The literature on pandemic planning and responses suggests that response to public health emergencies should be guided by specific ethical norms and considerations, in addition to medical and military logistical skills [1,2]^[1][2]. Lessons learned from past pandemics and epidemics such as SARS (2003) have demonstrated the reasons for and ways in which incorporating ethical concerns into pandemic plans and policies may have made and can still make a substantial impact in resolving many ethical issues that a pandemic crisis may present. Researchers have argued that there are ethical concerns identified in almost every aspect of pandemic planning, including allocating healthcare resources, prioritising the distribution of services, resolving conflicts between patient and community rights, and balancing healthcare workers’ professional and personal obligations. The World Health Organisation’s ^[3] guidance document “Ethical considerations in developing a public health response to pandemic influenza” was created to help member states include ethical values and considerations in pandemic planning. There were several alleged advantages of incorporating moral principles into pandemic response plans, from lowering death rates to increasing public collaboration [1,4]^[1][4].

Triage is a dynamic and complex decision-making process to prioritise access to medical care, both healthcare treatments and hospital care. It involves an ethical element to secure fair access to available healthcare facilities and resources and has been the subject of many debates [6]^[5]. Intensive Care Units (ICUs) might be considered as free from triage due to the sensitivity and criticality of patient conditions; however, triage was actually conducted in ICUs during COVID-19 pandemic where these units were overwhelmed with critical cases and resources were limited despite the pandemic preparedness of countries [7]^[6]. A deeper look into the ICU triaging principles revealed that countries developed ICU guidelines to deal with mass casualties and with a great variance in principles: saving the maximum number of lives through medical prognosis, adopting age, life expectancy, quality of life, etc. [7]^[6]. This variance had been a concern for some researchers as the adopted triage process had overlooked the existing health inequities and contributed to widening the health gap in societies [8]^[7].

In the context of the need of ethics for ICU triaging, there are areas of agreement in the literature that indicate that scarce medical resources of the ICU such as beds, ventilators, etc. are to be distributed fairly and reasonably during a pandemic [19,20,21]^[8][9][10]. Literature also specifies that resources are to be distributed fairly and reasonably to make them accessible to all. However, there is limited understanding of standard ethical principles in ICU triage decision making, especially in South Asian countries [20]^[9]. Out of the five countries, only the Pakistan guidelines explicitly mention the need of ethical principles for ICU triaging during pandemics like COVID-19 ([22]^[11], p. 4). Nepal’s plan, on the other hand, implicitly indicates how differential groups such as migrants, people with co-morbidities, etc. are not to be overlooked for disease screening, but these undermined groups have been mentioned only for the public health screening and not for the ICU admission protocol ([23]^[12], p. 46). Hence, no consistent awareness or concern of the need of ethics for ICU triaging has been noticed in the South Asian guidelines.

Disagreements on the (Ethical) Framework

There is disagreement on the rationale principle behind the just allocation during the crisis [24,25,26,27,28]^{[13][14][15][16][17]}. A requirement of strengthened national guidance for the protocol and policy for ICU triaging [29]^[18] was highlighted. To conduct a deeper assessment, ICU triage frameworks for the South Asian countries were revisited. In general, a variety of criteria were given for ICU admissions to inform decisions on who should be admitted to the ICU based on the parameters of respiratory rate, SPO2 level, probability of survival, co-morbidities, and age. All of the guidelines agreed that components of these characteristics should be utilised in combination in ICU admission decision making, and the onus remains on the clinical teams led by physicians to assess the final admission criteria for individual patients. However, when it comes to an ethical ICU triage process, it is only Pakistan’s guidelines which mention using a compassionate, respectful, and empathetic approach ([22]^[11], p. 5). The Nepal guidelines specify different socioeconomically vulnerable groups, but these groups have been undermined in the context of ICU admission and treatment. Hence, no consistent guideline on ethical triaging or need of ethical framework for ICU triaging has been found in the relevant South Asian documents.

 ICU Triage Protocols Are to Be Transparent

ICU triage protocols are expected to be transparent, built upon trust, to be inclusive, and to include public health values [24]^[13]. Multiple ethical values need to be balanced for various interventions and circumstances to develop prioritisation guidelines and standard operating protocols [30]^[19]. There are limited data which support advanced ethical consultation and reflection to make the process more inclusive and value-based in the South Asian guidelines and plans. The importance of open and transparent information sharing had been hinted at by the Nepal and Pakistan guidelines. The Pakistan guideline, specifically, highlights that Standard Operating Procedures (SOPs) need to be more coherent ([22]^[11], p. 4). On the other hand, the Bangladesh plan used the term “open” but with different connotations, such as “Do not go near any open flames when using oxygen…” ([31]^[20], p. 33). Hence, no indication of clear, transparent, and standardised ethical ICU protocol could be identified in the plans and guidelines.

