conversations sought to identify ethical perspectives, to quickly provide guidance on whether and how to prioritize healthcare and other essen- tial workers in a broader resource allo- cation policy, and to strengthen our community. A one-to-one approach was utilized due to the potential emo- tional burden of these discussions and time constraints of coordinating larger groups. Some stakeholders described feeling safer sharing their views indi- vidually with one ethicist rather than within a larger group. Clinical ethicists led the conversations and, as needed, a designated note-taker took notes.

Stakeholders were identified by drawing on preexisting, trusted net- works of caregivers and patient volun- teers. The Cleveland Clinic uses the term caregivers to indicate both clinical and nonclinical employees, all of whom contribute to the common goal of patient care. The patient-volunteer pro- gram includes patients and family members who share their uniquely valuable firsthand perspective on the care process. They serve as an advisory group to ensure patient voices are heard and that patient safety and well-being remain our highest priorities.

Fourteen caregivers and seven patients participated in the conversa- tions. Caregivers represented a range of organizational locations including five nurses from different units and enterprise hospitals, six physicians from various specialties, one social worker, one clinical speech pathologist, and one hospital system police officer. With respect to demographics, patients spanned a broad age-range (17–69years old). Three patients identified as female and four as male, with five who con- sidered themselves Caucasian and two African American. One patient was still in high school, two had completed

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1–3 years of college (some college, tech- nical school, or associate degree), one had a college degree, and three had completed graduate education.

In each conversation, the ethicists conversed with stakeholders about whether healthcare workers and other essential personnel, such as first responders (emergency medical ser- vices, police, and firefighters), grocery store and parcel delivery workers, and other human services operation person- nel directly interfacing with the public, who acquire COVID-19 should be pri- oritized over others to receive COVID- 19 treatment. Each conversation began with more general terms and moved into more specific types of scarce resource allocation questions, such as how to allocate vaccines and ventilators. See Figures 1 and 2 for additional details about questions posed to caregivers and patients.

Findings

Generally, there is broad consensus among experts, healthcare workers,

leaders, and communities that a pri- mary goal in a public health crisis is to maximize the number of lives saved, with consideration also given to minim- izing suffering.35,36,37 This guides deci- sions made about allocating available resources. What is less clear is whether priority should be given to healthcare workers and/or other types of essential personnel.We sought to explore towhat extent a wider group of caregivers, patients, and ethicists agreed about these priorities in the midst of the unfolding COVID-19 crisis.

Ethical prioritization schemes gener- ally fall into four frameworks: (1) treat- ing people equally, (2) favoring the worst off (prioritarianism), (3) maximiz- ing total benefits and reducing harms (utilitarianism), and (4) promoting and rewarding social usefulness.38,39,40

Instrumental value and reciprocity are ethical arguments that use a largely utilitarianism perspective and the ethos of promoting and rewarding social use- fulness. Instrumental value specifies that certain people who are central to the crisis response are given priority for

Figure 1: Outline of Questions Posed to Patients *Although initial conversations with patient stakeholders did not address the prioritization of healthcare and other essential workers for vaccines and PPE, these topics were addressed in follow-up conversations and during the writing of this paper.

1. Should healthcare workers with COVID-19 infection be prioritized to receive treatment

[For questions #1 & #2, a strong argument for both a yes and no response were presented as probes to the stakeholder with clarification and examples of the specifics of the question]

before others? 2. Should other kinds of workers engaged in essential services be prioritized for treatment

if they get sick with COVID-19? 3. Only answer if #2 is yes: Who in your mind is an essential worker that should get

priority? 4. Should prioritizing one type of worker over another include life-saving treatment when

there is not enough for everyone, or only evaluation/treatment up to the point of needing life-savingtreatment?

For example, if there is only one more ventilator and multiple people meet the medical criteria for being offered the ventilator, the treatment team could choose to give the ventilator to the healthcare worker/essential worker, or it could use a lottery system to randomly select who will get the ventilator.

