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Abstract

Triage is the selection of some people in need of care from a larger group of needy people. This entry focuses on mass casualty circumstances (war and civilian disasters) in which a healthcare team with limited resources must choose who should become a patient and who remains outside its reach of care.

The fundamental values of military triage, international humanitarian law, and humanitarianism values are equality and priority to “medical urgency.” However, the circumstances, resources, type of care team, and other factors might bear on the planning and execution of triage.

Whereas maximization of life saved, health promoted, and suffering reduced is the ultimate goal of healthcare, especially in disaster settings, only utilitarians are committed only to these goals alone.

Most authors behold mass emergencies as justiﬁcation for increased utilitarian considerations (but not necessarily purely utilitarian ethics). However, lack of scientiﬁc evidence undermines the validity of many utilitarian schemes of triage schemes. This obscurity is a risk factor for all sorts of bias. Hence, much of the ethics of triage depend on formal, rather than substantial, factors. This means that emphasis is given to structures and style of reasoning, execution, and revision.

Introduction

Triage is a method of setting priorities for the selection of patients for treatment, from a larger group of needy people. When people talk about triage, they usually refer to basic, lifesaving treatments when the resources available are meager relative to the number of needy people. Triage is inevitable only because resources are too scarce. However, one may also ﬁnd the word triage in broader contexts of distributive justice in healthcare.

The contemporary medical literature on disaster medicine deﬁnes triage as the process of categorizing patients according to the severity of their injuries or illness and prioritizing treatment according to the availability of resources and patients’ chances of survival and recovery. There is no one embraced method of triage; several are in use internationally, most of which specify between two and ﬁve categories of injury.

The most critical decision of triage is whether a needy person becomes a patient (and whether a patient is dismissed for the sake of another needy person). This entry addresses triage from an ethics perspective, focusing mainly on the question of patient selection in a situation of dire scarcity, when many need care but the resources can serve only a few.

History And Development

Until the Napoleonic wars, care for the wounded of the battleﬁeld was quite random, with explicit preference to nobility and ofﬁcers. Dominique Jean Larrey, who was the chief surgeon of Napoleon’s Imperial Guard, labored on rationalization and humanization of medical care in the battleﬁeld. Even though he might have not used the word “triage” (derived from the French trier – to sort out), his methodology embodies the ﬁrst known system of triage. Within Larrey’s descriptions, we ﬁnd three principles: the ﬁrst is that medical care be given according to systematic and rational standards; the second is that these standards be based on medical urgency, entirely without regard to rank or distinction; and the third is that efforts be made to avoid bias.

In the face of obvious scarcity, he advocated rationalized triage based on medical urgency as instrumental to saving as many lives as possible. In addition to this utilitarian consideration, Larrey observed that a rational and fair triage boosts the morale of the soldiers. He practiced humane treatment of prisoners of war and enemy civilians, but he did not grant the wounded of the enemy equal standing in his triage scheme. Even though the concept and theory of triage was born within military medicine, today military triage is a special subcategory of triage.

Since Larrey did not explicate fully the urgency-based priority, this criterion may be interpreted in diverse manners. One way of implementing the urgency-only criterion is to go for the most urgent cases (i.e., those whose lives are most immediately at peril in the sense that only immediate intervention is likely to save them). A rule-utilitarian justiﬁcation may assert that this is the most efﬁcient “rule of thumb” (heuristics). However, contemporary conceptions of triage are a little more complex. Kenneth Iserson asserts, “A critical and treatable patient should not be given priority for treatment if the time required to provide that treatment would prevent treatment for other patients with critical but less complicated injuries” (Iserson and Moskop 2007, p. 278). The World Medical Association’s Statement on Medical Ethics in the Event of Disasters adopted this approach (WMA 2006). Although the WMA’s statements condemn physicians who persist with attempts to save hopeless patients “at all costs,” there is no similar statement regarding a conscientious and effective persistence in saving the few, even one patient, at the expense of resources that may save many.

Because determination of urgency could be a very complicate task, and triage ofﬁcers in disaster settings are usually healthcare professionals with little training and experience in emergency medicine, let alone in mass casualty settings, there is a growing trend to simplify triage guidelines. Additionally, nuanced and elaborate ethical and medical principles are likely to add emotional burden on caregivers and risk of bias in decision-making. Therefore, from the very beginning, schemes of triage have contained three key elements: the context of commitment, the medical criteria, and fairness.

