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Despite advances in palliative care, some patients still suffer significantly at the end of life. Terminal Sedation (TS) refers to the use of sedatives in dying patients until the point of death. The following limits are commonly applied: (1) symptoms should be refractory, (2) sedatives should be administered proportionally to symptoms and (3) the patient should be imminently dying. The term ‘Expanded TS’ (ETS) can be used to describe the use of sedation at the end of life outside one or more of these limits.In this paper, we explore and defend ETS, focusing on jurisdictions where assisted dying is lawful. We argue that ETS is morally permissible: (1) in cases of non-refractory suffering where earlier treatments are likely to fail, (2) where gradual sedation is likely to be ineffective or where unconsciousness is a clinically desirable outcome, (3) where the patient meets all criteria for assisted dying or (4) where the patient has greater than 2 weeks to live, is suffering intolerably, and sedation is considered to be the next best treatment option for their suffering.While remaining two distinct practices, there is scope for some convergence between the criteria for assisted dying and the criteria for ETS. Dying patients who are currently ineligible for TS, or even assisted dying, should not be left to suffer. ETS provides one means to bridge this gap.

Background: Death in the neonatal intensive care unit commonly follows a decision to withdraw or limit life-sustaining treatment. Advances in medicine has changed the nature of life-sustaining interventions available and the potential prognosis for many newborn conditions. Objective: To assess changes in causes of death and end-of-life care over nearly four decades. Methods: A retrospective review of infants dying in the neonatal intensive care unit was performed (2017-2020) and compared with previous audits performed in the same centre (1985-1987 and 1999-2001). Diagnoses at death were recorded for each infant as well as their apparent prognosis and any withdrawal or limitations of medical treatment. Results: In the recent epoch there were 88 deaths out of 2084 admissions (4.2%), a reduction from the previous epochs (132/1362 (9.7%) and 111/1776 (6.2%) respectively for epochs 1 and 2). More than 90% of infants died after withdrawal of life-sustaining treatment, an increase from the previous two epochs (75%). There was a reduction in deaths from chromosomal abnormalities, complications related to prematurity and severe birth asphyxia. Conclusions: There continue to be considerable changes in both the diagnoses leading to death and approaches to withdrawal of treatment in the neonatal intensive care unit. These may reflect ongoing changes in both prenatal and postnatal diagnostics as well as changing attitudes towards palliative care within the medical and wider community.

In the response to this pandemic two vital, but controversial, ethical questions are how we should allocate ventilators to patients with severe respiratory failure, and how we should distribute vaccines to people at risk of contracting coronavirus. There are opposing ethical views about how to prioritize, and countries have taken different approaches. There is a strong ethical argument that policies should take a pluralistic approach to allocation that reflects multiple ethical values—both because of the diversity of viewpoints within communities and the recognition that there are competing relevant ethical values. This chapter looks at the epistemic and normative problems raised by pluralistic allocation in this pandemic and suggests implications for future pandemics. Some of the relevant evidence about the public’s views and values relating to prioritization are summarized. The chapter also explores some practical approaches to prioritization of scarce resources in the face of contrasting and competing ethical values.

We provide ethical criteria to establish when vaccine mandates for healthcare workers are ethically justifiable. The relevant criteria are the utility of the vaccine for healthcare workers, the utility for patients (both in terms of prevention of transmission of infection and reduction in staff shortage), and the existence of less restrictive alternatives that can achieve comparable benefits. Healthcare workers have professional obligations to promote the interests of patients that entail exposure to greater risks or infringement of autonomy than ordinary members of the public. Thus, we argue that when vaccine mandates are justified on the basis of these criteria, they are not unfairly discriminatory and the level of coercion they involve is ethically acceptable—and indeed comparable to that already accepted in healthcare employment contracts. Such mandates might be justified even when general population mandates are not. Our conclusion is that, given current evidence, those ethical criteria justify mandates for influenza vaccination, but not COVID-19 vaccination, for healthcare workers. We extend our arguments to other vaccines.

When is life-sustaining treatment not in the best interests of a minimally conscious child? This is an extremely difficult question that incites seemingly intractable debate. And yet, it is the question courts in England and Wales have set out to answer in disputes about appropriate medical treatment for children.

