Abstract
- Ethical principles such as maximizing benefit, fairness, and procedural justice are frequently invoked in discussions on critical care resource allocation during public health emergencies. The coronavirus disease 2019 (COVID-19) pandemic, however, demonstrated that the mere presence of ethical principles does not ensure their operation in real-world crisis settings. In Lombardy and New York, allocation decisions defaulted to individual clinicians under extreme pressure. This review examines the institutional and governance prerequisites for ethical allocation of critical care resources during surge conditions. Rather than proposing normative allocation criteria, we analyze how ethical principles are translated—or fail to be translated—into practice through institutional arrangements. Using Ontario, Canada, as an empirical reference point, we conduct a comparative analysis of crisis standards of care, governance structures, regional coordination mechanisms, data infrastructures, and legal protections that support collective decision-making in critical care. We propose a multilevel analytical framework comprising three interdependent levels: national and governance, hospital and regional operations, and individual clinical application. Across international experiences, failures in critical care allocation arise when key functions are absent or misaligned across these levels, concentrating ethical, legal, and emotional burdens on frontline clinicians. Applying this framework to the Korean context, we identify structural gaps in crisis standard activation, governance authority, coordination mechanisms, and institutional decision-making capacity, indicating that ethical allocation is not solely a moral challenge, but a systems-level governance problem requiring institutional preparedness beyond ethical consensus.
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Key Words: COVID-19; health care rationing; institutional ethics; intensive care units; Republic of Korea; triage
Infographics
INTRODUCTION
The coronavirus disease 2019 (COVID-19) pandemic exposed a persistent gap between ethical principles for critical care allocation and their implementation under crisis conditions. In Lombardy and New York, allocation decisions frequently devolved to individual clinicians under extreme pressure, not because ethical frameworks were lacking but because the institutional conditions required to operationalize them were insufficient [1,2]. Across multiple countries, this pattern caused widespread moral distress among clinicians who bore allocation responsibility without commensurate institutional authorization or protection [3].
This gap reflects a deeper structural problem. Critical care allocation under scarcity is both a complex clinical task and a high-stakes policy decision [4]. Normative theory reinforces this point: the legitimacy of allocation decisions rests not on the moral reasoning of individual clinicians but on the institutional conditions under which those decisions are made and enforced [5,6]. Absent these conditions, predictable distortions emerge. Allocation becomes person-dependent rather than system-governed, causing substantial variability in intensive care unit (ICU) admission practices even among experienced clinicians [7,8], and hospitals act as isolated units rather than coordinated elements of a regional response [9].
These dynamics are not confined to settings of absolute resource scarcity. During the massive COVID-19 outbreak in the city of Daegu in February 2020, known as the Daegu surge, Korea mounted a rapid national response, designating hospitals, deploying personnel, and coordinating bed counts. Nevertheless, over 2,000 patients awaited hospital admission, compelling the Korean Society of Critical Care Medicine to independently survey available ICU beds through its own professional network while frontline clinicians improvised a telephone-based severity scoring system in the absence of any pre-existing triage protocol [10,11]. These events raise a question that motivates the present analysis: why did a system capable of large-scale administrative mobilization fail to translate that capacity into organized clinical allocation in the emergent desperation of the public health crisis?
This review examines the institutional conditions required across governance, operational, and clinical levels for ethical allocation principles to function under crisis demand. Rather than proposing new normative criteria, we analyze how institutional arrangements translate or fail to translate ethical principles into practice. We address this through a comparative analysis of pandemic responses in Korea and Ontario, Canada. Ontario serves not as a normative ideal but as a well-documented empirical case where this translation process is traceable. This analysis is particularly urgent for Korea, in contrast, where structural gaps exposed during COVID-19 remain largely unaddressed.
METHODS
Sources and Scope
Because no single international standard defines the institutional requirements for crisis-level critical care allocation [12,13], this study adopts a narrative comparative approach integrating operational evidence with established normative frameworks. This design was chosen because the primary analytical task of identifying where essential institutional functions are located, misassigned, or absent requires examining how specific governance arrangements operate in documented practice rather than measuring outcomes across comparable populations.
