Resuscitation needs justice: an intersectional view on justice, equity, diversity, and inclusion

Abstract

Disparities in cardiac arrest survival persist across gender, race, age, disability, socioeconomic status, and geographical location in part due to unequal access to life-saving interventions such as bystander cardiopulmonary resuscitation (CPR) and early defibrillation. Inequities in access to training, equipment, and local implementation may reinforce these disparities across the chain of survival. Current diversity, equity and inclusion (DEI) approaches to disparities in resuscitation research often examine inequities in isolation, limiting their ability to explain how structural, social, and institutional factors interact to influence outcomes. To address these limitations, this concept paper proposes examining the chain of survival through an intersectional lens, which considers Justice at the forefront of Equity, Diversity, and Inclusion (JEDI). Adding justice as an ethical principle aims to target these broader factors, and when combined with DEI efforts, may lead to a more comprehensive approach on examining inequities in resuscitation. Within the European Resuscitation Council (ERC), this intersectional JEDI lens provides a support for identifying inequities and barriers across both the chain of survival and the formula of survival, including medical science, educational efficiency, and local implementation, so that giving and receiving high-quality resuscitation becomes realistically attainable for everyone.

Introduction

Disparities in cardiac arrest outcomes and access to life-saving interventions, like high-quality bystander cardiopulmonary resuscitation (CPR) and early defibrillation, remain persistent.1, 2, 3, 4, 5 Gender, race, disability, age, language barriers, socioeconomic status, and geographical location continue to influence who receives life-saving interventions.5, 6, 7, 8, 9, 10 Such inequities are not limited to the chain of survival. They can also arise across the formula of survival: medical science, educational efficiency, and local implementation. In science, inequities affect who is represented in research and guidelines.¹¹ In education, they influence access to CPR training, with trained laypersons more likely to perform bystander CPR.4, 12, 13, 14 This reinforces inequities throughout the chain of survival.9, 15 In local implementation, inequities appear through barriers such as unequal access to equipment, training, and financial resources.¹¹ While the chain of survival helps detect inequities in time-critical intervention moments, the formula for survival provides the broader systems perspective needed to address how those inequities in science, education, and local implementation are produced and reproduced. Strategically addressing inequities through these key areas deserves further consideration.

Proposing a concept for the European Resuscitation Council (ERC)

To address these inequities, the European Resuscitation Council Diversity, Equality and Inclusion (DEI) Committee would like to propose a new focus on these disparities by zooming out and examining resuscitation systems, like the chain of survival, through an intersectional lens, which considers Justice at the forefront of equity, diversity, and inclusion – summarised in the acronym “JEDI”.¹⁶ Justice is not treated as a parallel add-on to DEI, but as an ethical principle that improves the applicability of DEI in practice.

Why JEDI and not “just” Diversity, Equity and Inclusion (DEI)?

While DEI efforts remain essential in resuscitation, because cardiac arrests occur globally in diverse populations, JEDI goes further by asking not only who is excluded, underrepresented, or underserved, but also which structural conditions produce and sustain inequities. Focusing on the analysis of these structural conditions and systemic barriers allows recommendations to be made to target root causes of inequities rather than symptoms. From a human rights perspective, life-saving interventions should not depend on gender, race, disability, age, language, socioeconomic position, or geography.17, 18 Justice therefore concerns the fair organisation of systems, institutions, and resources so access to resuscitation training and care becomes realistically attainable for all.15, 19 Applied to resuscitation, this highlights the ethical importance of ensuring equitable access to life-saving interventions regardless of demographic or socioeconomic characteristics by looking beyond isolated policies toward the broader social, educational, and organisational conditions that influence who can give and receive CPR.

The ERC DEI Committee proposes defining JEDI principles as:

• •Justice refers to recognising and addressing the broader social and institutional factors that shape unequal access to care and training, such as segregation, economic deprivation, legal exclusion, or discriminatory policies. In resuscitation, justice requires changing systems, laws, and resource allocation so that giving and receiving high-quality resuscitation becomes realistically attainable for everyone.
• •Equity refers to the fair distribution of resources, opportunities, and support that takes existing disadvantages into account. Applied to resuscitation, equity means tailoring training, equipment, and post-resuscitation care to the physical, cognitive, and linguistic needs of survivors and co-survivors, as well as their environmental contexts. This would include considerations on how equipment is designed, communicated, and placed within communities, rather than assuming that the same intervention will work equally well for everyone and everywhere.
• •Diversity refers to the presence and recognition of people with varied social and professional backgrounds, identities, and lived experiences within resuscitation systems. Within the ERC context, this includes diversity in patients, lay responders, clinicians, educators, researchers, and decision-makers, reflecting the population the organisation serves.
• •Inclusion refers to the degree to which diverse individuals can participate fully, safely, and meaningfully in resuscitation-related activities and decision-making. Inclusive systems create environments where CPR providers, cardiac arrest survivors, and co-survivors are respected, listened to, and involved in shaping education and research.