In the era of evidence-based medicine, triage schemes are also evaluated by a fourth element, which is the search of statistical support, in the form of their inter-rater reliability, ease of use, and similar indexes.

Conceptual Clarifications

The most fundamental distinction is between conventional and nonconventional triage. During conventional triage, medical supplies are ample and medical personnel can successfully treat all of the wounded (Gross 2006, p. 145). Hence, the triage process is about timing, convenience, and the allocation of low-risk burdens. Those who are not selected by triage will have to wait, without suffering anything beyond the minor inconvenience and a modicum of risk associated with the delay. For example, when a patient with myocardial infarction and one with high fever enter simultaneously the emergency department, the team will triage the one with immediate life-threatening condition, infarction, knowing that a delay of an hour or two in the care for fever is rarely dangerous. It might have been better if the system was able to care for both patients at the same time, without letting a febrile and distressed person to wait out. However, it is quite possible that the large reserves needed in order to avoid conventional triage are overall wasteful. Ordinary triage is part of good and efﬁcient healthcare services. At least in public care settings, every patient seeking a medical service must pass through a sieve of conventional triage that determines eligibility and place on queue.

When healthcare services are inadequate (e.g., shortage of ICU beds), and in situations of mass casualty disasters (which overwhelms even adequate healthcare services), it is impossible to provide satisfactory care for every needy person. Some will have to wait more than is medically acceptable. Triage will not be a question of timing, convenience, and minor risk but of access to basic and lifesaving care. Those left out by triage will not receive basic, lifesaving healthcare that they need. These are situations of nonconventional triage.

In the time of Larrey, the context of commitment was military medicine, in which equality of all citizens and preservation of morale were valued. International law prohibits discrimination (“adverse distinction”) that is based on considerations other than medical need (ICRC 2006). However, this general prohibition against adverse discrimination raises a few issues. For example, some military triage schemes grant the highest priority to wounded soldiers who are likely to return to combat duties (e.g., US army and NATO). This approach places military efﬁciency over healthcare utility, thus rendering wartime triage different from other triage settings. Moreover, it would be quite unreasonable to argue, on the basis of nondiscrimination, that wounded soldiers of the enemy who might be restored to combat capacity should be given priority. Indeed, the prohibition against adverse discrimination in the context of war seems relevant to denial of treatment motivated by unequal levels of respect and care, not owing to other especially practical and victory-oriented considerations. Rather, in the face of shortages of slots of care, it may be moral to select for treatment one’s own soldiers before the enemies wounded are offered care. However, preference of low-risk and mildly wounded soldiers at the expense of lifesaving care of enemy soldiers seems unacceptable.

Disaster medicine is the other major context for triage. This may be divided into two categories. The ﬁrst is care offered by the local healthcare services as an extension of society’s legal, moral, and political responsibilities for its territory and people. The second is care offered by humanitarian missions operating as temporary guests of good will in disaster-afﬂicted areas. Some such expeditions are military units dispatched by friendly states; others represent NGOs. Hence, military medical ethics might bear on peacetime disaster medicine.

Some contexts contain more layers of sophistication. For example, in epidemics, many patients are also potential threats. Patients afﬂicted by contagious diseases may be triaged according to considerations of public health, rather than merely by the individual clinical criteria of medical urgency.

Although equal treatment is the hallmark value of disaster medicine, there is a debate whether preference should be given to pivotal persons, mainly healthcare providers and community leaders, whose survival is key to the recovery of society. This might be another justiﬁcation for deviation from strict adherence to the principle of urgency. A prominent factor allowing such deviations is the fact that in the contexts of nonconventional triage, there is a paucity of scientiﬁc knowledge that can support clear application of the principle of urgency. Moreover, especially in disaster settings, the more extreme is the gap between needs and the available resources, the lower is the level of conﬁdence in professional judgment. This is of special concern in the face of shortage in the most crucial resource. This resource is professionals’ mental capacity for making reasoned and multiple hard decisions under the physically and emotionally stressful and inadequate conditions of many triage settings.

