Facing Covid-19 in Italy: Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line

Bottom Line:

In Italy, resource scarcity in hospitals resulted in an ethical dilemma of deciding which patient gets access to the limited number of ventilators. The article discusses important process–related principles when approaching resource scarcity and highlights the importance of transparency and inclusivity in patient care.


Rosenbaum, L. Facing Covid-19 in Italy—ethics, logistics, and therapeutics on the epidemic’s front line. New England Journal of Medicine (2020). https://www.nejm.org/doi/full/10.1056/NEJMp2005492

Date Published:

14 May 2020


As of mid-March, northern Italy had thousands of confirmed COVID-19 cases and more than 1000 deaths. While citizens continue to fight the social restrictions imposed, doctors have emphasized the gravity of the situation, and the lethal consequences if the virus has been contracted. Specifically, the current healthcare system in northern Italy is unable to meet the needs of an overwhelming number of critically ill patients. Furthermore, it is difficult to protect both patients and healthcare workers from exposure in the hospital, even with proper personal protective equipment. Perhaps the biggest challenge is to watch patients die because of the limited availability of ventilators, with decisions made based on who will benefit the most and survive the longest. At some point, certain hospitals had lowered the age cutoff for ventilatory support in order to address the problem of resource allocation, and even the Italian College of Anesthesia, Analgesia, Resuscitation, and Intensive Care committee acknowledged that an age limit may ultimately be needed to be set. However, this means that many elderly individuals that have a good chance of survival will be  denied ventilatory support, which was met with criticism and accusations of practicing ageism. In order to address this issue, Biddison et al. offered three process-related strategies. The first strategy is to separate direct care providers from decision-making triage officers. The triage is supported by a team of healthcare experts that will assist with resource-allocation decisions and communicate that information to every person involved. The second strategy is to have these decisions reviewed regularly by a centralized monitoring body to address any inequities. The third strategy is to update the triage algorithm regularly as knowledge of the disease becomes updated. 

Summary by: Winston Li