Ontario, Canada, serves as the primary empirical reference. It was selected not as a normative model for replication, but because it offers an unusually traceable institutional record. Publicly accessible command-level documents specify activation thresholds and decision authority; published operational records describe regional coordination infrastructure and near-real-time data systems; policy and peer-reviewed sources document debates over protocol activation and clinician indemnity; and quantitative reports describe ICU load balancing and inter-facility transfers. This combination allows us to examine not only what institutional functions existed, but how they were operationalized and where they remained contested. Indeed, this degree of analytical traction is not available in most other jurisdictions for which pandemic-era critical care governance is documented.
Our study draws on three complementary source categories. First, the Ontario policy directives, clinical guidelines, and empirical literature described above [14-24]. Second, normative frameworks developed for COVID-19, particularly the American College of Chest Physicians (CHEST) Task Force guidance [13] and the National Academy of Medicine (NAM) Crisis Standards of Care framework, as well as selected United States (US) state-level implementation models [25,26]. These provide evidence of the practical application and structural limitations of these principles under surge conditions. Third, we reviewed Korean peer-reviewed literature and legal analyses examining the systemic impacts of the pandemic response, encompassing both the localized 2020 Daegu surge and national-level critical care dynamics, alongside the broader statutory environment governing resource allocation at the time [11,27-32]. In the Korean context, the absence of certain document types was itself treated as a finding, confirmed through targeted searches of government sources, national society publications, and legal literature. Absent document types included crisis standard activation thresholds, triage committee operating guidelines, functional ICU capacity monitoring systems, allocation documentation protocols, and procedural indemnity provisions.
Analytical Framework
Our analysis is structured around three interdependent institutional levels at which critical care allocation functions are distributed during crisis. Level 3 (governance) encompasses the foundational rules of allocation, including crisis standard activation criteria, designation of final coordination authority, and the legal framework governing liability and standard-of-care transition. Level 2 (operational) comprises the organizational mechanisms that translate governance-level rules into institutional practice, including hospital-level decision-making structures, regional coordination centers, and data infrastructure. Level 1 (clinical decisions) represents the point of bedside application, where allocation decisions are enacted within the constraints established at higher levels.
While existing frameworks recognize the importance of governance and clinician protection [13,25,26,33,34], we employ this three-level structure specifically as a diagnostic tool designed to identify where essential functions are located, misallocated, or left unassigned across institutional levels (Figure 1). Some functions, however, span the boundaries of levels rather than residing within a single level. In Figure 1, these are represented as interface components and are discussed in the Results as cross-cutting functions. Thus the framework provides an analytical perspective for examining not only what allocation functions exist, but also at which level they operate and what happens when they are absent.
Procedure of Analysis
The sources described above are analyzed in two stages. First, we examined how each source described the institutional arrangements surrounding crisis activation, allocation decision-making, inter-facility coordination, legal protection, and clinician support. From these descriptions, we extracted and refined the functional components defined above, assessing whether each function was explicitly assigned, partially implemented, or left unaddressed. An initial set of components was derived from the Ontario case and major normative frameworks (NAM and CHEST) and, subsequently, was iteratively tested and refined against the remaining sources to assess generalizability and completeness. This process yielded seven functional components, presented in Table 1 alongside their primary operating level and the diagnostic question addressed by each.
Second, each component was mapped onto the three analytical levels according to the level at which it was primarily articulated and enacted. This mapping enabled systematic comparison of how the same function was institutionally located across different jurisdictions. Complete mapping across source documents is provided in Supplementary Table 1. Results are organized by the three analytical levels rather than by functional component because several components operate across multiple levels. This procedure is not intended to produce an exhaustive inventory of all possible institutional arrangements, but rather to identify the minimum set of functions whose absence or misplacement consistently produces allocation failure across the cases examined.
RESULTS
Level 3: Governance and Crisis Activation
Normative frameworks, such as those from NAM, stipulate that crisis allocation requires an explicit governance architecture: predefined activation thresholds, formal transition of the standard of care, and a designated clinical command structure [13,33,34]. Minnesota’s 2019 Crisis Standards of Care framework exemplifies this proactive institutionalization. Long before the COVID-19 pandemic, the state of Minnesota established a Science Advisory Team to embed critical care, ethics, and public health expertise directly into the state-level governance body responsible for sanctioning allocation decisions [26].
