Ethical Allocation Research Articles

Governing the Responsible Investment of Slack Resources in Environmental, Social, and Governance (ESG) Performance: How Beneficial are CSR Committees?

AbstractPossessing slack resources enables businesses to invest in innovative and stakeholder-focused initiatives. Therefore, we posit that higher slack resources encourage businesses to allocate these resources to improve their environmental, social, and governance (ESG) performance. Moreover, as a central sustainability governance mechanism, we hypothesize that the corporate social responsibility (CSR) committee supports investing slack resources in ESG initiatives. Using data from Nasdaq-100 firms, we find initial support for a positive effect of slack resources for ESG. However, further analyses reveal that slack resources become detrimental to ESG after an economically relevant threshold, indicating an inverted U-shaped effect of slack resources. Additionally, despite their generally positive effect, we uncover that CSR committees cannot effectively enhance the benefits of low or moderate slack levels for ESG nor prevent the detriments of elevated slack levels for ESG. Therefore, our study significantly contributes to the ongoing discourse surrounding slack resources, ESG, and the usefulness of CSR committees. These findings hold significant implications for ethical resource allocation, urging firms and their decision-makers to reconsider the dual-edged role of slack resources in the unique ESG context and support the CSR committee in realizing its potential for promoting sustainability and ethical practices within the organization.

Kidney After Lung Transplants or Combined Kidney-Lung Transplantation: A Single-Center Retrospective Cohort Study.

BACKGROUND End-stage renal disease is a major issue in the management of patients undergoing lung transplantation. Combined kidney-lung transplantation (CKLT) and kidney after lung transplantation (KALT) are the 2 preferred solutions to manage this situation. To evaluate these strategies, we describe kidney and lung graft outcomes and patient survival in patients managed with CKLT and KALT. MATERIAL AND METHODS We conducted a retrospective single-center cohort study. Patients who underwent a CKLT or a KALT were included in this study. Retrospective extraction of data from medical records was performed. RESULTS Seventeen patients underwent CKLT and 9 underwent KALT. Most of the patients had cystic fibrosis and presented renal failure related to anti-calcineurin toxicity. The 30-day and 1-year survival of CKLT recipients were both 75.6%. No patients with KALT died during the follow-up. Kidney graft prognosis was almost exclusively influenced by patient survival in relation to postoperative lung transplant complications. The rate of severe surgical complications was close to 60% for CKLT compared with 30% for KALT. The kidney graft function (estimated kidney graft function) did not differ according to the transplantation strategy. CONCLUSIONS KALT is a safe option, with postoperative morbidity and renal graft function identical to those of kidney transplantation in non-lung-transplanted patients. The results of CKLT depend mainly on the morbidity associated with lung transplantation but remain an attractive option for patients with respiratory failure associated with end-stage renal disease. The choice of transplant strategy must also take into account the most ethical and efficient allocation of kidney grafts.

Doubly adaptive biased coin design to improve Bayesian clinical trials with time-to-event endpoints.

Clinical trialists often face the challenge of balancing scientific questions with other design features, such as improving efficiency, minimizing exposure to inferior treatments, and simultaneously comparing multiple treatments. While Bayesian response adaptive randomization (RAR) is a popular and effective method for achieving these objectives, it is known to have large variability and a lack of explicit theoretical results, making its use in clinical trials a subject of concern. It is desirable to propose a design that targets the same allocation proportion as Bayesian RAR and achieves the above objectives but addresses the concerns over Bayesian RAR. We propose the frequentist doubly adaptive biased coin designs (DBCD) targeting ethical allocation proportions from the Bayesian framework to satisfy different objectives in clinical trials with time-to-event endpoints. We derive the theoretical properties of the proposed adaptive randomization design and show through comprehensive numerical simulations that it can achieve ethical objectives without sacrificing efficiency. Our combined theoretical and numerical results offer a strong foundation for the practical use of RAR in real clinical trials.

Healthcare resource allocation decisions and non-emergency treatments in the aftermath of Covid-19 pandemic. How should children with chronic illness feature in prioritisation processes?