In the psychological literature, this is the “bandwidth” available in one’s mind for coping with a task. Overall, in nonconventional triage, the prime value of “medical urgency” is always beset by “epistemic vagueness” regarding the precise application of this value to concrete cases.

Hence, even utilitarians who advocate efﬁcient optimization of beneﬁt in wellbeing as the only ultimate value may concede that in nonconventional triage, epistemic vagueness erodes the commitment to medical efﬁciency. It is easier to tell the number of patients receiving basic care (e.g., painkillers, comfort, water) than to come up with reliable calculations of beneﬁts and harms of compromised medical care (e.g., the value of short-term mechanical ventilation in a ﬁeld hospital). Usually, the more sophisticated are the medical means, the scarcer they tend to be in circumstances of nonconventional triage, and the less reliable the professional predictions become regarding its ultimate impact on healthcare.

Ethical Dimensions: The Planning Of Triage

Triage is a process comprised of four major phases, on the basis of which planners devise schemes of triage, which are the guidelines for actual practice.

It is possible to delineate four major phases of triage. The ﬁrst occurs when the rescue and healthcare services receive information about a crisis and have to decide which kind of relief effort to send. This could be an ambulance, a helicopter, or even an airborne hospital. The second phase occurs at the meeting point between victims who wish to become patients and healthcare professionals. The caregivers conduct a very brief assessment of every person encountered. Only simple and obviously lifesaving interventions are carried out at this stage (i.e., airway clearance, stoppage of massive bleeding by means of artery blockade), while the dead, the dying, and the trivially injured are set aside. In the third phase, the team sets priorities of care based on the fast clinical evaluation of all the rest. Overall, triage on site is executed with regard to the following key decisions: assessment, basic resuscitation, prioritization of medical care, and referral for advanced level of care. The fourth possible phase of triage is “reverse triage,” in which patients who had been accepted in an early triage process are reevaluated in order to decide whether care continues or not. In reverse triage, patients are discharged earlier than they would have been under ordinary conditions.

A triage system need not be an “all or nothing” approach. It may be argued that the healthcare team is committed to a certain, rather minimal, level of care, such as morphine and comfort, to all patients, including those whose triage leaves outside the scope of proper medical care, such as the dying. One may argue that the fundamental value of human dignity posits basic humane care to everybody in par with the value of saving as many lives as possible. It may be also argued that a system that is only efﬁcient (e.g., optimizes the number of lives saved) is less morally desirable than a system that grants a minimum level of care to everybody (or as many as possible) at the price of lower efﬁciency.

For the four phases of triage, it is possible to propose triage schemes according to the exigency and level of epistemic conﬁdence in medical judgment.

Triage begins with the planning of care. Some emergency expeditions bring with them mechanical ventilators; some do not. Some carry equipment for obstetric and neonatal care; some do not. We may refer to such choices as “macro-triage” as they facilitate and preempt clinical triage. If there is no equipment for neonatal care, neonates will not be triaged.

Policies of care bear on availability of resources and the menu of interventions that are considered “treatments.” For example, in order to accommodate more needy patients, instead of keeping patients with chest tubes under observation in the hospital, the team may discharge these people with instructions to come back for follow-up in a few days. A policy of compromised, short-term, inpatient care for chest wound injuries will give this kind of care a high priority relative to others. A policy of uncompromised care of chest wound injuries will reduce the number of patients overall and, consequently, may reduce the slots allotted to chest wound cases. Such policies combine “need” in terms of urgency and the impact of his or her care on the resources remaining for other needy patients.

Triage is a system of gatekeeping. Once a needy person is selected by triage, he or she becomes a “patient” like any other, receiving the best available clinical care. Even if the patient does not get better, the team keeps struggling for his or her life and health as long as the patient has reasonable chances. However, some scholars have proposed schemes of midcourse triage (“repeat triage,” “reverse triage”), arguing that it is unjust to spend plenty of resources on patients whose conditions have deteriorated, while others who need much less resources and have better prognoses are not selected for treatment due to shortage of beds (Eyal and Firth 2012). Hence, the argument goes, a turn to the worse in terms of either prognosis or consumption of resources justiﬁes withdrawal of care in order to accommodate other needy persons waiting outside without care. Whereas such policy is justiﬁable by a utilitarian mode of reasoning, it is not easy for healthcare professionals to stomach. This is because aversion to patient abandonment is deeply rooted in clinical ethics, especially when done in the beneﬁt of someone else. Additionally, because the team’s familiarity with the patient already under care is much better than its capacity to assess the condition of a new one, an overwhelming prognostic imbalance might be necessary to render “reverse triage/repeat triage” justiﬁable. Ethicists also debate whether “repeat triage” is tantamount to action, while rejection during the initial triage is akin to inaction.

