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]. 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].

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]. 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]. 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]. 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].

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]. 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]. 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], 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], 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