In the aftermath of the Coronavirus disease 2019 (Covid-19) pandemic, allocation of non-urgent medical interventions is a persistent ethical challenge as health systems currently face an unprecedented backlog of patients requiring treatment. Difficult decisions must be made that prioritise certain patients over others. Ethical resource allocation requires that the needs of all patients are considered properly, but at present there is no guidance that can help support such decision-making which explicitly considers the needs of children with chronic and complex conditions. This paper reviews the NHS guidance for priorities and operational planning and examines how the needs of children with chronic illness are addressed in NHS objectives for restoring services and meeting elective care demands. The usual criteria for prioritisation featured in the NHS guidance fail to account for the distinct needs of children with chronic illnesses and fail to match more general considerations of what constitutes fair resource allocation decisions. To address this issue, two considerations, namely 'protecting age-related opportunity' and 'recognising complexity of care,' are proposed as additions to the existing approach. By providing a broader conception of needs, these criteria address inefficiencies of the current guidance and relevant ethical frameworks and help to embed a currently missing children-related ethical approach to healthcare policy making in general.

Ethical Resource Allocation in Policing: Why Policing Requires a Different Approach from Healthcare

This article examines the inherently ethical nature of resource allocation in policing. Decision-makers must make trade-offs between values such as efficiency vs. equity, individual vs. collective benefit, and adopt principles of distribution which allocate limited resources fairly. While resource allocation in healthcare has been the subject of extensive discussion in both practitioner and academic literature, ethical resource allocation in policing has received almost no attention. We first consider whether approaches used in healthcare settings would be suitable for policing. Whilst there are some high-level similarities in the relevant ethical considerations and processes—such as aiming for efficient and equitable resource deployment—there are also fundamental differences between the two settings, which we argue necessitate a different approach. These differences include: (1) greater diversity and incommensurability of the benefits of policing, (2) more frequent non-linearity in returns on policing investment, (3) greater “ethical divisibility” (permissible scaling down) of programs in policing, (4) a requirement to assess “need” for policing resources at the collective (rather than individual) level, and (5) clearer primacy of equity considerations in policing. Having drawn out the implications of these differences, we sketch some tentative proposals for ethical resource allocation in policing.

Multicriteria decision support system for triage and ethical allocation of scarce resources to COVID-19 patients

Multicriteria decision support system for triage and ethical allocation of scarce resources to COVID-19 patients

Healthcare resource allocation decisions and non-emergency treatments in the aftermath of Covid-19 pandemic. How should children with chronic illness feature in prioritisation processes?

Background: In the aftermath of the Coronavirus disease 2019 (Covid-19) pandemic, allocation of non-urgent medical interventions is a persistent ethical challenge as health systems currently face an unprecedented backlog of patients requiring treatment. Difficult decisions must be made that prioritise certain patients over others. Ethical resource allocation requires that the needs of all patients are considered properly, but at present there is no guidance that can help support such decision-making which explicitly considers the needs of children with chronic and complex conditions. Methods: This paper reviews the NHS guidance for priorities and operational planning and examines how the needs of children with chronic illness are addressed in NHS objectives for restoring services and meeting elective care demands. Results: The usual criteria for prioritisation featured in the NHS guidance fail to account for the distinct needs of children with chronic illnesses and fail to match more general considerations of what constitutes fair resource allocation decisions. To address this issue, two considerations, namely 'protecting age-related opportunity' and 'recognising complexity of care,' are proposed as additions to the existing approach. Conclusion: By providing a broader conception of needs, these criteria address inefficiencies of the current guidance and relevant ethical frameworks and help to embed a currently missing children-related ethical approach to healthcare policy making in general.

An optimal sequential design in ethical allocation with an adaptive interim analysis

The present article provides a distribution-free test procedure for comparing the effectiveness of two competing treatments A and B, say, in a clinical trial. Here, the relative treatment effect is measured by the functional θ = P ( X < Y ) , where X and Y are respectively the response variables corresponding to two treatments, A and B. The treatment comparison is done through a testing of hypothesis regarding θ under a patient-benefit oriented two-stage response-adaptive design with an interim analysis in which an optimal sequential sampling scheme with equal randomisation is adopted in stage 1 and a response-adaptive randomisation is employed in stage 2 with the objective of allocating more patients to more promising treatment. The performance of the proposed procedure is compared with that of various other competitive procedures.