ObjectiveThis study aimed to assess US/UK adults’ attitudes towards COVID-19 ventilator and vaccine allocation.DesignOnline survey including US and UK adults, sampled to be representative for sex, age, race, household income and employment. A total of 2580 participated (women=1289, age range=18 to 85 years, Black American=114, BAME=138).InterventionsParticipants were asked to allocate ventilators or vaccines in scenarios involving individuals or groups with different medical risk and additional risk factors.ResultsParticipant race did not impact vaccine or ventilator allocation decisions in the USA, but did impact ventilator allocation attitudes in the UK (F(4,602)=6.95, pConclusionsAlthough living in countries with high racial inequality during a pandemic, most US and UK adults in our survey allocated ventilators and vaccines preferentially to those with the highest chance of survival or highest chance of severe illness. Race of recipient led to vaccine prioritisation in cases where risk of illness was similar.

We discuss whether and under what conditions people should be allowed to choose which COVID-19 vaccine to receive on the basis of personal ethical views. The problem arises primarily with regard to some religious groups’ concerns about the connection between certain COVID-19 vaccines and abortion. Vaccines currently approved in Western countries make use of foetal cell lines obtained from aborted foetuses either at the testing stage (Pfizer/BioNTech and Moderna vaccines) or at the development stage (Oxford/AstraZeneca vaccine). The Catholic Church’s position is that, if there are alternatives, Catholic people have a moral obligation to request the vaccine whose link with abortion is more remote, which at present means that they should refuse the Oxford/AstraZeneca vaccine. We argue that any consideration regarding free choice of the vaccine should apply to religious and non-religious claims alike, in order to avoid religion-based discrimination. However, we also argue that, in a context of limited availability, considering the significant differences in costs and effectiveness profile of the vaccines available, people should only be allowed to choose the preferred vaccine if: 1) this does not risk compromising vaccination strategies; and 2) they internalize any additional cost that their choice might entail. The State should only subsidize the vaccine that is more cost-effective for any demographic group from the point of view of public health strategies.

I am grateful to the commentators for their deep engagement with the issues raised in my paper (Wilkinson 2020). They raise a number of important challenges and questions about the use of frailty i...

In a world with limited resources, allocation of resources to certain individuals and conditions inevitably means fewer resources allocated to other individuals and conditions. Should a patient's personal responsibility be relevant to decisions re- garding allocation? In this project we combine the normative and the descriptive, conducting an empirical bioethical examination of how both Norwegian and British doctors think about principles of responsibility in allocating scarce healthcare re- sources. A large proportion of doctors in both countries supported including re- sponsibility for illness in prioritization decisions. This finding was more prominent in zero‐sum scenarios where allocation to one patient means that another patient is denied treatment. There was most support for incorporating prospective responsi- bility (through patient contracts), and low support for integrating responsibility into co‐payments (i.e. through requiring responsible patients to pay part of the costs of treatment). Finally, some behaviours were considered more appropriate grounds for deprioritization (smoking, alcohol, drug use)—potentially because of the certainty of impact and direct link to ill health. In zero‐sum situations, prognosis also influenced prioritization (but did not outweigh responsibility). Ethical implications are discussed. We argue that the role that responsibility constructs appear to play in doctors' decisions indicates a needs for more nuanced—and clear—policy. Such policy should account for the distinctions we draw between responsibility‐sensitive and prog- nostic justifications for deprioritization.

Die vorliegenden Leitlinien des European Resuscitation Council zur Versorgung und Reanimation des Neugeborenen nach der Geburt beruhen auf dem International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support (NLS). Sie beinhalten Empfehlungen zur Versorgung und Reanimation des reifen Neugeborenen und zur Stabilisierung des Fruhgeborenen. Sie umfassen den aktualisierten Algorithmus zur Reanimation des Neugeborenen, die Vorbereitungen vor der Versorgung eines Neugeborenen, die Themen Training und Ausbildung, Warmemanagement, Empfehlungen zum Abnabeln, die initiale Beurteilung und Einschatzung des Neugeborenen, das Atemwegsmanagement, inklusive einer Notfallbeatmung, und die Kreislaufunterstutzung im Falle einer vollen Reanimation. Daruber hinaus finden sich Empfehlungen zur Kommunikation mit den Eltern und ethische Uberlegungen, in welchen Situationen erwogen werden soll, auf Reanimationsmasnahmen zu verzichten bzw. Reanimationsmasnahmen nicht fortzufuhren.