In clinical ethics, we may ﬁnd arguments against “reverse triage” and against reduced levels of care for the sake of accommodating more needy people. In the tradition of “good samaritanism,” there is a strong moral calling to help the needy; there is no similar calling to interrupt essential care for one needy person for the sake of another one. Hence, especially when their hands are overwhelmingly busy with caregiving, medical ethics does not expect providers to undertake additional responsibilities. Healthcare professionals have completely different kinds of duties to needy non-patients on the one hand and patients on the other hand. From the perspective of clinical ethics, triage is a means to differentiate needy victims that are non-patients from patients, not a factor that degrades quality of care and loyalty to patients. The ethical tension experienced by professionals in situations where nonconventional triage applies is the dual role that they embody. On the one hand, they have to face the difﬁcult situation of caring for patients with little resources. Yet, on the other hand, it is even more excruciating to have to decide in the ﬁrst place who will be their patients and who, in turn, will be “left out.”

Paradoxically, the more limited the resources, the more justiﬁed is the clinical approach. This is so because with very limited resources, the compromised standards of care fall far beyond the range of epistemic certainty, which is the foundation of the utilitarian approach. Suppose a standard course of antibiotics takes 10 days. It might make sense to shorten it by 2 days for the sake of treating a few more patients; it makes little sense to shorten it to 2 days in order to treat many more patients. A 2 instead of a 10-day course is more likely to be no treatment at all. Theoretically, it might be possible that 2 days of treatment might work overall (i.e., mortality rates among all treated people are lower relative to the morality rate among the same people, only some of whom receive 7-day or 10-day courses). However, the epistemic certainty behind the 2-day course is much lower than that behind the 7-day course. Disaster settings compel many and diverse deviations from ordinary practice. Some are matters of omission (e.g., shorter antibiotic courses); some are matters of makeshift solutions (e.g., using a screw made for one kind of orthopedic procedure in another). Taken separately, many of these deviations are reasonable, even innovatively smart. Nonetheless, simultaneous adaptation of too many creative and partial solutions might push care beyond the boundaries of defensible practice. Too many compromises might create an illusion of care for the many. Because follow-up on patients is almost impossible in such settings, nobody might become aware of the grim outcome. In such a way, overt adherence to utilitarian principles might be self-defeating.

Consequently, if a certain kind of injury merits a week of intravenous antibiotics, but resources allow only 5 days, there are good reasons to suppose that treatment might work almost as well. But, if resources are so scarce as to allow 1 day of intravenous antibiotics, one may argue that it is better to admit less patients and offer a reasonable level of care to the few selected.

In ordinary care settings, guidelines and modes of operation streamline numerous decisions, almost automatically. Mass casualty emergencies challenge established roles. Good and applicable guidelines help cope with many difﬁcult decisions (e.g., there is no need to deliberate each time the length of antibiotic course). Clariﬁcation of roles and especially role boundaries in disaster settings is a key target for every team operating in extraordinary circumstances. Familiarity and identiﬁcation with one’s professional role may not overlap one’s role in a particular disaster setting, in which, for example, performance of triage, bandaging patients, and cleaning may be the roles allocated to particular persons.

The kind of team and the circumstances of triage seem to bear on triage policy and practice. Even though one or two caregivers are active at the triage point, triage is a team’s task. Usually, team members rotate the triage duty. For the sake of equal treatment, the team needs uniform criteria for triage as not to allow triage decisions to vary signiﬁcantly from one shift to another. Such a hapless practice may invite patients rejected at one point to try their luck again later on, thus adding burden on an already overstretched healthcare service. Moreover, since negative triage decisions weigh heavily on the triage ofﬁcer’s heart, it would be unfair collegially and quite frustrating if one triage ofﬁcer acts opposite to another. The team has a collective duty to demarcate its triage policy and to create ad hoc and post-factum revision processes. It would help team members tremendously to know that they all share the responsibilities of tough decision-making.