Risk-based allocation of COVID-19 personal protective equipment under supply shortages

The COVID-19 outbreak put healthcare systems across the globe under immense pressure to meet the unprecedented demand for critical supplies and personal protective equipment (PPE). The traditional cost-effective supply chain paradigm failed to respond to the increased demand, putting healthcare workers (HCW) at a much higher infection risk relative to the general population. Recognizing PPE shortages and high infection risk for HCWs, the World Health Organization (WHO) recommends allocations based on ethical principles. In this paper, we model the infection risk for HCWs as a function of usage and use it as the basis for distribution planning that balances government procurement decisions, hospitals’ PPE usage policies, and WHO ethical allocation guidelines. We propose an infection risk model that integrates PPE allocation decisions with disease progression estimates to quantify infection risk among HCWs. The proposed risk function is used to derive closed-form allocation decisions under WHO ethical guidelines in both deterministic and stochastic settings. The modelling is then extended to dynamic distribution planning. Although nonlinear, we reformulate the resulting model to make it solvable using off-the-shelf software. The risk function successfully accounts for virus prevalence in space and in time and leads to allocations that are sensitive to the differences between regions. Comparative analysis shows that the allocation policies lead to significantly different levels of infection risk, especially under high virus prevalence. The best-outcome allocation policy that aims to minimize the total infected cases outperforms other policies under this objective and that of minimizing the maximum number of infections per period.

Ethical Challenges in Ventilator Allocation during COVID-19 Crisis Level Care in a Low-Resource Setting, Subtitle: Who gets the last ventilator?

Health crisis-level situations, such as the COVID-19 pandemic, has brought the challenge of ethical allocation of scarce life-saving resources (e.g. mechanical ventilator) in the face of sudden demand by critically ill patients. The problem is heightened in low-resource countries with limited number of ventilators. This article analyzes the ethical challenges in mechanical ventilator allocation during the COVID-19 pandemic in low to middle-income countries (LMIC), such as the Philippines. Among the three rationing principles of substantive justice, maximizing the benefit of the limited and vital resource for the most in society is acknowledged by majority of public health experts to be the prevailing principle to guide resource allocation. In low-resource settings, such as low to middleincome countries, with pre-existing health inequities in health care resources and absence of legal framework supporting advance directives, the principle of maximizing benefit is tempered with proportionate need focused on the vulnerable population sectors that may have suffered from inequities even before the COVID-19 crisis. The procedural aspect of the allocation decision formulation and implementation should ensure community engagement with solidarity, openness, veracity, transparency and accountability as values to be consistently manifested. Painful decisions will still be made at the frontline on who will receive the life-saving ventilator or not, but, as long as there is transparency and community participation in these decisions, then the decision-makers will be able to live with these decisions without undue burden on their conscience.

‘Prioritized Distribution of Equal Shares’—An Ethical and Practicable Allocation Framework for COVID-19 Vaccines

In the context of the global COVID-19 pandemic, the fast and equitable distribution of effective vaccines worldwide is one of the challenges faced by international institutions in charge, as global equity in vaccine supply has not yet been achieved. Our paper explains the current state of ethical research on equity in global COVID-19 vaccine allocation, focusing on the COVAX Facility established by the WHO, acting as the global vaccine distributor. The article presents a detailed analysis of the first year of COVAX allocation in 2021 identifying problematic aspects of its allocation framework regarding the implementation of COVAX’s fundamental allocation principles. We argue that the COVAX Facility has developed a proper concept to deal with global vaccine allocation—but to address uncovered defaults, we introduce the ‘Prioritized Distribution of Equal Shares’ model—a both ethical and practically feasible alternative allocation framework to protect the value of human lives in both high- and low-income countries through fair and fast global vaccine distribution in health emergencies. Nonetheless, we argue that the COVAX Facility remains the main organization to provide equitable access to vaccines. Yet, the global community has to consider further aspects such as patent protection, vaccine production and the lack of power of global structures to address the inequities that have arisen. Since new wars and further crises have arisen, a shift in public global attention endangers the processing of COVID-19-related issues. That is why now more than ever extensive efforts to achieve vaccine equity are needed.

Ethical Challenges with Multiple Myeloma BCMA Chimeric Antigen Receptor T Cell Slot Allocation: A Multi-Institution Experience