In response to the COVID-19 pandemic philosophers and governments have proposed scarce resource allocation guidelines. Their purpose is to advise healthcare professionals on how to ethically allocate scarce medical resources. One challenging feature of the pandemic has been the large numbers of patients needing mechanical ventilatory support. Guidelines have paradigmatically focused on the question of what doctors should do if they have fewer ventilators than patients who need respiratory support: which patient should get the ventilator? There is, however, an important higher level allocation problem. Namely, how are we to ethically distribute newly obtained ventilators across hospitals: which hospital should get the ventilator(s)? In this paper, we identify a set of principles for allocating newly obtained ventilators across hospitals. We focus particularly on low and middle income countries, who frequently have limited pre-existing intensive care capacity, and have needed to source additional ventilators. We first provide some background. Second, we argue that the main population healthcare aim during the COVID-19 pandemic should be to save the most lives. Next, we assess a series of potential heuristics or principles that could be used to guide allocation: allocation to the most densely populated cities, random allocation, allocation based on the ratio of patients to ICU personnel, prioritisation in terms of intrahospital mortality, prioritisation of younger populations, and prioritisation in terms of population mortality. We conclude by providing a plausible ranking of the principles, while noting a number of epistemological challenges, in terms of how they best further the aim of increasing the probability of saving the most lives.

Informed by a series of systematic reviews, scoping reviews and evidence updates from the International Liaison Committee on Resuscitation, the 2021 European Resuscitation Council Guidelines present the most up to date evidence-based guidelines for the practice of resuscitation across Europe. The guidelines cover the epidemiology of cardiac arrest; the role that systems play in saving lives, adult basic life support, adult advanced life support, resuscitation in special circumstances, post resuscitation care, first aid, neonatal life support, paediatric life support, ethics and education.

Every infant, child, and adolescent will experience pain at times throughout their life. Childhood pain ranges from acute to chronic, and includes procedural, disease-related, breakthrough, and other types of pain. Despite its ubiquity, pain is a major challenge for individuals, families, health-care professionals, and societies. As a private mental experience, pain is often hidden and can go undiscussed or ignored. Undertreated, unrecognised, or poorly managed pain in childhood leads to important and long-lasting negative consequences that continue into adulthood, including continued chronic pain, disability, and distress. This undertreatment of pain should not continue, as there are available tools, expertise, and evidence to provide better treatment for childhood pain.

This article is about the potential justification for deploying some form of affirmative action (AA) in the context of healthcare, and in particular in relation to the pandemic. We call this Affirmative Action in healthcare Resource Allocation (AARA). Specifically, we aim to investigate whether the rationale and justifications for using prioritization policies based on race in education and employment apply in a healthcare setting, and in particular to the COVID-19 pandemic. We concentrate in this article on vaccines and ventilators because these are both highly scarce resources in the pandemic, and there has been a need to develop policies for allocating them. However, as will become clear, the ethical considerations relating to them may diverge. We first set out two rationales for AAs and what they might entail in a healthcare setting. We then consider some disanalogies between AA and AARA, as well as the different implications of AARA for allocating ventilators as opposed to vaccines. Finally, we consider some of the practical ways in which AARA could be implemented, and conclude by responding to some key objections.

We would like to thank each of the commentators on our feature article for their thoughtful engagement with our arguments. All the commentaries raise important questions about our proposed justification for natural immunity exemptions to COVID-19 vaccine mandates. Thankfully, for some of the points raised, we can simply signal our agreement. For instance, Reiss is correct to highlight that our article did not address the important US-centric considerations she helpfully raises and fruitfully discusses. We also agree with Williams about the need to provide a clear rationale for mandates, and to obtain different kinds of data in support of possible policies.Unfortunately, we lack the space to engage with every one of the more critical comments raised in this rich set of commentaries; as such, in this response, we shall focus on a discussion of hybrid immunity, which underlies a number of different arguments evident in the commentaries, before concluding with some reflections responding to Lipsitch’s concern about the appropriate standard of proof in this context.

The COVID-19 pandemic has led a number of countries to introduce restrictive ‘lockdown’ policies on their citizens in order to control infection spread. Immunity passports have been proposed as a way of easing the harms of such policies, and could be used in conjunction with other strategies for infection control. These passports would permit those who test positive for COVID-19 antibodies to return to some of their normal behaviours, such as travelling more freely and returning to work. The introduction of immunity passports raises a number of practical and ethical challenges. In this paper, we seek to review the challenges relating to various practical considerations, fairness issues, the risk to social cooperation and the impact on people’s civil liberties. We make tentative recommendations for the ethical introduction of immunity passports.