These four principles rarely exist in isolation, they are interdependent. Applying JEDI effectively requires understanding what their interaction means for an organisation like the ERC. This can be looked at through an intersectional lens.

Why JEDI needs intersectionality

Intersectionality began in social science research examining power and inequality, but is now increasingly used in healthcare science to understand how multiple systems of oppression interact.20, 21 In resuscitation, an intersectional JEDI lens can be an analytical tool to consider how social identities like race, socioeconomic status, age, living with a disability, gender, and language overlap to advantage or disadvantage someone’s chances of surviving cardiac arrest with good neurological outcome.²² To keep a silo view on the different components of JEDI may cause further inequities as the effects of the single components might be underestimated or misinterpreted. Disparities in cardiac arrest outcomes are rarely caused by a single factor and often reinforce each other. Underserved communities may have limited access to CPR training (equity gap), fewer automated external defibrillators (AEDs) in their neighbourhoods due to historic and current patterns of disinvestment (justice gap), greater hesitancy to start CPR because of cultural or linguistic barriers (inclusion gap), and reduced participation in research protocols that influence clinical practice (diversity gap). Considering the interaction of these JEDI dimensions helps to offer a clearer understanding of how inequities in cardiac arrest outcomes are produced and reproduced.22, 23 Applied to resuscitation, the intersectional lens considers the whole system that saves lives, from CPR training and providers to dispatch systems, in-hospital cardiac arrest teams, and long-term post-resuscitation care.24, 25 Using intersectionality as an analytic approach in resuscitation research helps clarify how racism, sexism, socioeconomic disadvantage, and other systems of power interact to influence access to CPR training and cardiac arrest care. Adding this intersectional approach is a strong step to prevent inequities from being treated as isolated differences and reduces the risk of reproducing them through incomplete or fragmented evidence.5, 24

Recognition of disparities in resuscitation

Research reports how cardiac arrest patients’ characteristics and socioeconomic status influence survival.6, 26 Women sustaining cardiac arrest are less likely to receive CPR due to social norms about exposing the bare chest.10, 27, 28 Language barriers between dispatchers and callers, along with AEDs lacking multilingual options, delay proper needed treatment.29, 30 Some communities may mistrust healthcare systems stemming from historically rooted discrimination, unequal access to healthcare, experiences of stigma, and concerns related to migration or legal status, all of which can discourage engagement with emergency services.31, 32 Technology may either worsen or reduce existing inequities, depending on how it is designed and used.33, 34 When technologies rely on biased design choices, assume an implicit standard user, or are unevenly accessible, they may reinforce existing disparities.³⁵ In contrast, technologies that are accessible, multilingual, and adapted to local contexts can support more equitable CPR training, recognition of cardiac arrest, and emergency response.32, 33 Standard manikins are often adult, white, slim, male bodies limiting realism and reinforcing gender bias, whereas diverse manikins reflecting varied ages, body types, and sexes may improve skill transfer and engagement.³⁶ Digital learning often excludes older, neurodiverse, or low-connectivity learners, as inclusive, multilingual, and multimodal learning designs remain rare.⁴ Finally, geography compounds these barriers, as rural, low-income, and low-resource areas face structural obstacles to both CPR training and timely response to cardiac arrest,26, 37 while economic inequity and structural racism further restrict training opportunities.6, 24 These disparities need solutions that move beyond individual discrepancies to examine the systems underlying these outcomes.

ERC’s commitment to inclusion

Many determinants of resuscitation and survival inequities lie beyond the ERC’s direct control, but the ERC can influence how science, education, guideline development, and implementation account for and respond to them. Its mission “to save lives through resuscitation”, together with its activities, shows how these systemic solutions can take form. Integrating an intersectional JEDI lens in resuscitation aligns with the ERC’s goal of making high-quality resuscitation available to all. Through guideline development, collaboration with ERC’s National Resuscitation Councils, and initiatives like Restart a Heart Day, Kids Save Lives, Get Trained Save Lives, Creating Cardiac AWAREness at Work, Patient and Public Involvement and Engagement (PPIE) through Community Partnerships, and the Low-Resource Settings Taskforce, the ERC is already working to reduce barriers and expand CPR education across diverse communities.

To support this work, the ERC created a DEI Committee in 2024 to integrate the described principles into ERC activities and policies.³⁸ DEI principles were integrated for the first time into the ERC Guidelines on Resuscitation 2025.³⁹ The ERC DEI Committee’s next step is to extend this work by applying JEDI more explicitly as a systems standard. To initiate these efforts, a closer examination of the chain of survival through an intersectional lens is needed, to identify where further action is required and to strengthen each link to create a more just, respectful, and inclusive resuscitation system. In a further step, this can be considered across the formula for survival to identify structural inequities and strengthen inclusion in science, education and implementation, in both healthcare and governance.