Chimeric antigen receptor T cell (CAR-T) therapies are Food and Drug Administration (FDA)-approved for patients with triple refractory multiple myeloma (MM). Real-world access to CAR-T therapy remains challenging owing to supply chain limitations impacting manufacturing. The goal of this study was to evaluate the extent of this issue and how major centers are handling the challenges of CAR-T manufacturing slot allocation. MM CAR-T physician leaders at each CAR-T treatment center across the United States were surveyed. We received responses from 17 of 20 centers. A median of 1 slot is allocated per month per center, and the median number of patients per center on the waitlist since the FDA's approval of idecabtagene vicleucel is 20 (range, 5 to 100). As a result, patients remain on the waitlist for a median of 6 months (range, 2 to 8 months) prior to leukapheresis. For patient selection, all centers reported using a committee of experienced CAR-T physicians to ensure consistency. To ensure transparency, 15 centers make selection criteria, selection timelines, and priority scores readily available for CAR-T providers. Centers also reported using ethical values for selection: (1) equal treatment: time spent on waiting list (n=12); (2) priority to the worst-off: limited therapeutic options (n=14), MM burden (n=11), high Hematopoietic Cell Transplantation Comorbidity Index (n=5); (3) maximize benefit: most likely to complete apheresis (n=13) or infusion (n=13) or to achieve response (n=8); and (4) social value: younger patients (n=3). Maximizing benefit was considered the most important criterion by 10 centers. This study is the first attempt to evaluate existing issues with CAR-T access for patients with MM and the variability and challenges in patient selection. Integrating ethical resource allocation strategies, similar to those described here, into formal institutional policies would help streamline access to CAR-T therapy and protect the needs of both current and future patients and physicians.

Children as an afterthought during COVID-19: defining a child-inclusive ethical framework for pandemic policymaking

BackgroundFollowing the SARS pandemic, jurisdictions around the world began developing ethical resource allocation frameworks for future pandemics—one such framework was developed by Thompson and colleagues. While this framework offers a solid backbone upon which decision-makers can rest assured that their work is driven by rigorous ethical processes and principles, it fails to take into account the nuanced experiences and interests of children and youth (i.e., young people) in a pandemic context. The current COVID-19 pandemic offers an opportunity to re-examine this framework from young people’s perspectives, informed by advances in childhood ethics and children’s rights.Main bodyIn this paper, we revisit the Thompson et al. framework and propose adaptations to the ethical processes and values outlined therein. This work is informed by expertise in clinical ethics and literature related to impacts of COVID-19 and other pandemics on the health and well-being of children around the world, though with particular attention to Canada. During the processes of drafting this work, stakeholders were consulted—aligned with the approach used by Thompson and colleagues—to validate the interpretations provided. We also propose a new principle, namely practicability, to indicate the complex balance between what is possible and what is convenient that is required in ethically sound decisions in the context of services affecting young people. We outline and discuss the strengths and limitations of our work and indicate next steps for scholars in the areas of childhood studies and child health.ConclusionEfforts to ensure frameworks are truly child-inclusive should be the status-quo, so pandemic impacts and policy implications can be considered in advance of emergency preparedness contexts.

Criteria for Ethical Allocation of Scarce Healthcare Resources: Rationing vs. Rationalizing in the Treatment for the Elderly

This paper stems from the current global worsening of the scarcity of resources for healthcare, which will deepen even more in future public emergencies. This justifies strengthening the reflection on the allocation of resources which, in addition to considering technical issues, should also involve ethical concerns. The two plans in which the allocation of resources develops—macro and micro—are then systematized, both requiring the identification of ethical criteria for the respective complex decision-making. Then, we describe how the complexity at the macro level focuses on the joint consideration of the rectitude of the principles, the goodness of the ends, and the integrity—respectively the deontological, teleological, and procedural perspectives; and at the micro level, it focuses in prioritizing people, which can result in the exclusion of some, as happened with the elderly during peaks of COVID-19. The main objective of this article is to show that, in public health emergency situations, in which the daily criteria for prioritizing access to health care are not efficient, it is possible not only to ration the available means but also to rationalize them. We argue that rationing and rationalization are different concepts, entail different consequences, have different ethical foundations, and draw different guidelines for patient care. We apply them to the distribution of intensive care and vaccines to the elderly thus demonstrating the ethically legitimate domain of implementation of each of these two prioritization criteria. We conclude that rationalization respects more strictly the core ethical principles of our common morality.

S1307 Provider Perceptions of Code Status for Patients With End-Stage Liver Disease