As the COVID-19 pandemic impacts on health service delivery, health providers are modifying care pathways and staffing models in ways that require health professionals to be reallocated to work in critical care settings. Many of the roles that staff are being allocated to in the intensive care unit and emergency department pose additional risks to themselves, and new policies for staff reallocation are causing distress and uncertainty to the professionals concerned. In this paper, we analyse a range of ethical issues associated with changes to staff allocation processes in the face of COVID-19. In line with a dominant view in the medical ethics literature, we claim, first, that no individual health professional has a specific, positive obligation to treat a patient when doing so places that professional at risk of harm, and so there is a clear ethical tension in any reallocation process in this context. Next, we argue that the changing asymmetries of health needs in hospitals means that careful consideration needs to be given to a stepwise process for deallocating staff from their usual duties. We conclude by considering how a justifiable process of reallocating professionals to high-risk clinical roles should be configured once those who are ‘fit for reallocation’ have been identified. We claim that this process needs to attend to three questions that we consider in detail: (1) how the choice to make reallocation decisions is made, (2) what justifiable models for reallocation might look like and (3) what is owed to those who are reallocated.

Infants are unable to make their own decisions or express their own wishes about medical procedures and treatments. They rely on surrogates to make decisions for them. Who should be the decision-maker when an infant’s biological parents are also minors? In this paper, we analyse a case in which the biological mother is a child. The central questions raised by the case are whether minor parents should make medical decisions on behalf of an infant, and if so, what are the limits to this decision-making authority? In particular, can they refuse treatment that might be considered best for the infant? We examine different ethical arguments to underpin parental decision-making authority; we argue that provided that minor parents are capable of fulfilling their parental duties, they should have a right to make medical decisions for their infant. We then examine the ethical limits to minor parents’ decision-making authority for their children. We argue that the restricted authority that teenagers are granted to make medical decisions for themselves looks very similar to the restricted autonomy of all parents. That is, they are permitted to make choices, but not harmful choices. Like all parents, minor parents must not abuse or neglect their children and must also promote their welfare. They have a moral right to make medical decisions for their infants within the same ‘zone of parental discretion’ that applies to adult parents. We conclude that adult and minor parents should have comparable decision-making authority for their infants.

COVID-19 vaccine requirements have generated significant debate. Here, we argue that, on the evidence available, such policies should have recognised proof of natural immunity as a sufficient basis for exemption to vaccination requirements. We begin by distinguishing our argument from two implausible claims about natural immunity: (1) natural immunity is superior to ‘artificial’ vaccine-induced immunity simply because it is ‘natural’ and (2) it is better to acquire immunity through natural infection than via vaccination. We then briefly survey the evidence base for the comparison between naturally acquired immunity and vaccine-induced immunity. While we clearly cannot settle the scientific debates on this point, we suggest that we lack clear and convincing scientific evidence that vaccine-induced immunity has a significantly higher protective effect than natural immunity. Since vaccine requirements represent a substantial infringement of individual liberty, as well as imposing other significant costs, they can only be justified if they are necessary for achieving a proportionate public health benefit. Without compelling evidence for the superiority of vaccine-induced immunity, it cannot be deemed necessary to require vaccination for those with natural immunity. Subjecting them to vaccine mandates is therefore not justified. We conclude by defending the standard of proof that this argument from necessity invokes, and address other pragmatic and practical considerations that may speak against natural immunity exemptions.

In early 2021, cases of rare adverse events were observed in individuals who had received the Astra Zeneca COVID-19 vaccine. Countries around the world differed radically in their policy responses to these observations. In this paper, we outline the ethical justification for different policy approaches for managing the emerging risks of novel vaccines in a pandemic. We begin by detailing the precautionary approach that some countries adopted, and distinguishing ethical questions regarding the management of known and unknown risks. We go on to outline the harms of adopting a highly precautionary approach in a pandemic context, and explain why an appropriate policy approach should accommodate the benefits as well as the risks of vaccination. In the final section, we outline three policy approaches that can accommodate the different benefits of vaccination, whilst taking into account the harms of precaution. Whilst we do not set out to defend one particular policy approach, we explain how different moral theories lend different degrees of support to each of these different approaches. Our analysis elucidates how fundamental value conflicts in public health ethics played out on the global stage of vaccine policy.