Early in 2021, Ontario developed an explicit governance architecture for crisis-level allocation. The province’s “Adult Critical Care Clinical Emergency Standard of Care for Major Surge” specifies a three-level triage framework based on short-term mortality risk, explicitly positioned as a measure of last resort, to be considered only after internal surge strategies have been exhausted and regional load balancing is no longer feasible [17,20]. Authority to activate or deactivate this framework was centralized in the Ontario Critical Care COVID Command Centre (OCCCC), which held operational responsibility for system-wide situational assessment, inter-regional patient movement, and ventilator redistribution [16,19]. A key feature of this arrangement was the integration of senior critical care clinicians into the command structure. The OCCCC brought together provincial incident leadership with regional medical leads and hospital chiefs of critical care, allowing allocation-related directives to reflect both bedside clinical considerations and real-time system capacity data [19].
This governance function was implemented through a regional coordination infrastructure. Ontario was organized into four critical care regions, each led by a regional incident commander with access to near-real-time ICU capacity information and the authority to mandate inter-hospital transfers when local capacity was exceeded [16,19]. Through this mechanism, 976 critically ill patients were transferred across facilities between November 2020 and April 2021, enabling redistribution of clinical load without immediate reliance on formal triage activation [15].
Korea’s crisis governance framework is grounded in the Framework Act on the Management of Disasters and Safety and the Infectious Disease Control and Prevention Act. At the highest alert level, these statutes grant the government authority to designate hospitals and mobilize beds and personnel [35]. However, neither law specifies clinical or ethical criteria for patient prioritization when demand exceeds available critical care capacity. As a result, administrative surge mobilization is not accompanied by a corresponding transition in clinical standards of care.
This disconnect between administrative authority and clinical governance has been acknowledged at the policy level. Senior advisors involved in Korea’s national pandemic response have noted that while public health administration functioned through established governmental networks, medical crisis response lacked a dedicated institutional system and instead depended on improvised practices and individual clinician sacrifice rather than codified procedures [36]. Korea’s crisis alert system functions primarily as a mechanism for administrative capacity mobilization, encompassing facility designation, personnel deployment, and bed counting, rather than as a framework for structured clinical standard transition. Hospitals can be ordered to convert beds for designated patients, yet no statute or national guideline defines when, or on what basis, patients should be prioritized once ICU capacity is exceeded.
The clinical implications of this gap were evident during the 2020 Daegu surge. Existing prevention guidelines did not include prioritization criteria for hospital bed shortages, thereby compelling frontline clinicians to develop an ad hoc telephone-based severity scoring system in the absence of institutional triage protocols [28]. Inter-hospital coordination focused largely on reported bed counts rather than clinical load balancing, and patient transfers relied on informal networks and bilateral negotiations rather than predefined procedures. During this period, transfer of critically ill patients required sequential approval from local and receiving municipal authorities, with documented delays exceeding 24 hours due to refusals or non-response [30]. Transfer processes were streamlined only after repeated appeals from frontline clinicians to public health authorities, underscoring the absence of an institutionalized coordination mechanism during peak demand [30].
Level 2: Operational Infrastructure
At the operational level, two interdependent functions translate governance standards into institutional practice. The first function comprises decision-making structures that render individual judgments collective, removing allocation authority from the bedside clinician and relocating it within an institutional framework. The second function is data infrastructure and documentation that provides an evidentiary basis for these judgments. Across crisis standards of care frameworks, a core operational principle is the structural separation of allocation decisions from bedside clinical responsibility [33].
