Ethical Decision-Making and Institutional Support for ECMO and Ventilator Allocation During the COVID-19 Pandemic: A Nationwide Cross-Sectional Survey of Designated Physicians at Japan’s Advanced Critical Care Centers

Background During the global COVID-19 pandemic, many countries issued formal national or professional guidelines for the allocation of ECMO and ventilators. Although these guidelines were generally non-binding, they offered structured recommendations to support triage decisions. In contrast, Japan lacked even such formal policies, leaving decisions to individual advanced critical care and emergency centers. Empirical evidence on how these ethically complex decisions were made at the facility level remains limited. Methods We conducted a retrospective postal survey of all 50 Advanced Critical Care and Emergency Centers (ACCECs) in Japan (Feb–Mar 2025). One physician per center involved in ECMO or mechanical ventilation allocation during the COVID-19 pandemic (2020–2023) completed a 16-item questionnaire covering therapy restriction, clinical criteria, ethical principles, psychological burden, and institutional ethics support. Descriptive analyses explored facility-level variation and decision-making patterns. Results Twenty-seven centers (54%) responded. Among the 26 centers with pre-pandemic ECMO implementation, 38% reported restricting ECMO use. For mechanical ventilation, 19% of centers imposed restrictions. Clinical criteria included patient age (ECMO: 80%; ventilation: 100%), severity of illness, and estimated survival probability. Efficiency was the most frequently prioritized ethical principle (57%), followed by equality and autonomy (22% each). Forty-eight percent of responding physicians reported greater psychological burden than in routine care, especially those affiliated with centers that restricted ECMO (70% vs. 35%) or used age-based criteria (63% vs. 42%). Thirty-seven percent reported that internal rules were in place, and 19% had used ethics consultation. Restriction was more common in centers with internal rules (70% vs. 18%), which also reported greater psychological burden (70% vs. 35%). Conclusions Many physicians relied on clinical criteria in making triage decisions, and nearly half did not report increased psychological burden. These findings suggest that, even without uniform national guidance or comprehensive institutional support, relatively consistent and ethically grounded decisions were being made. However, internal rules or ethics consultation were not uniformly associated with either clinical decisions or emotional outcomes, underscoring the need for more context-sensitive ethical support frameworks.