Introduction: Liver transplantation (LT) is the only curative option for patients with end-stage liver disease (ESLD). Patients with ESLD have high rates of in-hospital mortality and low rates of survival to hospital discharge after in-hospital CPR. As ESLD is one of the few diseases where patients are close to death but also to a total cure, some studies suggest that LT listing and hospice referral should not be mutually exclusive. While many centers require that a patient be “full code” for LT listing or evaluation, this is not a United Network for Organ Sharing (UNOS) mandate. This study aims to assess LT providers’ awareness of organizational policies and their perspectives on code status requirement, with the eventual goal of providing patients with goal-concordant care while balancing the need of ethical solid organ allocation for transplant. Methods: Healthcare providers involved in the LT evaluation process at a high-volume transplant center anonymously completed a 13-question survey. Provider specialties are shown in Table. Answers were displayed using descriptive statistics. Results: Out of 83 providers who filled out the survey, 40% reported that they either often or always discussed code status with patients, often in a hospital setting. 62% were unaware of the institutional protocol that patients had to be full code for LT evaluation or listing, and 95% were unaware that UNOS did not have a full code requirement for the LT process. 93% of participants felt that patients undergoing LT evaluation should discuss code status. 15% felt that patients should remain full code throughout, 54% felt that patient should have their choice of code status during LT evaluation and listing, and 31% felt that patients should have their choice during evaluation but become full code once listed. Conclusion: These results show a need for increased educational initiatives among providers involved in the LT process, as there is a lack of knowledge among providers regarding policy on code status. Among the subset who was aware of a protocol, knowledge of the actual requirements varied. While most providers believe that a discussion regarding code status is necessary for patients who wish to undergo LT, there was a diverse range of opinions on code status requirement throughout the LT evaluation and listing process. Initiatives to further the dialogue of code status and advanced care planning in a high mortality patient population are needed. Table 1. - Description of Survey Respondents Role on LT team Number of Respondents Gastroenterology/Hepatology Attending 6 Critical Care Attending 5 Transplant Surgeon 3 Palliative Medicine Attending 3 Gastroenterology Fellow 9 Internal Medicine Resident 32 Advanced Practice Provider 14 Transplant Coordinator 6 Transplant Selection Committee 1 Social Worker 1 Other 3

Fieldwork for public health responses during pandemics: lessons from the New South Wales Health experience with COVID-19

Problem: Fieldwork is a vital component of public health emergency response, yet little has been published on undertaking fieldwork safely. Safety is of particular importance with emerging pandemic viruses, which can pose additional risks to public health fieldwork staff. Context: During a pandemic, surge health staff may be drawn from diverse professional backgrounds; they may have limited experience in fieldwork or be unfamiliar with the risks posed by a novel virus. Novel pathogens pose dangers to fieldwork staff, particularly when there are global or local shortages of personal protective equipment. Action: During the coronavirus disease 2019 (COVID-19) pandemic, New South Wales (NSW) Health’s Public Health Emergency Operations Centre (PHEOC) deployed staff for fieldwork in a range of settings. The PHEOC developed a protocol to systematize planning, risk assessment and management for COVID-19 fieldwork. The protocol was accompanied by training, discussion exercises and debriefs to support PHEOC fieldwork staff. Lessons learned: Effective fieldwork is an essential component of outbreak investigation and management, including stakeholder management. Here, we share and discuss key elements of the NSW Health protocol to support fieldwork during outbreak responses for emerging communicable diseases across various resource contexts. Limited understanding of novel viruses, particularly in the early phases of a pandemic, must be considered in decisions to deploy fieldwork staff and implement precautionary risk mitigation approaches. Planning is essential to protect staff and ensure ethical allocation of resources. Through appropriate selection of teams and training, surge staff can be supported to effectively conduct fieldwork.

How Should Deceased Donor Organs Be Allocated? The Patient's Perspective Derived from Semi-Structured Interviews.

PurposeThe gap between the supply and demand for deceased donor organs is increasing worldwide, while patients on waiting lists for organ transplantation die. This situation requires ethical donor organ allocation rules. The patients’ perspective on donor organ allocation rules offers a highly relevant and unique perspective that may differ from the perspectives of physicians and the general public.Patients and MethodsSemi-structured telephone interviews were conducted with the regional group coordinators of the federal self-help organization for organ transplanted patients and their relatives in Germany in early 2021. Twelve interviews were conducted with patients and relatives of transplantation patients who received transplants for the affected organs including the lungs, heart, kidney, and liver. Transcripts were analyzed using the deductive framework method which was based on an earlier study. All criteria were reported following the COREQ statement.ResultsParticipants emphasized aspects of “medical urgency” and “effectiveness/benefit” of transplantation and associated trade-offs as well as the recipient’s responsibility for organ failure (“own fault”), the appreciation for the gifted graft and the patient’s capability of taking care of it (“appreciation/responsibility”). Patients acknowledged that urgent patients should be prioritized and they showed a clear preference toward allocation rules that strive to maximize both the life years and quality of life gained by transplantation.ConclusionThe patients’ perspective is unique in that patients agree on certain rules for allocation and share many preferences, but also have a hard time finding clear cutoff points when considering selecting a participant for allocation. Patient representatives should therefore be consulted in the debate on donor organ allocation rules.