5. Do you have any additional thoughts on allocating scarce healthcare resources during the COVID-19 pandemic?

Figure 1. Outline of questions posed to patients.

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preventive measures and therapeutic treatments in order to maintain an adequate workforce.41 For example, frontline healthcare workers save the lives of others and reduce harm to those who become ill; to accomplish this necessary societal role, they must remain healthy, protected from infec- tion by personal protective equipment (PPE) and vaccines, once available. While instrumental value may support treatment for those who do become ill if such treatment means they may return to the workforce quickly, reciprocity accounts retrospectively to reward employees who have already taken life-threatening risks, even if they may not be able to reenter the workforce.42

Reciprocity arguments recognize that essential workers are risking their lives to do their jobs and argues these work- ers therefore should have priority for treatment and vaccines as they become available.

We found that caregivers and patients rely on both instrumental value and reciprocity arguments to support priori- tization of healthcare providers and first

responders in allocation policies. Patients and caregivers felt that those who have direct patient contact, whether in the hospital or as first- responders, should be prioritized for healthcare resources. Interestingly, all seven patients believed that healthcare workers should be prioritized for treat- ment. Rooted in instrumental value, one patient’s perspective was representa- tive: “If you really want to curb the spread and impact of the virus, you need to priori- tize those who can help others and save more lives.” In addition, one patient com- mented: “As one who has lost a first responder family member, I would gladly volunteer to forego scarce treatment, know- ing it would be used to aid a vital service provider’s recovery.” Likewise, 10 of the 1443 caregivers drew on instrumental value to argue for the prioritization of healthcare workers. A nurse explained:

“The healthcare worker could poten- tially, when recovered from illness, go back into the workforce to help treat other COVID-19 patients. If they can return to the workforce, then they

Figure 2: Outline of Questions Posed to Caregivers 1. What is your biggest concern as a caregiver during the COVID-19 pandemic? 2. What can the hospital system do to alleviate your concerns or otherwise support you at this time? 3. If a vaccine for COVID-19 is developed, do you expect to be prioritized over non- caregivers to receive it?

a. If so, why? b. If not, why not? c. Who/who else should be prioritized to receive any vaccine developed?

4. If an effective treatment for COVID-19 is developed, do you expect to be prioritized over non-caregivers to receive it?

a. If so, why? b. If not, why not? c. Who/who else should be prioritized to receive any treatment developed?

5. If you were to require life-saving ventilation or ECMO due to COVID-19, do you expect to be prioritized over another non-caregiver patient with an otherwise equal prospect of survival with this treatment?

a. If so, why? b. If not, why not? c. Who/who else should be prioritized to receivelife-saving treatment?

6. Would decisions regarding the prioritization of any vaccine, treatment or life-saving treatment have any impact on yourwork?

Figure 2. Outline of questions posed to caregivers.

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should be prioritized for the reason of helping others. Although it is difficult to make these decisions, the technical natureof [and intensive training required for] these professions make that reason a consideration for prioritization.”

The nurse elaborated on the view that healthcare workers provide necessary help to others that typical community members cannot. Patients and caregivers contributed to a consensus that the pri- ority should be to preserve a healthy, safe healthcare workforce to serve patients in order to reduce the most amount of harm from the pandemic.

Similarly, caregivers and patients agreed that healthcare workers should be prioritized to receive PPE and a vac- cine. This perspective was largely rooted in instrumental value, that is, healthcare workers must remain healthy in order to care for others. A physician’s response noted this instru- mental value argument: “Healthcare pro- viders should be vaccinated first and then first-responders. We’re at higher risk so we need protection first so that we can take care of everyone else.” Emphasizing the need to save the most lives, the physician recognized that healthcare workers need to remain safe and healthy. A nurse supported this sentiment, adding, “While these are very uncomfortable things to consider, the fact remains that there are not endless resources.” Likewise, a patient advocated, “[We] need to dedicate proper PPE and vaccinations to caregivers from the start, so all hands are available to treat the community.” Raising both agreement and some issues for debate, another patient elaborated why all caregivers in the hospital who have patient contact should be included:

“Keep in mind that a clean hospital is a safe hospital. Environmental Service workers keep hospitals clean and safe for everyone. They should be a high priority for PPE, screenings, and vaccines.”

