Health professionals’ knowledge about ethical criteria in the allocation of resources in the COVID-19 pandemic

{"Background": "The COVID-19 pandemic created unprecedented scarcity of healthcare resources such as ICU beds, ventilators, and personal protective equipment, forcing health professionals to make distressing decisions about which patients should receive life-saving resources. Traditional principialist bioethics, centered on individual patient care, may be insufficient for public health emergencies requiring population-level thinking. Several ethical frameworks were proposed, including the Accountability for Reasonableness model by Gruskin and Daniels, which emphasizes transparency, relevance of decisions, review mechanisms, and regulatory oversight. This study aimed to analyze Brazilian health professionals' knowledge of ethical criteria for resource allocation during the pandemic, assessing their preparedness to apply fair priority-setting conditions based on this model.", "Methods": "This cross-sectional, descriptive, survey-type study was conducted from June to December 2020 with health professionals working at different care levels during the COVID-19 pandemic in Brazil. Inclusion criteria required participants to be health professionals from medicine, nursing, physiotherapy, nutrition, pharmacy, psychology, speech therapy, occupational therapy, social work, or dentistry; over 18 years old; and working for at least six months during the pandemic. Non-probabilistic snowball sampling was used. Data were collected via a self-completed online questionnaire (Google Forms) with 25 questions: 14 assessing ethical criteria knowledge in hypothetical resource allocation scenarios and 11 characterizing the sample profile. Each correct response received 5 points (maximum 70). The instrument was pre-tested with five professionals. Statistical analyses included Fisher's Exact test and Kruskal-Wallis test, with 95% confidence level. The study was approved by the Research Ethics Committee of UFMS (CAAE 31479820.5.0000.0021, opinion n\u00ba 4.042.275).", "Key Results": "Of 197 participants, 37.6% were nurses and 22.8% physicians. Most worked in healthcare (64.5%), at Family Health Units (28.4%), in the Midwest region (50.3%), with specialization-level training (46.2%). Mean age was 37.7 years (SD=9.7, range 20-70). Regarding self-assessed bioethics knowledge, 76.1% considered themselves knowledgeable, acquired mainly during undergraduate studies (49.8%). However, 9.5% of nurses, 18.2% of dentists, and 24.4% of physicians reported no prior bioethics knowledge. No medical or dental professionals reported extensive knowledge. The mean knowledge assessment score was 45.4 (SD=7.2, range 20-65) out of 70. Physicians scored significantly higher (mean 48.11, SD=5.96) than other professionals (p=0.0321). Hospital workers scored significantly higher (mean 47.98, SD=5.87) than those in PHCU/FHU (mean 43.75, SD=7.65) (p=0.0127). Significant associations were found between profession and self-reported bioethics knowledge (p=0.0486), knowledge acquisition method (p=0.0125), knowledge level (p=0.0315), and perceived importance of bioethics for policy-making (p=0.0444).", "Clinical Implications": "The findings reveal a critical gap between self-perceived bioethics knowledge and actual ability to apply ethical criteria in resource allocation decisions. The mean score of 45.4/70 suggests that many health professionals may not be adequately prepared to make ethically sound decisions in scarcity scenarios. Physicians and hospital-based workers demonstrated better knowledge, likely due to greater exposure to ethical dilemmas in acute care settings. The study underscores the urgent need for continuing education programs in bioethics, particularly for primary care professionals, and for integrating ethical frameworks like Accountability for Reasonableness into clinical training. These results are consistent with pre-pandemic studies from Nepal, India, and sub-Saharan Africa showing similar knowledge gaps. Strengthening bioethics education\u2014both in undergraduate curricula and through in-service training\u2014is essential for ensuring fair, transparent, and justifiable resource allocation during public health emergencies."}