As the northern hemisphere winter comes to a close, and many are looking forward to what is hopefully the end of the COVID-19 pandemic, there is a need to look back at the lessons to be learned.

This chapter addresses the possibility of artificial wombs. The technology of developing a fetus from embryo to birth in an artificial environment is sometimes called “ectogenesis.” Ectogestation, if it comes to fruition, might offer the extraordinary possibility of saving or improving the lives of babies born extremely early, barely halfway through a normal pregnancy. It could also free women from various forms of gender oppression and liberate people from the constraints of anatomy. On the other hand, some feminists worry that this potential technology could undermine the importance of motherhood, render natural child-bearing a luxury, and diminish the value of women’s lives. Like many advances in reproductive medicine and neonatal care, ectogestation is sure to be accompanied by challenging ethical questions. The chapter then considers the ethical implications of ectogestation in neonatal ethics and abortion.

Hepatitis B virus (HBV) is a potentially chronic infection that can be transmitted from mother-to-child with the risk of developing cirrhosis, liver failure, and hepatocellular carcinoma. There is a safe and effective vaccine to prevent vertical transmission that is recommended to be given as soon as possible after birth, and within 24 hours. When a woman with HBV refuses the birth dose of HBV vaccine for her baby, infectious diseases and safeguarding teams are asked to provide urgent opinions on whether this crosses the threshold for triggering child protection mechanisms. We consider a low-infectivity HBV vertical transmission scenario where there is parental refusal of HBV vaccination, and focus on ethical arguments for and against over-ruling parental refusal in the child’s best interests. We propose a dialogue process for managing scenarios where a pregnant woman with HBV has concerns about vaccinating her baby when born.

The prospect of vaccinating children and young people against COVID-19 raises questions that apply more widely to vaccination in children. When can children or adolescents consent, on their own, for vaccination? What should happen if children and their parents disagree about the desirability of a vaccine? When, if ever, should vaccination proceed despite a child’s dissent or apparent refusal? A range of ethical dilemmas may arise (box 1). In this article, we will address general ethical issues relating to consent for vaccination, highlighting their relevance to COVID-19. We will not address the wider ethical questions of whether or when children should be vaccinated against COVID-19. Box 1 ### Ethical dilemmas relating to vaccine consent for children and young people In general, parents play a key role in making decisions about medical treatment and procedures in their children. Except in an emergency, informed consent is always sought from a caregiver with parental responsibility prior to significant medical interventions. For childhood vaccinations in the UK, consent from parents is currently routinely required, although some groups have argued that mandatory vaccination would promote children’s best interests. If parents decline immunisations after being counselled about the evidence for vaccine safety and efficacy, their decision would usually be respected. Rarely vaccination may proceed against parental wishes; for example, for a child in care, or a child at particularly high …

We review the possibilities for and ethics of the use incentives and disincentives to increase vaccination uptake. We argue that disincentives (or mandatory vaccination), such as fines, restriction of movement or education and withholding of benefits can be justified depending on four factors: the gravity of the public health emergency, the safety and effectiveness of vaccines, the comparative expected utility of mandatory measures compared to other alternatives, and the proportionality of costs imposed. We provide a decision algorithm for the ethical use of incentives. Incentives face problems of undue inducement and exploitation. We propose a novel Payment Model which would include economic costing of time, pain, risk of adverse events, including death, and compensation. If education, encouragement and facilitation fail to achieve herd immunity quickly enough, payment for vaccination maybe the fairest way to facilitate uptake of vaccination.

Paediatricians sometimes learn that parents plan to take a child overseas for medical treatment (box 1). How should they respond? Box 1 ### Cases of medical tourism in children 1. A child with severe eczema whose parents are first-generation immigrants. Parents plan to return to their home country for a second opinion. 2. A child with relapsed malignancy with a short time to live. Parents are planning to take abroad for an experimental vitamin therapy. 3. A child with autism. Parents plan to take overseas for intrathecal stem cell therapy. 4. A young person with complex epilepsy. Parents planning to take overseas for cannabinoid-based medications. 5. A child in a minimally conscious state, ventilated in intensive care. Parents wish to take to another country for tracheostomy and ongoing intensive care. 6. A girl with no medical conditions. Parents plan to take overseas for female circumcision. Child medical tourism is ‘the bi-directional movement of children … to and from a country to seek advice, diagnosis and treatments’.1 In the UK, it is estimated that (pre-COVID-19) 63 000 adult patients sought treatment abroad yearly. The number of children (patients