ICU Triaging Needs Equitable Approach with Consideration of Underlying Health Inequities

ICU triaging needs an equitable consideration safeguarding the right to health of all [32]^[21]. However, the main and generic focus of equity has been utilitarian– saving maximum lives; lottery-based rationing thereby overlooks the underlying health inequities. Hence, a just and fair approach with consideration of an equitable framework is desirable for the ICU triage decision-making during pandemics. In this context, only Nepal’s guidelines have mentioned equity (Table A5), but this has not been extended to set the criteria for ICU admissions and treatment. Four fundamental ethical values, obtained from previous pandemic models, are usually popular in ICU triaging: Maximising the benefits produced by scarce resources; Treating people equally; Promoting and rewarding instrumental value; Giving priority to the worst off [30]^[19]. In some plans and guidelines of South Asian countries, although these concepts have been used, they have been used for different contexts, such as for general health care and public health concerns, but not specifically for ICU triaging. The Pakistan plan, though, encourages not overlooking other patients for ICU admissions; in all countries, the ICU admission criteria are founded on the basis of medical conditions, overlooking socioeconomic and health inequities. Hence, more research is needed to incorporate the perspective of existing health inequities in just and fair ICU rationing during pandemics.

Need of Regional Mapping of Capacities and Better Modelling

With lessons learnt from past pandemics, the literature recommends maintaining a central database of ICU resources in order to evaluate health system performance, both within and between countries, which may help to develop related health policy [33]^[22]. Regional modelling is needed to cope with the pandemic pressure for the ICU [24,34]^[13][23]. As a pandemic respects no borders, ICUs of the region can also be overwhelmed at the same time with no capacity to transfer patients and COVID-19 has shown evidence of this. While Nepal mentions inter-country and regional collaboration, nothing has been remarkably highlighted for mapping regional capacities in any other plans. Hence, there is a need to have a better insight into the regional ICU triaging process. Recently, COVID-19 has highlighted that pandemic preparedness, including ICU preparation in a South Asian context, needs to be founded on a better framework [24,34]^[13][23]. However, there is an oversight of the framework recommendation with insights of underlying health inequities. Therefore, there is a need for research to revisit the framework recommendation, which is founded on equitable rationalisation. In addition to these thematic analyses, inclusion of ethical terms/expressions were searched for in the South Asian guideline and plans for the second time. In general, the usage of ethical language in the guidelines and plans, once again, is said to be low. None of the plans, except Pakistan’s, has a separate section on ethical considerations; whatever ethical terms have been found are used as part of the content of the plan in general. Out of the 18 terms searched for, the common terms used for COVID-19 are communication, protection, and responsibility. The terms which have not been found in any COVID-19 plans’ guidance are Accountability, Fair/Fairness, and Responsiveness. Collaboration signifies working together. However, it is only the Nepal and Pakistan guidelines which mention intersectoral collaboration and collaborative decisions. Ethics, the other term, appears again in Nepal’s and Pakistan’s guidelines which use the term to promote better public health interventions and the rational allocation of healthcare resources. The Nepal plan has shown concern for equity but for public health measures, not particularly for ICU triage. It has also used strategies to boost the morale of the healthcare workers. It is the only plan to use the context of rights (human rights). Minimising risk of transmission was the most used expression in the Sri Lanka plan and has been used to designate areas to prevent a COVID-19 spread. The expression Reasonableness was used in the Bangladesh plan and has been used in the context of rationale imagination but not in relation to reasonable ICU allocation. Representation/represent was used in the Nepal, Sri Lanka, and India plans to indicate intersectoral representations in the COVID-19 prevention team. However, no representations of the vulnerable groups have been mentioned in any documents. Finally, the context of Transparency and Trust were mentioned in the Nepal and Pakistan guidelines to indicate open sharing of information and building rapport among the teams and community. Importantly, although the COVID-19 pandemic led to many issues and challenges in relation to the ICU, with the exception of the Pakistan guidelines, no other plans use the term ICU prioritisation, though they discuss vaccination strategies. In the crisis hours of a pandemic, an open and transparent ethical ICU triage can help avert many irrational strategies impacting the service delivery and can also save many unwanted and premature deaths. Inequalities in society are unavoidable. However, if they are thoughtfully incorporated in the pandemic planning, many real-time disasters can be averted. And for this, more research, with a vision of social justice, is needed in this domain.