In both Ontario and the state of New York, this principle was implemented through institutionally designated decision-making roles. Attending physicians remained responsible for generating standardized clinical assessments—such as short-term mortality risk estimates based on predefined indicators—but were explicitly removed from final allocation authority [17]. In Ontario, allocation decisions were assigned to designated institutional actors, including on-call administrators or formal triage teams operating under provincial guidance [13,33]. Similarly, New York’s ventilator allocation guidelines, developed as an early implementation of the National Academies’ crisis standards framework, mandate that all allocation decisions be made by a dedicated triage officer or committee rather than the attending physician, with mandatory reassessments at 48 and 120 hours to maintain alignment with evolving resource availability [25]. Despite differences in governance structure, both systems operationalize the same foundational principle: allocation decisions are institutional acts, distinct from individual bedside clinical judgment.
This decision-making structure was supported by the Critical Care Information System (CCIS), a provincial data infrastructure designed and mandated by the Ministry of Health to enable near-real-time submission of ICU-level clinical data from all level 2 and 3 ICUs across the province [37]. Using CCIS data derived from actual bedside activity, Ontario classified ICUs according to functional rather than nominal capacity. Classification was based on measures of clinical activity, such as rates of mechanical ventilation use and arterial monitoring per patient-day, rather than on administrative designation alone. This approach enabled the system to identify facilities with verified operational capability and to align patient placement accordingly [22].
The CCIS platform was integrated with CritiCall Ontario, a provincially coordinated physician-led service responsible for triaging requests for urgent specialty care and coordinating inter-facility transfers. Through this linkage, central authorities were able to use real-time clinical capacity data to identify emerging crisis thresholds and to coordinate patient movement across institutions and regions [16,18,19]. At the documentation level, command memoranda explicitly stated that authority for ventilator allocation resided with the Command Centre rather than with individual hospitals. Activation of triage protocols was defined as a system-level decision requiring province-wide situational awareness, thereby relocating both decision-making authority and accountability from individual clinicians to an institutional structure [20]. Consistent with international normative frameworks, each triage decision was required to be formally recorded, with details including criteria applied, institutional roles involved, and alternative options considered [17,19].
In Korea, neither of these operational functions is institutionally established. Hospital-level triage committees are not mandated by legislation or national guidance, and there is no documented evidence of systematic operation of any such committees during the COVID-19 pandemic. Existing hospital ethics committees are largely limited to end-of-life consultation under the Life-Sustaining Treatment Decision Act and have no defined role in collective allocation decision-making under conditions of resource scarcity [38].
At the data level, no real-time system exists that distinguishes functional ICU capacity from nominal bed counts. During the Daegu surge, the Korean Society of Critical Care Medicine independently surveyed available ICU beds through its professional network. However, these data were not incorporated into the official patient transfer process [11]. Nationally, 9,800 mechanical ventilators and 350 extracorporeal membrane oxygenation devices were registered nationally, yet no system existed to identify their location or redistribute them to areas of acute need [11]. Throughout the pandemic, capacity reports reflected administratively registered beds rather than operationally available units, limiting accurate situational awareness and coordinated response.
The inability to distinguish statistical capacity from operational capability results in recurrent mismatches between reported resources and bedside availability during surge conditions. Recent evidence demonstrates the clinical consequences of this gap. In Korea, rigid policy-driven ICU access restrictions, rather than absolute resource scarcity, were the primary drivers of reduced critical care admissions and increased mortality due to COVID-19 [32]. These effects were identified only retrospectively, as the absence of real-time monitoring infrastructure precluded dynamic system adjustment during the crisis. Standardized documentation protocols for allocation decisions are similarly absent. Individual clinical decisions on ICU admission, discharge, or transfer remain unrecorded against explicit institutional criteria.
Cross-Cutting Function: Legal Protection and Liability Transfer
Legal protection functions as a cross-cutting institutional requirement for crisis allocation. Across international crisis standards of care frameworks, three legal design elements recur as prerequisites for allocation decisions to operate as institutional rather than individual acts. The first is explicit legal recognition that, during formally declared crises, the applicable standard of care shifts from individualized best-possible care to feasible care under conditions of scarcity [34,39]. The second element is conditional limitation of liability based on procedural adherence, in which compliance with approved protocols, rather than individual clinical outcomes, defines the boundary of legal exposure [33]. Third is the relocation of responsibility, defining allocation decisions as institutional acts authorized through governance mechanisms rather than individual clinical judgments [40]. These legal elements are functionally dependent on documentation and traceability at the operational level. Without standardized records of allocation decisions, including evidence of protocol application and decision-making authority, claims of procedural compliance cannot be substantiated. In consequence, legal protection cannot be effectively operationalized.