Put succinctly, one police officer pro- vided this summary:

“I think it’s essential that when push comes to shove that certain people get the vaccine, especially clinical staff who take care of patients. If [those] staff go down, every- thing implodes.”

The police officer’s views recognized that in a severe resource shortage, healthcare workers have particular training necessary for addressing crisis and therefore should have priority. Drawing on each of their organizational positions as well as on their identities as members of a team of specialized caregivers or patients, these statements generally recognized that healthcare workers are uniquely trained to care for patients; thus, it is instrumental to keep them healthy so that they can do their jobs and keep the pandemic under control. Most of the groups’ rationale around PPE and vaccines followed such instrumental logic and supported the utilitarian framework.

While there was agreement among caregivers and patients that healthcare workers should be prioritized for some levels of COVID-19 treatment, several areas of divergence emerged. For example, prioritization of other essen- tial workers beyond healthcare pro- viders and first responders was one such source of debate. Another area of divergence was that, for those workers deemed to warrant priority, caregivers and patients voiced a variety of perspec- tives on whether to allocate life-saving ventilators and intensive care to them. Most caregivers commented that this decision is more complex than the others, with some even expressing repugnance at the mention of such a possibility. Caregivers spoke of the need to follow important considerations per usual medical need, age, comorbidities, and likelihood of survival, while

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patients either did not distinguish between effective and life-saving treat- ment or valued the essential role health- care workers play in society. For example, a physician explained:

“Nurses, doctors, front desk hospital work- ers, anyone who puts themselves at risk fighting this disease should be prioritized for life-saving treatment. Like the army and Veterans Affairs—they risked their lives and now we give them care.”

Drawing on reciprocity arguments, this physician voiced the framework for pro- moting and rewarding social usefulness. This was in contrast to another physician who suggested that utilitarianism (that does not include giving healthcarework- ers priority) should remain the guiding framework and offers a perspective for saving the most lives and life-years:

“I think we should continue to use co-morbidities and age considerations; and likelihood to survive. We should not priori- tize healthcare providers over others in terms of treatment and intensive care.”

Like the caregivers, patients also debated how to allocate life-saving ven- tilators and intensive care. Four of the seven patient participants reported that prioritization of treatment should include life-saving treatments. One patient summed up their views using an “all or nothing” framework: “You have to go the whole nine yards, including vent. That is necessary treatment.” Another patient framed their perspec- tive using instrumental value,

“If it gets to the point of life-saving treat- ment, our number one goal shouldn’t be a question of whose lives matter more; it should be an objective question of how best to curb the spread of the disease.”

Three patients voiced other sides of the debate, stating that healthcare providers

should only receive priority up to the point of life-saving treatment. In the words of one patient,

“No one group or person should be making a decision about who lives and who does not get life-saving treatment. At some point on the continuum, I don’t think we should say this person gets it and this person does not.”

In the same vein, another commented, “That’s where I see the lottery come in. We should treat everyone equally at that point.”

It was apparent that both caregivers and patients found the questions harder to consider as they progressed by degree of intervention.44 Some responded with uncomfortable laugh- ter; others with exclamations like “wow,” “that’s a tough question,” and “I know it’s horrid, but…” before they shared their perspectives. Nevertheless, caregivers and patients acknowledged the importance of preparing such pol- icies to guide clinical decision-making and to prevent moral distress. In the words of one patient,

“I [am glad] a definite protocol [is being] developed to make these decisions should it become necessary. Otherwise the psycho- logical damage caused to frontline care- givers forced to make these decisions could be catastrophic.”