Some teams arrive with the mission of humanitarian relief; others target speciﬁc conditions, such as orthopedic injuries. An NGO operating in a disaster-stricken and remote country is primarily committed to the humanitarian values of neutrality, impartiality, and independence, whereas a military team deployed in its own country has a primary commitment to the country’s own citizens and the operational structure of the army.

The US army deployed in Iraq and Afghanistan operates three separate tracts of care: one for American troops, one for local allies, and one for enemy soldiers. Whereas US soldiers may be ﬂown for high-level care in Germany, the care of locals terminates in local hospitals. In defense of this triage scheme, one may argue that everybody receives good medical care and that the participating governments and soldiers have agreed in advance to the arrangement. The debate over this practice brings into relief the potential relevance of context in the ethics of triage. One may also try to differentiate among military triage, humanitarian triage (i.e., voluntary disaster relief), and triage by local and overwhelmed services.

Whereas the tensions between “utilitarian” and “clinical” schemes of triage are unresolved, agreement has been consolidating with regard to some fundamental features of triage schemes:

The caring team must ﬁrst survey local needs and resources.
The caring team should plan its triage policy in advance and in accordance with the results of the survey and the team’s mission and resources.
There is a growing awareness of a need of revision processes, including ad hoc ethics committees and clinical consultations with overseas experts (when satellite or other modes of communication are available). These processes reﬂect awareness of the enormity and complexity of moral and clinical dilemmas in circumstances that require nonconventional triage. They help team members live peacefully with difﬁcult decisions and help them examine the probity of their ad hoc policies and style of practice.

Ethical Dimensions: The Execution Of Triage

Bias is deﬁned as inﬂuence of irrelevant factors. Adverse discrimination is bias that is driven by hostile, negligent, or disrespectful attitude to the patients (i.e., victims). Fairness is deﬁned as the absence of bias. Larrey identiﬁed rank as one kind of bias, but the natural tendency to rush to those who scream and writhe at the expense of the unconscious and weak may be another kind of bias. We now know that in military and trauma medicine, the ﬁrst hour after injury is critical for saving the lives of those at risk; almost all those who survive the ﬁrst day survive their injury. Hence, the supreme importance of timely detection of people whose lives are at peril is evident. Bias and inefﬁcient triage may cost many human lives.

The presence of bias renders any action unjust. Bias undermines trust and legitimacy as well. Bias may operate unconsciously or even as a manifestation of good will. A doctor may be unaware of his or her tendency to react more strongly to burn victims than to other kinds of injuries. He or she may wrongly assume that women tolerate suffering “better” than men do. The more taxing is the circumstances and difﬁcult is the decision, the higher the risk of bias. Hence, the most efﬁcient way to avoid bias is to transfer decisions from human judgment to nonhuman factors. Lottery is a paradigmatic example of an unbiased system. Lottery is always fair. Triage by lottery is also fair, but it may be unjust or unwise overall. Absence of bias is a necessary condition to justice. Often, it is not sufﬁcient. Many caregivers and victims would loath the notion that people’s lives are determined by sheer luck. However, especially when decisions are very difﬁcult, controversial, and complicated, lottery might be the only just way out. Put in other words, when no other justice-relevant considerations prevail, one may fall back on fairness (pure procedural justice).

Some systems of selection that appear random and consequently unbiased may actually not be so. A queue is a case in point. The one who suffers symptoms ﬁrst is the ﬁrst to receive care. Once the doctors conclude that two cases are very similar in terms of urgency, they are justiﬁed in caring for the one arriving ﬁrst. After all, the order of events is nobody’s choice. Nonetheless, it might also be possible that the order of arrival reﬂects in reverse patients’ vulnerability, for example, mothers carrying their infants will arrive after a young man who sustained identical injuries at the same moment.