Jurisdictions with institutionalized allocation ensure the explicit link of legal immunity to procedural documentation. In Ontario, the Emergency Management and Civil Protection Act reframed crisis allocation as the operative standard of care during formally declared emergencies. Activation of triage protocols by the OCCCC defined allocation as a sanctioned institutional act, thereby providing legal protection to clinicians who adhered to approved procedures [17,19]. Minnesota offers a parallel example. Under the Emergency Health Powers Act, civil immunity is contingent on an active disaster declaration, formal public health activation of crisis standards, and demonstrable compliance with publicly available protocols [26]. In both settings, good-faith clinical judgment alone is insufficient. Legal protection depends on traceable documentation establishing adherence to authorized processes.
In contrast, Korea lacks this crisis-specific legal architecture, leaving clinicians exposed to severe legal risks. Three bodies of law address adjacent domains without providing a coherent legal basis for prioritization under scarcity. The Infectious Disease Control and Prevention Act grants government authority to mobilize beds and personnel, but does not define criteria for prioritization when demand exceeds capacity. The Emergency Medical Service Act mandates treatment of the most urgent patient first, without incorporating therapeutic efficacy criteria applicable under resource constraint. The Life-Sustaining Treatment Decision Act governs end-of-life withdrawal, but does not address ICU admission, discharge, or inter-patient prioritization. None of these statutes recognizes a distinct standard of care for formally declared crises, nor do frameworks for conditional liability exist for protocol-adherent actions. As a result, allocation-related decisions remain legally framed as individual clinical judgments rather than as authorized institutional acts.
Legal analyses have identified concrete risks arising from this statutory environment [29]. Allocation-related decisions may be reinterpreted under criminal law as negligent homicide. In particular, the withdrawal of a mechanical ventilation from a patient who subsequently dies may expose clinicians to homicide liability. This risk is grounded in the Boramae Hospital precedent, based on an incident in 1997, in which the Supreme Court of Korea upheld a conviction in 2004 for aiding and abetting homicide against a physician who removed ventilatory support at the request of the patient’s family [41]. Civil liability presents an additional source of exposure. Discharge from the ICU followed by rapid clinical deterioration may result in tort claims, even when the decision is motivated by the need to reallocate scarce resources to another patient with a higher probability of benefit. Reflecting these concerns, the Korean Society of Critical Care Medicine issued a public statement during the COVID-19 pandemic calling for legal clarification of triage criteria and conditional immunity for actions taken in adherence to approved protocols [42]. However, no substantive legal or policy progress followed this request.
Consequently, this legal uncertainty induces defensive clinical behaviors. To avoid unpredictable legal exposure, clinicians resort to “first-come, first-served” practices, rely on informal bilateral transfers, or defer to family demands to avoid making explicit rationing decisions. More fundamentally, the absence of legal protection neutralizes collective decision-making and documentation functions (level 2). Without statutory indemnity, officially documenting a rationing decision does not distribute responsibility; instead, it generates prosecutorial evidence against the individual clinician. Therefore, decisions are forced to be made informally or framed as routine clinical judgments, structurally precluding the institutional documentation required for after-action reviews and systemic learning.
Cross-Cutting Function: Workforce Sustainability and After-Action Learning
According to international crisis standards frameworks, clinician support and blame-free after-action review are designated as core components of crisis response rather than supplementary measures [13,33]. Clinician support runs from the operational level downward. These structural approaches, including explicit triage protocols and team-based decision-making, are intended to mitigate moral injury, which arises when clinicians are forced to compromise fundamental ethical commitments under conditions of extreme scarcity [13]. The effectiveness of these mechanisms depends on the presence of legal protection. Statutory indemnity is required for institutions to document rationing decisions without exposing clinicians to prosecutorial risk. Such documentation at the operational level enables retrospective examination of allocation decisions and converts individual clinical actions from sources of legal vulnerability into evidence for identifying systemic weaknesses and for supporting institutional learning [13,33].