Likewise, a physician was grateful that the preemptive ethical decision-making would “[shoulder] the weight of trauma- tizing, life-altering decisions that will need to be made,… lighten[ing] the load felt by [myself and other caregivers].”

Furthermore, caregivers and patients were eager to be involved as stake- holders in the ethical decision-making. For example, a physician confided to the team of authors, “I wanted to extend my gratitude, first for including me in this discussion of utmost importance, and sec- ondly for bringing my voice to this

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publication.” Patients also echoed this, as one expressed, “including us... fill[s] a gap which is not often recognized... but is vital to patient care.” It “allowed our voice[s] to be heard, [which is] especially important dur- ing a crisis like this.” This feedback sug- gested that not only did this contributor not find the process of providing input too burdensome, but also did they appreciate the opportunity to engage in this collaborative process. From the voices of caregivers and patients them- selves, these quotes emphasize the value of stakeholder involvement for the stakeholders. Furthermore, we view this feedback as a collective recognition of shared learning and empathy for the gravity of the pandemic. Through this series of exchanges and synthesis of stakeholder views, we learned of each other’s perspectives, which contributed to the development of policy and this article.

The Policy

Conversations with stakeholders, a lit- erature review, a survey of the ethicists in our hospital system, and dialogue with other ethicists in our region grounded our process of rapidly devel- oping an institutional policy regarding prioritization of essential workers for COVID-19 treatment. This process was informed by several concurrent steps and led by a group of individuals from the bioethics department and the research team. First, the group engaged caregivers and patients in the stake- holder input process. Second, we con- ducted a literature review regarding severity of the COVID-19 crisis and its potential impact on healthcare and other essential workers. Third, the group surveyed ethicists within the hos- pital system regarding their individual perspectives. The survey intended to elucidate areas of disagreement and agreement as well as help each ethicist

further clarify his/her own thought pro- cess. Survey questions centered on defining who counts as an essential worker45 and which, if any, of these essential workers should receive prior- ity for testing, outpatient management, admission to the regular nursing floor, access to critical care in the intensive care unit (ICU), and life-sustaining treatment such as ventilatory support or extracorporeal membrane oxygen- ation (ECMO).

Importantly, the ethicists—after rigorous debate—agreed upon a defin- ition of essential worker that included all healthcare workers and emergency medical service personnel who regu- larly interface with patients in the same physical environment in which the patient is receiving (or did receive) care. The definition included all workers regardless of setting (acute care hos- pital, ICU, nursing home, long-term acute care hospitals, regular nursing floors, and outpatient services). For example, nurses, physicians, respiratory therapists, speech therapists, physical therapists, occupational therapists, social workers, chaplains, environmen- tal service workers, and law enforce- ment personnel would all be included as essential workers. Healthcare work- ers only interfacing with patients virtu- ally or who provide supportive services in other settings in which patients are not being cared for were excluded from the definition of essential workers. Other first responders (e.g., police, fire- fighters, etc.) would also qualify as essential workers if they interfaced dir- ectlywith the public andwere necessary to maintaining safety, law, and order. Informed by a relationship-centered approach, the policy included consider- ations for a diverse group of caregivers across our hospital system.

Notably, therewas no clear consensus among ethicists within our hospital sys- tem on prioritizing essential workers for

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critical care and life-saving therapies. Including stakeholder views became a crucial aspect of resolving this area of disagreement. For example, one ethicist, who previously supported the proprior- itization of healthcare workers for crit- ical care and life-sustaining therapies based on reciprocity and instrumental value, found these arguments less per- suasive after some of the caregivers themselves expressed that they did not expect or find such prioritization ethical. Such a change underscores the import- ance of obtaining stakeholder input in ethical decision-making including the variegated opinions of caregivers and patients. Arguments in favor drew on the instrumental and reciprocal logic reflected in literature and stakeholder comments. Arguments against focused on justice concerns. The commonalities that did exist centered on the ethical supportability of prioritizing essential workers who are necessarily exposed to higher risk of infection by the nature of their work for testing and evaluation, PPE, and other prevention efforts such as vaccines when they are available. Due to conversations with stakeholders, we could feel more secure in knowing that our institutional policy fairly reflected a wider range of caregivers’ and patient’s perspectives in our com- munity.