A call to action

The ERC 2025 chain of survival highlights the time-sensitive interventions needed to improve the survival chances of victims of cardiac arrest.³⁹ Applying an intersectional JEDI lens to its four rings (early recognition and call for help, early CPR and defibrillation, advanced and post-resuscitation care, survival and recovery) enables the identification of factors that impact survival chances and how they may overlap. Fig. 1 illustrates the intersectional integration of the JEDI principles into the chain of survival. Applying these requires ethical and practical reasoning to turn these principles into applicable, context-sensitive, and locally implementable actions, for example:

• 1.Early recognition and call for help: Local training should reflect community languages, cultures, and social norms, which could help address disparities in early response to an emergency and improve communication and trust between Emergency Medical Services (EMS) dispatchers and callers. Providing freely accessible, multilingual educational materials and visual guides for Basic Life Support and First Aid for adults and children may further reduce barriers to recognising cardiac arrest and initiating help.
• 2.Early CPR and defibrillation: The use of teaching materials and manikins in courses should address diverse ages, genders, body types, and relevant disabilities, accounting for the diversity of learners and instructors. Facilitators should ensure that venues are physically accessible (e.g. elevators, ramps, accessible washrooms) to support equitable participation. In areas of low socioeconomic status, free, accessible training materials can facilitate dissemination of this content. Using multilingual AED instruction modes along with pictographs can help reach diverse groups (e.g., locals, tourists). Understanding local geography can help communities guide AED positioning by using equity-based mapping. Equal and unrestricted access to AEDs is only possible if AEDs are placed publicly and unlocked available 24-h and 7-days a week for every member of a community to deliver and to use an AED if needed.
• 3.Advanced and post resuscitation care: Involving family members of cardiac arrest patients in care discussions and providing information in clear, uncomplicated language may improve understanding and support involvement in decision-making about future care, expectations on outcome, or organ donation.
• 4.Survival and recovery: Healthcare systems may consider structural factors such as cost, accommodation, and travel for survivors of cardiac arrest and co-survivors in the rehabilitation phase. Recognising the needs of survivors and co-survivors e.g. through support groups may help create more inclusive long-term programmes, and might improve long-term quality of life after surviving cardiac arrest. Survivor networks incorporating multiple languages can strengthen this community.

Fig. 1.

Integrating justice, equity, diversity and inclusion principles in the chain of survival.

Summary

Cardiac arrest outcomes depend not only on proper and timely clinical response, medical interventions, or patient factors, but they are also influenced by societal and institutional conditions. Persistent outcome disparities would benefit from having justice, equity, diversity and inclusion (JEDI) applied through an intersectional approach on resuscitation to help identify underlying structural inequities across research, education and implementation. This can provide a pathway for the ERC to move beyond recognising these disparities and towards addressing the systems that produce and sustain them. Looking at the chain of survival through this intersectional JEDI lens may be a first step helping to understand persistent survival gaps and inform ways to address them. In a further step this can be considered across the components of the formula for survival, thereby improving survival outcomes. Every person deserves an equitable and inclusive opportunity to benefit from high-quality resuscitation and the chance to survive after cardiac arrest.

Declaration of AI and AI-assisted technologies in the writing process

During the preparation of this work the authors used OpenAI's ChatGPT-4 to improve readability and language. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

CRediT authorship contribution statement

Olfa Chakroun-Walha: Writing – review & editing, Writing – original draft, Supervision, Conceptualization. Eve Kiebooms: Writing – review & editing, Writing – original draft, Supervision, Conceptualization. Sule Ozbilgin: Writing – review & editing, Writing – original draft, Conceptualization. Sanin Bilic: Writing – review & editing, Writing – original draft, Conceptualization. Jacques Delchef: Writing – review & editing, Conceptualization. Cecilie Langkilde Lauesen: Writing – review & editing, Conceptualization. Robert Greif: Writing – review & editing, Writing – original draft, Supervision. Jacqueline Eleonora Ek: Writing – review & editing, Writing – original draft, Supervision, Conceptualization.

Declaration of competing interest

The author is an Editorial Board Member/Editor-in-Chief/Associate Editor/Guest Editor for Resuscitation Plus and was not involved in the editorial review or the decision to publish this article.

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: RG is the ERC Director of Guidelines and ILCOR; the ILCOR’s Task Force chair Education, Implementation and Team (EIT); member of the editorial board of Resuscitation Plus. JEE is the chair and JD is the vice chair of the ERC Diversity, Equality and Inclusion Committee (DEI), OCW, EK, SO, SB, CLL are members. JEE and CLL are also members of the Young ERC.