Vulnerable patients also defy pure utilitarian schemes of triage. Provision of lifesaving care to a baby may not ultimately save his or her life unless there is somebody to care for this baby in the end. Even though a strict utilitarian perspective may justify any scheme that brings forth more life years and quality of life overall, there are strong contractarian and human dignity considerations in favor of triage schemes that are less utilitarian but more accommodating of diverse kinds of people and needs. It follows that in light of the team’s overall mission, resources available, and actual need, the team may decide to allocate a speciﬁc number of beds to a vulnerable group of patients (e.g., babies) and conduct triage relative to this allocation. If the team dedicates three “beds” to children, only children arriving at the triage point will be eligible to have them or the needy children will have priority access to these beds even over adult patients. This strategy of distributive justice is known as “intra-area efﬁciency.” The team members should bear in mind that any nonutilitarian choice entails acceptance of helping less than it is possible.

Such acceptance may give way to considerations of “symbolic triage” (Barilan et al. 2014). Veterans of humanitarian missions often testify to events in which much pressure was applied in order to persuade the triage ofﬁcer to admit persons in the name of nonmedical considerations. A victim might be “the only survivor among seven siblings,” “a girl who miraculously survived a week under rubble,” “an old woman who got injured while heroically saving many others,” “a man who is the sole breadwinner of a huge family,” and the like. Opening up triage considerations to such nonmedical factors ﬂies in the face of the fundamental principles of medical triage. On the other hand, it is almost impossible to ﬁnd an actual triage point, which has never bent toward symbolic considerations. Hence, allocating a percentage of slots (e.g., one in ﬁfty) to extraordinary humane or symbolic considerations and the judgment of more than one triage ofﬁcer (if possible) in the application of this vague criterion may offer a satisfactory solution.

The successful execution of triage schemes hinges on a balance between the policy and the revision process. Especially when decision-making is complex and carried out under stress and pressure, there is an increased risk of unconscious bias and of rationalization of bias. A great merit of formal policies is their relative immunity to individual bias. Adherence to preset guidelines eases the mental load of deliberating difﬁcult choices on a case-by-case basis, and it also reduces the chances of bias. However, very strict adherence to an a priori set of guidelines is associated with lack of ﬂexibility and adaptation to the actual situation at hand. A third, balanced approach would be to include structures for deliberation and revision within the operative guidelines. Post-event debrieﬁng may help healthcare professionals cope with the stress, even trauma and guilt feelings they experience over tough decisions, while improving guidelines for future events. It is also a token of respect for human dignity to have fateful decision such as triage being scrutinized and revisited, rather than being merely executed in a conveyer belt manner. In sum, streamlining by means of simple and clear guidelines and efﬁcient teamwork saves a lot on scarce mental resources (e.g., attention, concentration) and safeguards against bias. Modules of reﬂection and revision improve the whole process and allow respect for persons, even in very tragic and busy circumstances.

Conclusion

Conceptually, triage schemes are either “utilitarian” or “nonutilitarian.” The “utilitarian” will always be committed to the maximization of life saved or the maximization of some other “hard” health indexes (e.g., QALY). The “nonutilitarian” rejects this absolute commitment. While celebrating optimization of outcome at the heart of disaster and military medicine, the nonutilitarian incorporates additional moral considerations. The chief utilitarian argument is that any deviation from utility entails a higher rate of death, morbidity, and suffering. However, especially in the extraordinary circumstances of nonconventional triage, the epistemic (scientiﬁc) support to any utilitarian scheme is rather weak. It follows that the power of utilitarian thinking in military and disaster medicine is a function of epistemic clarity than a matter of moral reasoning and principles.

Good triage schemes strive to reduce to the minimum any tension between utilitarian and other moral considerations. In such schemes, most of the time, utilitarian considerations overlap with the nonutilitarian alternatives.

The ubiquity of the risk of bias and the tentative nature of many decisions in military and disaster medicine prevail upon the team to construct a priori guidelines, a culture and method of deliberation, and processes of evaluation and revision. These are the formal elements necessary for a good triage scheme.

Because nonconventional triage involves heart-wrenching dilemmas, much attention is given to the formal rather than substantial considerations. This means that in the face of inability to choose the seemingly “right” choice, the team relies on appropriately chosen and decently conducted modes of choice. The ethics of triage seem to hinge on the “how” much more on the “what” on the morality of the procedure and the virtues of the responsible people, rather than on the content of each and every decision.

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