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The COVID-19 pandemic has highlighted the vulnerability of countries worldwide and their abilities to cope with the fast-paced demands of the research and medical community. A key to promoting ethical decision-making frameworks is by calibrating the sustainability at regional, national, and global levels to incorporate coordinated reforms. We performed a sustained ethical analysis and critically reviewed evidence addressing country-level responses to practices during the COVID-19 pandemic using PubMed (MEDLINE), Scopus, and CINAHL. The World Health Organization’s ethical framework proposed for the entire population during the pandemic was applied to thematically delineate findings under equality, best outcomes (utility), prioritizing the worst off, and prioritizing those tasked with helping others. The findings demarcate ethical concerns about the validity of drug and vaccine trials in developing and developed countries, hints of unjust healthcare organizational policies, lack of equal allocation of pertinent resources, miscalculated allocation of resources to essential workers and stratified populations. doi: https://doi.org/10.12669/pjms.38.4.4755 How to cite this:Sarfraz A, Sarfraz Z, Ashraf M, Ashraf H. Sustained ethical analysis of global dilemmas and country-level decision making during and post the COVID-19 pandemic: A systematic review. Pak J Med Sci. 2022;38(4):---------.  doi: https://doi.org/10.12669/pjms.38.4.4755 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.