In Ontario, these functions were explicitly incorporated into the response design. Team-based staffing models were structured to redistribute clinical workload and supervisory roles, and clinician support and after-action review were identified as integral components of crisis response planning [15,21]. Although implementation was uneven under surge conditions, these elements reflect an intentional design to buffer individual clinicians from the full burden of allocation-related responsibility [14,15].
In Korea, neither function is systematically established. No structured clinician support programs specific to crisis allocation were institutionalized at the time of the Daegu surge, nor have they been subsequently formalized. The absence of standardized documentation protocols identified at level 2 means individual allocation decisions remain unrecorded for systematic reconstruction or review. After-action learning from crisis allocation therefore lacks the institutional material required for systematic reconstruction and review. Across the institutional levels examined, the presence, partial implementation, or absence of each functional component in Ontario and Korea is summarized in Table 2 [10,11,14-22,24,27-31,35-38,41,42].
DISCUSSION
Our analysis demonstrates that crisis allocation failures arise not from unresolved ethical disagreement or absolute resource scarcity, but from misaligned institutional functions across governance, operational, and clinical levels. When essential functions such as crisis standard activation, coordination authority, collective decision-making, documentation, and legal protection are unassigned or misplaced, allocation responsibility does not disappear. Instead, it concentrates at the bedside, where it was never designed to reside nor is protected in its residence. Comparing Ontario and Korea illustrates how this alignment is constructed, as well as the consequences of its absence.
Ontario demonstrates that institutional alignment for crisis allocation is possible when governance authority, operational coordination, and clinical input are deliberately integrated. Centralized command authority, predefined triage protocols, and data-enabled regional coordination in Ontario preceding the COVID-19 outbreak allowed the system to manage surge demand primarily through load balancing and inter-facility transfers, delaying or avoiding the need for explicit bedside rationing [15]. In this configuration, robust governance and operational functions buffered frontline clinicians from direct allocation responsibility, illustrating how ethical principles can be operationalized through institutional design rather than individual judgment.
The Ontario experience should not be interpreted as a resolved model, however. This institutional architecture carried significant limitations at multiple levels. At the macro level, triage protocol development proceeded without broad public consultation. Daniels and Sabin’s ethical framework known as accountability-for-reasonableness (A4R) dictates that legitimate allocation requires publicly accessible rationales, relevance to the allocation problem, mechanisms for appeal and revision, and institutional enforcement [5,6]. Ontario’s process satisfied none of these conditions fully. The Ontario Human Rights Commission explicitly identified this failure, noting the absence of a human rights-based evaluation of pre-existing social disadvantages [43]. These limitations echo broader challenges identified in the 2021 NAM workshop on crisis standards of care, highlighting that integrating equity and mitigating structural disparities remain the most profound unresolved challenges in operationalizing ethical allocation [44]. At the institutional level, the provincial government declined to provide a formal legal mandate for triage protocol, treating it as clinical guidance rather than statutory authority [23,24]. This gap explains the system’s intense reliance on load balancing and transfers. By avoiding formal activation, the state bypassed the political burden of authorizing the withdrawal of life-sustaining care while leaving clinicians without statutory immunity [24]. At the micro level, team-based staffing models prevented system collapse at the cost of severe burnout, emotional isolation, and moral injury among frontline clinicians, particularly nurses and allied health professionals [14]. Ontario thus represents a lower bound rather than an endpoint, marking a threshold where allocation ceases to be purely individualized at considerable human cost.
