When ethics is not enough: institutional governance of critical care allocation under crisis conditions

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.