Recent animal research suggests that it may soon be possible to support the human fetus in an artificial uterine environment for part of a pregnancy. A technique of extending gestation in this way (“ectogestation”) could be offered to parents of extremely premature infants (EPIs) to improve outcomes for their child. The use of artificial uteruses for ectogestation could generate ethical questions because of the technology’s potential impact on the point of “viability”—loosely defined as the stage of pregnancy beyond which the fetus may survive external to the womb. Several medical decisions during the perinatal period are based on the gestation at which infants are considered viable, for example decisions about newborn resuscitation and abortion, and ectogestation has the potential to impact on these. Despite these possible implications, there is little existing evidence or analysis of how this technology would affect medical practice. In this paper, we combine empirical data with ethical analysis. We report a survey of 91 practicing Australian obstetricians and neonatologists; we aimed to assess their conceptual understanding of “viability,” and what ethical consequences they envisage arising from improved survival of EPIs. We also assess what the ethical implications of extending gestation should be for newborn and obstetric care. We analyze the concept of viability and argue that while ectogestation might have implications for the permissibility of neonatal life‐prolonging treatment at extremely early gestation, it should not necessarily have implications for abortion policy. We compare our ethical findings with the results of the survey.

In mid February 1400, King Richard II is said to have died of starvation in a castle in northern England. He had been deposed, but the people of England were reluctant to execute the king. Instead ...

Diffusion MRI of the neonatal brain allows investigation of the organisational structure of maturing fibres during brain development. Post-mortem imaging has the potential to achieve high resolution by using long scan times, enabling precise assessment of small structures. The Forget-Me-Not study, part of the Developing Human Connectome Project (dHCP), aims to acquire and publicly distribute high-resolution diffusion MRI data for unfixed post-mortem neonatal brain at 7T with a custom-built head coil. This paper describes how the study addressed logistical, technical and ethical challenges relating to recruitment pipeline, care pathway, tissue preservation, scan setup and protocol optimisation. Results from the first subject recruited to the study demonstrate high-quality diffusion MRI data. Preliminary voxel-wise and tractography-based analyses are presented for the cortical plate, subplate and white matter pathways, with comparison to age-matched in vivo dHCP data. These results demonstrate that high quality post-mortem data can be acquired and provide a sensitive means to explore the developing human brain, as well as altered diffusion properties consistent with post-mortem changes, at high resolution.

BackgroundECMO is a particularly scarce resource during the COVID-19 pandemic. Its allocation involves ethical considerations that may be different to usual times. There is limited pre-pandemic literature on the ethical factors that ECMO physicians consider during ECMO allocation. During the pandemic, there has been relatively little professional guidance specifically relating to ethics and ECMO allocation; although there has been active ethical debate about allocation of other critical care resources. We report the results of a small international exploratory survey of ECMO clinicians’ views on different patient factors in ECMO decision-making prior to and during the COVID-19 pandemic. We then outline current ethical decision procedures and recommendations for rationing life-sustaining treatment during the COVID-19 pandemic, and examine the extent to which current guidelines for ECMO allocation (and reported practice) adhere to these ethical guidelines and recommendations.MethodsAn online survey was performed with responses recorded between mid May and mid August 2020. Participants (n = 48) were sourced from the ECMOCard study group—an international group of experts (n = 120) taking part in a prospective international study of ECMO and intensive care for patients during the COVID-19 pandemic. The survey compared the extent to which certain ethical factors involved in ECMO resource allocation were considered prior to and during the pandemic.ResultsWhen initiating ECMO during the pandemic, compared to usual times, participants reported giving more ethical weight to the benefit of ECMO to other patients not yet admitted as opposed to those already receiving ECMO, (p p = 0.002). If the clinical team recommends that ECMO should cease, but family do not agree, the majority of participants indicated that they would continue treatment, both in usual circumstances (67%) and during the pandemic (56%).ConclusionsWe found differences during the COVID-19 pandemic in prioritisation of several ethical factors in the context of ECMO allocation. The ethical principles prioritised by survey participants were largely consistent with ECMO allocation guidelines, current ethical decision procedures and recommendations for allocation of life-sustaining treatment during the COVID-19 pandemic.