The research, published in BMC Health Services Research, was conducted by a team spanning Hanyang University College of Medicine, Kyung Hee University College of Medicine, the National Medical Center, Chung-Ang University, and Keimyung University. Corresponding author Juyeon Lee of Keimyung University’s Department of Public Health led the study alongside Yeori Park of Hanyang University’s Department of Medical Humanities and Ethics, Ji Eun Park of Kyung Hee’s Center for Digital Health, Myoung-hee Kim of the National Medical Center’s Center for Public Health Data Analytics, and Sunmin Hong of Chung-Ang University’s Department of Sociology.

The study’s methodological design reflects a deliberate effort to capture perspectives that rarely appear together in health policy research. Thirty-one participants took part: sixteen healthcare providers with direct experience treating COVID-19 patients, and fifteen civil society advocates who supported socially marginalized populations during the pandemic. Providers participated in semi-structured individual interviews, while advocates took part in focus group interviews. Both formats incorporated written vignettes based on ethically contested resource-allocation policies actually implemented in South Korea during the pandemic, allowing participants to react to concrete scenarios rather than abstractions. An infectious disease specialist consulted on the development of the interview guide and the vignettes to ensure clinical accuracy. Data collection ran from August 2025 to March 2026, and the team analyzed the material primarily inductively using reflexive thematic analysis, an approach in which themes emerge from the data itself rather than being imposed from predefined theoretical categories. The study was approved by the Institutional Review Board of the National Medical Center and conducted in accordance with the Declaration of Helsinki, with written informed consent obtained from all participants.

The analysis surfaced four interrelated themes that expose a deep structural fault line in how pandemic scarcity was perceived. The first concerns the nature of scarcity itself. Healthcare providers, working inside hospitals, understood scarcity primarily as a shortage of tangible clinical assets: beds, personnel, and treatment capacity within the walls of medical institutions. Civil society advocates, by contrast, described scarcity in terms of barriers that prevented marginalized people from ever reaching those institutions or from remaining connected to them once inside. For a homeless individual, an undocumented migrant, or a person with severe mental illness, the ventilator supply was almost irrelevant if they could not access testing, isolation facilities, or basic medical attention in the first place. In other words, one group saw the queue as too short; the other saw that many people never made it into the queue at all.

The second theme concerned fairness. Providers foregrounded clinical need and clinical judgment, treating the bedside assessment of a patient’s condition as the natural and legitimate basis for allocation decisions. Advocates, however, explicitly incorporated structural vulnerability and unequal access into their conception of fair allocation. From their vantage point, a distribution system that sorts patients purely by clinical criteria at the hospital door systematically disadvantages those whose life circumstances—poverty, disability, housing instability, social stigma—have already degraded their health and their ability to navigate the healthcare system. Fairness, in this view, cannot begin at triage; it must begin upstream, where the conditions that produce unequal clinical presentations are formed.

The third divergence revolved around the meaning of survival. Providers framed survival largely through the lens of mortality prevention and treatment capacity, a framing consistent with the acute-care orientation of clinical medicine: save the patient in front of you. Advocates broadened the concept to include what the researchers call social survival—the continuity of care for chronic conditions, the preservation of livelihoods, and the maintenance of everyday support networks. A pandemic response that maximizes COVID-19 survival rates while interrupting dialysis, cutting off income support, or severing community care arrangements may, by this broader metric, produce net harm. The finding suggests that the classic triage calculus, focused on immediate biological outcomes, captures only part of what stakeholders consider at stake in a public health emergency.

The fourth theme offers a rare point of convergence. Both groups agreed that ethical principles and institutional preparedness must be established before the next crisis arrives, not improvised under duress. Advocates went further, calling for standing participatory bodies that would include patients, civil society organizations, and healthcare professionals in ongoing governance of emergency preparedness. The idea is that legitimacy in resource allocation cannot be conferred solely by administrative decree or expert consensus; it requires structures through which affected communities help define the terms of the problem before scarcity forces the question.

Taken together, the four themes describe what the authors characterize as fundamentally different problem definitions rather than mere disagreements about solutions. Pandemic resource allocation, the study concludes, was shaped by differing understandings of what counted as a resource, who qualified as a legitimate subject of allocation, and what outcomes counted as survival. These are not technical disputes resolvable by better data or refined scoring systems. They are conceptual disputes about the boundaries of the moral community that a health system serves, and they persisted even among participants who shared the same national context, the same pandemic, and often the same patients.

The implications extend well beyond South Korea, which was widely praised for its early pandemic containment but, like every country, faced wrenching allocation decisions as the crisis wore on. Most existing scholarship on pandemic ethics has concentrated on triage criteria and distributive principles—maximizing benefits, treating equals equally, prioritizing the worst off—with far less attention to how different social and institutional actors construe the allocation problem itself. This study demonstrates that those construals diverge systematically along professional and social lines. A policymaker who consults only hospital administrators and physicians will hear a coherent account of the problem defined by beds and ventilators. A policymaker who also listens to advocates for marginalized communities will hear about people who died of untreated cancer, who could not isolate because they had no home, or who avoided care for fear of immigration enforcement.

The findings arrive at a moment when many governments are conducting post-pandemic reviews and revising emergency preparedness frameworks. The study’s central message for those efforts is that equity safeguards and participatory governance must be institutionalized in advance of a public health emergency. Under crisis conditions, there is neither time nor political space to negotiate what fairness means; whatever definitions were embedded in plans beforehand will govern. If those plans define resources narrowly as clinical capacity and patients narrowly as those who present at hospitals, the invisible exclusions documented by advocates will reproduce themselves automatically.

Methodologically, the study also illustrates the value of pairing individual interviews with focus groups and of using policy vignettes to ground abstract ethical discussion in concrete, historically real decisions. The vignette approach meant that participants were not reasoning about hypothetical dilemmas but reacting to policies their own society had enacted, which strengthens the ecological validity of the themes. The reflexive thematic analysis, by treating researcher positionality as integral to interpretation, aligns with contemporary qualitative standards and guards against the false objectivism that has sometimes plagued disaster ethics research.

The research was supported by the Korea Infectious Disease Overcoming Support Project, grant number 20250029, and the authors declare no competing interests. Published as open access under a Creative Commons Attribution 4.0 license, the article was released initially as a citable, peer-reviewed accepted version with a permanent DOI, subject to final editorial production.

What lingers after reading the study is a challenge to the conventional framing of pandemic preparedness, which typically emphasizes stockpiles, surge capacity, and predictive modeling. These are necessary, the findings imply, but insufficient. A system can be stocked to the ceiling and still fail its most vulnerable members if its definition of a resource excludes transport to care, if its definition of a patient excludes the unhoused, and if its definition of survival excludes the social fabric that keeps people alive between medical encounters. The next pandemic will test not only how much equipment a society has accumulated but how broadly it has drawn the circle of who counts. This study offers policymakers a map of where the circle’s edges currently lie—and a warning that they will not move on their own.