Polarized Citizen Preferences for the Ethical Allocation of Scarce Medical Resources in 20 Countries.

Objective. When medical resources are scarce, clinicians must make difficult triage decisions. When these decisions affect public trust and morale, as was the case during the COVID-19 pandemic, experts will benefit from knowing which triage metrics have citizen support. Design. We conducted an online survey in 20 countries, comparing support for 5 common metrics (prognosis, age, quality of life, past and future contribution as a health care worker) to a benchmark consisting of support for 2 no-triage mechanisms (first-come-first-served and random allocation). Results. We surveyed nationally representative samples of 1000 citizens in each of Brazil, France, Japan, and the United States and also self-selected samples from 20 countries (total N = 7599) obtained through a citizen science website (the Moral Machine). We computed the support for each metric by comparing its usability to the usability of the 2 no-triage mechanisms. We further analyzed the polarizing nature of each metric by considering its usability among participants who had a preference for no triage. In all countries, preferences were polarized, with the 2 largest groups preferring either no triage or extensive triage using all metrics. Prognosis was the least controversial metric. There was little support for giving priority to healthcare workers. Conclusions. It will be difficult to define triage guidelines that elicit public trust and approval. Given the importance of prognosis in triage protocols, it is reassuring that it is the least controversial metric. Experts will need to prepare strong arguments for other metrics if they wish to preserve public trust and morale during health crises.HighlightsWe collected citizen preferences regarding triage decisions about scarce medical resources from 20 countries.We find that citizen preferences are universally polarized.Citizens either prefer no triage (random allocation or first-come-first served) or extensive triage using all common triage metrics, with “prognosis” being the least controversial.Experts will need to prepare strong arguments to preserve or elicit public trust in triage decisions.

The development of Afghanistan's Integrated Package of Essential Health Services: Evidence, expertise and ethics in a priority setting process

Health systems in fragile states need to respond to shifting demographics, burden of disease and socio-economic circumstances in the revision of their health service packages. This entails making difficult decisions about what is and is not included therein, especially in resource-constrained settings offering or striving for universal health coverage. In this paper we turn the lens on the 2017–2021 development of Afghanistan's Integrated Package of Essential Health Services (IPEHS) to analyse the dynamics of the priority setting process and the role and value of evidence. Using participant observation of meetings and interviews with 25 expert participants, we conducted a qualitative study of the consultation process aimed at examining the characteristics of its technical, socio-cultural and organisational aspects, in particular data use and expert input, and how they influenced how evidence was discussed, taken up, and used (or not used) in the process. Our analysis proposes that the particular dynamics shaped by the context, information landscape and expert input shaped and operationalized knowledge sharing and its application in such a way to constitute a sort of “vernacular evidence”. Our findings underline the importance of paying attention to the constellation of the priority setting processes in order to contribute to an ethical allocation of resources, particularly in contexts of resource scarcity and humanitarian need.

“Community engagement via restorative justice to build equity-oriented crisis standards of care”

The COVID-19 (SARS-CoV-2) Pandemic has revealed multiple structural inequities within the United States (US), with high social vulnerability index communities shouldering the brunt of death and disability of this pandemic. BIPOC/Latinx people have undergone hospitalizations and death at magnitudes greater than White people in the US. The untold second casualties are health care workers that are suffering from increased risk of infection, death, and mental health crisis. Many health care workers are abandoning the profession all together. Although Crisis Standards of Care (CSC) mean to guide the ethical allocation of scare resources, they frequently use scoring systems that are inherently biased. This raises concern for the application of equity in CSC. Data examining the impact of these protocols on health equity is scarce.Structural maltreatment in healthcare and inequities have led to cumulative harms, physiologic weathering and structural adversities for residents of the US. We propose the use of Restorative Justice (RJ) practices to develop CSC rooted in inclusion and equity. The RJ framework utilizes capacity building, circle process, and conferences to convene groups in a respectful environment for dialogue, healing, accountability, and action plan creation. A phased, non-faith-based facilitated RJ approach for CSC development (or revision) that fosters ethically equitable resource distribution, authentic community engagement, and accountability is shared. This opportunity for local, inclusive decision making and problem solving will both reflect the needs and give agency to community members while supporting the dismantling of structural racism and oppressive, exclusive policies.The authors are asking legislative and health system policy makers to adopt Restorative Justice practices for Crisis Standards of Care development. The US cannot afford to have additional reductions in inhabitant lifespan or the talent pool within healthcare.