Representative ethicists in our hos- pital system had contributed to a work- ing group of ethicists from several other hospital systems in the region. The working group focused on building alignment between local healthcare institutions in order to provide consist- ent standards for the community at large. After several online discussions, the working group’s majority opinion recommended prioritizing essential workers for life-saving therapies if all other clinical factors were equal.

The bioethics department and the research team met virtually to prepare a

framing document with recommenda- tions for the prioritization of essential workers in healthcare allocation deci- sions at our institution. The agreed upon definition of essential worker was included, aswell as the recommendation to prioritize essential workers for testing and evaluation, PPE, and other preven- tion efforts such as vaccines when they are available. On the question of life- saving care, the bioethics department ultimately reached agreement that it would align with the regional working group’s majority opinion to prioritize essential workers for life-saving therap- ies if all other clinical factors were equal, given that this position had support among a number of patient and care- giver stakeholders and was not abso- lutely ethically contraindicated. The bioethics department reasoned on bal- ance that maintaining consistency across the hospitals in the region was an ethical priority grounded in justice consider- ations. The framing document was incorporated into the institution’s formal triage protocol for allocating critical care resources. The formal triage protocol, fortunately still unused, remains avail- able to guide allocation of scarce health- care resources in the case of an extreme escalation of COVID-19 patients within our hospital system.

Lessons for the Future

Our deliberative approach to developing recommendations regarding healthcare and essentialworker prioritization as part of our system’s COVID-19 triage policy resulted in several important lessons for the future. First, including stakeholder input in policy-making processes pro- duces more robust and ethically sound guidance. Good decision-making pro- cesses necessitate stakeholder input and relying on aligning an organizations’ choices with its institutional mis- sion.46,47,48 For healthcare institutions

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with an organizational mission focused on relationship- and patient-centered care, utilizing a deliberative approach honors these commitments, and regard- less of whether the outcomes of the delib- erations change, the process is fairer. Our process demonstrates that organizational ethics dilemmas that involve significant time pressures and other resource con- straints can be addressed using this approach, though we note that we bene- fited from our preexisting network of trusted caregivers and patient volunteers. With collaborative stakeholders, conver- sations do not substantially delay the development of organizational ethics pol- icies and, in fact, potentially improve them. Future work in this area and other organizational ethics issues should con- tinue to dialogue with patients, care- givers, and the general public to incorporate their perspectives.

Second, one of the limitations of our process was that we engaged a narrow group of patients and caregivers who were easily accessible, given the need to respond to the ongoing crisis quickly. Although we purposely sampled patients and caregivers from a range of organizational positions and aimed for heterogeneity in terms of background, age, gender, race, and profession, our results as described here are not gener- alizable to the United States population. In future work, larger sample sizes, more diverse stakeholders, and even incorporating rigorous research methods should be included whenever possible. Moreover, with more time, we might have improved our process by developing a formal prospective research study that included a randomly selected sample of stakeholders. Although we continued conversations with patients and caregivers until we elicited no new views, logics, or other information, future effortswould ideally involve a greater number of people

to establish thematic saturation. In add- ition, consensus might be built more traditionally and in a shared space, such as in the formof dialogue among a larger number of communitymembers in town hall meetings. We hope to do this in future iterations.