The institutional tensions observed in Ontario and Korea are not jurisdiction-specific. Comparative studies across multiple health systems during the COVID-19 pandemic describe a recurring pattern when crisis allocation functions are incompletely institutionalized. In such settings, explicit prioritization is often avoided, allocation decisions are reframed as routine clinical judgment, and institutions remain reluctant to document rationing because formal records increase rather than reduce individual legal exposure [4,45-47]. These behaviors do not reflect ethical disagreement or professional failure. Rather, they represent predictable responses to institutional environments in which governance authority, operational decision-making structures, and legal protection are misaligned. Evidence from diverse contexts reinforces this pattern. In the early stages of the COVID-19 crisis in the US, even in states that formally declared crisis capacity, triage committees were often not activated in practice [45] and liability protections were not experienced by frontline clinicians as meaningful operational safeguards [47], leaving resource allocation to ad hoc bedside judgment without consistent institutional backing [46]. In German ICUs, clinicians reported informally raising admission thresholds while institutional legal counsel explicitly discouraged documentation of prioritization decisions, further entrenching covert rationing practices [4]. Across these cases, the same structural outcome emerges. When collective decision-making and legal protection are absent or ambiguous, allocation responsibility is displaced downward to individual clinicians, where it becomes ethically burdensome and institutionally indefensible.
Across the cases examined, two mechanisms consistently drive the displacement of allocation responsibility from institutions to individual clinicians. The first mechanism functions at the operational level. When collective decision-making structures are absent or inactive, allocation judgments become privatized moral responsibilities. Decisions with system-wide consequences are made at the bedside without institutional mandate, standardized criteria, or mechanisms for review. In this setting, variation in allocation practice reflects not ethical disagreement but the absence of an organizational locus for decision-making [33].
The second mechanism concerns legal protection, which functions as an integrating condition across all three institutional levels [34,39]. Without a liability framework that recognizes crisis allocation as a legitimate standard of care, governance-level decisions lack enforceability, operational protocols remain unused, and documentation becomes a source of legal risk rather than institutional defense. Under these conditions, clinicians rationally avoid explicit prioritization and formal record-keeping, reframing allocation as routine clinical judgment to minimize personal liability. Together, these mechanisms ensure that allocation decisions remain ethically necessary yet institutionally indefensible, anchoring responsibility at the bedside—where responsibility is neither authorized nor protected.
The findings of this analysis point to a focused and sequential reform agenda. At the governance level, the most urgent requirement is formal recognition of crisis standards of care as a clinical norm rather than a purely administrative designation. This includes predefined activation thresholds, explicit designation of final clinical authority, and statutory recognition that allocation decisions made under declared crisis conditions constitute a legitimate standard of care. Without this foundation, downstream operational and clinical functions cannot be activated or enforced. At the operational level, institutions require protected collective decision-making structures and real-time data infrastructure capable of distinguishing functional from nominal critical care capacity. Hospital-level triage committees with defined authority, supported by regional coordination mechanisms and standardized documentation protocols, allow allocation pressure to be absorbed collectively rather than displaced to individual clinicians. Such structures enable load balancing, traceability, and institutional accountability, which are prerequisites for both legal protection and system learning. Finally, legal protection functions as an integrating condition across all levels. Conditional liability limitations tied to procedural adherence are necessary to ensure that documentation serves as institutional defense rather than personal risk. Without legal indemnity, formal allocation protocols remain unused, documentation is avoided, and after-action review becomes impossible. Addressing these gaps should not aim to recapitulate Ontario’s specific architecture. Rather, the explicit establishment of core functions is required within Korea’s unique legal and institutional context before the next surge renders ethical principles operationally irrelevant.
This analysis has several limitations. As a narrative comparative review, it does not quantify the relative contribution of individual institutional failures to allocation outcomes, nor does it capture variation across hospitals or regions within Korea. The comparison is structurally asymmetric. Ontario is documented through official operational reports, command documents, and systematic data collection, while the Korean case relies primarily on a smaller set of clinical reports, legal analyses, and the absence of institutional documentation—which is itself part of the finding. While this asymmetry limits the granularity of comparison, our diagnostic framework is not invalidated. The comparison is designed to identify where functions are assigned or unassigned rather than to measure their relative performance. Ontario’s legal and administrative context differs substantially from Korea’s, signifying that the specific institutional solutions observed in Ontario are not directly transferable. Finally, the analytic framework developed herein is intended to be diagnostic rather than prescriptive; in identifying functional gaps, we do not specify the singular institutional form through which each function must be fulfilled.