Third, it would be valuable to engage in further efforts to understand stake- holder viewpoints on the issues that generated the most disagreement dur- ing our process and, as knowledge sur- rounding the pandemic continues to evolve, to confirm stakeholder view- points on areas of agreement. Life- saving therapies were an area of debate among the ethicists in our hospital sys- tem. Similarly, there was no clear agree- ment among caregivers and patients on these issues. Given the significant dis- agreement this issue generated, and especially as clinical data, expert recom- mendations, and public views continue to evolve rapidly, it is worth continuing to explore this debate. Of note, a poten- tial limitation of our process was the fact that stakeholder conversations were held early in the pandemic. Stake- holders responded based on hypothet- icals for an event that they arguably could not feel the full weight of experi- encing. With new information about the disease, knowledge about the effective- ness of interventions like ventilator sup- port, and data about the disparate way the disease impacts communities of color, some of us find that our own views have shifted and suspect the views of other stakeholders may shift as well.

Lastly, more efforts should be made by public health authorities, the bioeth- ics community, and hospital systems to educate the public about scarce resource allocation and ethical decision-making in healthcare. If resource allocation con- siderations were better understood prior to the pandemic, our deliberative

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process and consensus building toward a new policy may have been quite dif- ferent. Engaging in dialogue about these questions regularlywill produce greater public health knowledge and trust. With public, patient, and caregiver com- mitment, healthcare professionals may be able to engage in more focused work with some sense of certainty and base- line consensus even amid a crisis situ- ation wrought with unknowns.

Conclusion

The process described here applies best practices in clinical ethical decision- making to an organizational ethics issue—namely, involving stakeholders in policy-making and aligning institu- tional practices to organizational mis- sion—to support decision-making during the COVID-19 pandemic. Even in times of crisis, inclusion of multiple stakeholders is a vital component of an ethical clinical decision-making pro- cess. Including stakeholders can lead to compassionate conversations, the exchange of knowledge, and the dis- covery of commonalities and collabor- ations. Incorporating stakeholder viewpoints benefited our institutional policy. As stay-at-home orders end and societies resume public life, the COVID-19 crisis continues to present unprecedented challenges. Yet the urgency of the COVID-19 pandemic should not dismantle clinical ethics or organizational ethics approaches to care and policy decision-making. Rather, crisis necessitates an even higher level of ethical commitment by the community engaged in the crisis and should be guided by ethical deci- sion-making processes informed by multiple stakeholders. The opportunity to initiate enhanced collaborations between patients, caregivers, and com- munities must be recognized. Further- more, in building consensus, it is

necessary to strengthen the collective response required to abate the wide- spread impact of COVID-19.

Notes

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2. Berlinger N, Wynia M, Milliken A, Cohn F, Guidry-Grimes LK, Bruce L, et al. Responding to Covid-19 as a regional public health chal- lenge: Preliminary guidelines for regional col- laboration involving hospitals. Hastings Center; 2020 Apr 29; available at https:// www.thehastingscenter.org/covid19-regional- ethics-guidelines (last accessed 2 July 2020).

3. Cookson R, Dolan P. Principles of justice in health care rationing. Journal of Medical Ethics 2000;26(5):323–9.

4. Danis M, Hurst SA. Developing the capacity of ethics consultants to promote just resource allocation. American Journal of Bioethics 2009;9 (4):37–46.

5. Daugherty Biddison EL, Gwon HS, Schoch- SpanaM, Regenberg AC, Juliano C, Faden R, et al. Scarce resource allocation during disas- ters: A mixed-method community engage- ment study. Chest 2018;153(1):187–95.

6. Gibson JL. Organizational ethics: No longer the elephant in the room. Healthcare Manage- ment Forum 2012;25(1):37–9.

7. Schoch-Spana M, Brunson EK, Gwon H, Regenberg A, Toner ES, Daughtery Biddison EL. Influence of community and culture in the ethical allocation of scarce medical resources in a pandemic situation: Deliberative democ- racy study. Journal of Participatory Medicine 2020;12(1):e18272.

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44. Caregivers and patients were asked to con- sider different scenarios. Caregivers’

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