CONCLUSIONS
This analysis shows that ethical allocation of critical care resources depends on institutional alignment rather than moral consensus alone. When governance authority, operational decision-making, and legal protection are misaligned, allocation responsibility devolves to frontline clinicians without mandate or protection. The Korean experience during COVID-19 illustrates how such misalignment renders ethical allocation practically inoperable. Without explicit institutional alignment, future crises will yield the same patterns of individualized burden and clinical distortion.
This study is a review of existing literature, policy documents, and normative frameworks, and does not involve human subjects or animal experiments. Therefore, Institutional Review Board approval and informed consent were not required.
KEY MESSAGES
▪ Critical care allocation failures during crises stem from institutional misalignment across governance, operational, and clinical levels, rather than from purely ethical disagreements.
▪ The Korean healthcare system lacks essential clinical crisis standards and legal indemnity frameworks, causing systemic deficits that leave resource allocation decisions institutionally unanchored.
▪ Proactive institutional reforms, including formal crisis standard activation and collective decision-making structures, are essential prerequisites for ethical and sustainable resource allocation during surge conditions.
NOTES
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CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.
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FUNDING
This research was supported by the Korea National Institute for Bioethics Policy.
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ACKNOWLEDGMENTS
During the preparation of this work, the authors used Claude 4.6 Opus from Anthropic in order to improve language and readability. After using this tool, the authors reviewed and edited the content as needed, and all authors take full responsibility for the content of the publication.
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AUTHOR CONTRIBUTIONS
Conceptualization: HKS, UJ, KL. Formal analysis: HKS. Methodology: HKS, UJ, KL. Visualization: HKS. Funding acquisition: KL. Writing - original draft: HKS. Writing - review & editing: UJ, KL. All authors read and agreed to the published version of the manuscript.
SUPPLEMENTARY MATERIALS
Supplementary materials can be found via https://doi.org/10.4266/acc.001872.
Figure 1.Three-level institutional framework for critical care allocation. Crisis allocation functions are distributed across governance (level 3), operational (level 2), and clinical (level 1) levels. Certain functions span level boundaries and are shown as arrow bars on the right; these are discussed as cross-cutting functions in our Results. When essential functions are unassigned at level 3 or level 2, decision-making and ethical burden default to frontline clinicians at level 1. The feedback loop depends on standardized documentation and legal protection; where these components are absent, crisis experience cannot inform future preparedness.
Table 1.Analytical framework for ethical critical care allocation
|
Operational level |
Core institutional component |
Functional question |
|
Level 3: Governance |
Definition and activation of crisis standards of care |
When and how does the system explicitly transition from conventional care to crisis allocation |
|
Multilevel governance structure |
Who holds final authority for allocation and system-wide coordination |
|
Level 2: Operations |
Regional coordination and resource redistribution mechanisms |
How are patients and critical care resources redistributed across hospitals |
|
Hospital-level triage committees |
How are individual clinical judgments transformed into collective institutional decisions |
|
Level 2-3: Interface |
Data infrastructure and documentation |
On what basis are allocation decisions justified, tracked, and reviewed |
|
Level 1-3: Interface |
Legal protection and institutional accountability |
Who is protected from liability, and under what procedural conditions |
|
Level 1–2: Interface |
Clinician support and after-action learning |
How are clinicians supported and how does the system sustain learning over time |
Table 2.Presence, partial implementation, or absence of institutional components for critical care allocation: Ontario and Korea
|
Core institutional component |
Level |
Ontario |
Korea |
|
Crisis standards activation |
L3 |
Present [17,19,20] |
Absent [28,35,36] |
|
Multilevel governance structure |
L3 |
Present [16,19] |
Partial [35,36] |
|
Regional coordination mechanisms |
L2 |
Present [15,16,18,19] |
Absent [10,11,28,30] |
|
Hospital-level triage committees |
L2 |
Present [17,24] |
Absent [38] |
|
Data infrastructure and documentation |
L2-3 |
Present [22,37] |
Absent [11] |
|
Legal protection and institutional accountability |
L1-3 |
Partial [17,19,24] |
Absent [29,41,42] |
|
Clinician support and after-action learning |
L1-3 |
Partial [14,21] |
Absent [27,31] |
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