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Triage is the medical assessment of patients to establish their priority for treatment. When medical resources are limited and immediate treatment of all patients is impossible, patients are sorted in order to use the resources most effectively. The process of triage was first developed and refined in military medicine, and later extended to disaster and emergency medicine.
In recent years, it has become common to use the term triage in a wide variety of contexts where decisions are made about allocating scarce medical resources. However, triage should not be confused with more general expressions such as allocation or rationing (Childress). Triage is a process of screening patients on the basis of their immediate medical needs and the likelihood of medical success in treating those needs. Unlike the everyday practice of allocating medical resources, triage usually takes place in urgent circumstances, requiring quick decisions about the critical care of a pool of patients. Generally, these decisions are controlled by a mixture of utilitarian and egalitarian considerations.
History of Triage
Baron Dominique Jean Larrey, Napoleon’s chief medical officer, is credited with organizing the first deliberate plan for classifying military casualties (Hinds, 1975). Larrey was proud of his success in treating battle casualties despite severe scarcity of medical resources. He insisted that those who were most seriously wounded be treated first, regardless of rank (Larrey). Although there is no record of Larrey’s using the term triage, his plan for sorting casualties significantly influenced later military medicine.
The practice of systematically sorting battle casualties first became common during World War I. It was also at this time that the term triage entered British and U.S. military medicine from the French (Lynch, Ford, and Weed). Originally, triage (from the French verb trier, “to sort”) referred to the process of sorting agricultural products such as wool and coffee. In military medicine, triage was first used both for the process of prioritizing casualty treatment and for the place where such screening occurred. At the poste de triage (casualty clearing station), casualties were assessed for the severity of their wounds and the need for rapid evacuation to hospitals in the rear. The emphasis was on determining need for immediate treatment and the feasibility of transport.
The following triage categories have become standard, even though terminology may vary:
- Minimal. Those whose injuries are slight and require little or no professional care.
- Immediate. Those whose injuries, such as airway obstruction or hemorrhaging, require immediate medical treatment for survival.
- Delayed. Those whose injuries, such as burns or closed fractures of bones, require significant professional attention that can be delayed for some period of time without significant increase in the likelihood of death or disability.
- Expectant. Those whose injuries are so extensive that there is little or no hope of survival, given the available medical resources.
First priority is given to those in the immediate group. Next, as time and resources permit, care is given to the delayed group. Little, beyond minimal efforts to provide comfort care, is given to those in the expectant category. Active euthanasia for expectant casualties has been considered but is almost never mentioned in triage proposals (British Medical Association, 1988). Those in the minimal group are sent to more distant treatment facilities or left to take care of themselves until all other medical needs are met.
From the beginning, the expressed reasons for such sorting were a blend of utilitarian and egalitarian considerations. Larrey stressed equality of care for casualties sorted into the same categories. On the other hand, one early text on military medicine advised, “The greatest good of the greatest number must be the rule” (Keen, p. 13). Over the years, it also became clear that the utilitarian principle could be interpreted in different ways. The most obvious meaning was that of limited medical utility: The good to be sought was saving the greatest number of casualties’ lives.
But the principle could also be construed to mean doing the greatest good for the military effort. When interpreted this way, triage could produce very different priorities. For example, it was sometimes proposed that priority be given to the least injured in order to return them quickly to battle (Lee). An oft-cited example of the second use of the utilitarian principle for triage occurred during World War II (Beecher). Commanders of U.S. forces in North Africa had to decide how to use their extremely limited supply of penicillin. The choice was between battle casualties with infected wounds and soldiers with gonorrhea. The decision was made to give priority to those with venereal disease, on the grounds that they could most quickly be returned to battle preparedness. A similar decision was made in Great Britain to favor members of bomber crews who had contracted venereal disease, because they were deemed most valuable to the continuation of the war effort (Hinds, 1975).
As military triage has evolved during the twentieth century, the goal of maintaining fighting strength has increasingly become the dominant, stated goal. In the words of surgeons Gilbert W. Beebe and Michael E. DeBakey, “Traditionally, the military value of surgery lies in the salvage of battle casualties. This is not merely a matter of saving life; it is primarily one of returning the wounded to duty, and the earlier the better” (p. 216).
The nuclear weapons used at the end of World War II introduced unprecedented destructive power. In the nuclear age, triage plans have had to include the possibility of overwhelming numbers of hopelessly injured civilians. In earlier days, it was not uncommon to plan for 1,000 or 2,000 casualties from a single battle. Now, triage planners must consider the likelihood that a single nuclear weapon could produce a hundred times as many casualties or more. At the same time a single blast could destroy much of a community’s medical capacity. Such probabilities have led some analysts to wonder if triage would be a realistic expectation following a nuclear attack (British Medical Association, 1983).
Triage has moved from military into civilian medicine in two prominent areas: the care of disaster victims and the operation of hospital emergency departments. In both areas, the categories and many of the strategies of military medicine have been adopted.
The necessity of triage in hospital emergency departments is due, in part, to the fact that a number of patients needing immediate emergency care may arrive almost simultaneously and temporarily overwhelm the hospital’s emergency resources (Kipnis). More often, however, the need for triage in hospital emergency departments stems from the fact that the majority of patients are waiting for routine care and do not have emergent conditions. Thus, screening patients to determine which ones need immediate treatment has become increasingly important. Emergency-department triage is often conducted by specially-educated nurses using elaborate methods of scoring for severity of injury or illness (Purnell; Wiebe and Rosen; Grossman).
Ethical Issues in Triage
The traditional ethic of medicine obligates healthcare professionals to protect the interests of patients as individuals and to treat people equally on the basis of their medical needs. These same commitments to fidelity and equality have, at times, been prescribed for the treatment of war casualties. For example, the Geneva Conventions call for medical treatment of all casualties of war strictly on the basis of medical criteria, without regard for any other considerations (International Committee of the Red Cross; Baker and Strosberg). However, this principle of equal treatment based solely on medical needs and the likelihood of medical success has competed with utilitarian considerations in military medicine. In such triage, healthcare professionals have sometimes thought of patients as aggregates and given priority to goals such as preserving military strength; loyalty to the individual patient has, at times, been set aside in order to accomplish the most good or prevent the most harm. The good that might have been accomplished for one has been weighed against what the same amount of effort and resources could do for others. The tension between keeping faith with the individual patient and the utilitarian goal of seeking the greatest good for the greatest number is the primary ethical issue arising from triage.
Triage generates a number of additional ethical questions. To what extent are the utilitarian goals of military or disaster triage appropriate in the more common circumstances of allocating everyday medical care, such as beds in an intensive care unit? If some casualties of war or disaster are categorized as hopeless, what care, if any, should they be accorded? Should their care include active euthanasia? Should healthcare professionals join in the triage planning for nuclear war if they are morally opposed to the policies that include the possibility of such war (Leaning, 1988)? What new issues arise for triage in a time of global terrorism (Kipnis)?
Triage is a permanent feature of contemporary medical care in military, disaster, and emergency settings. As medical research continues to produce new and costly therapies, it will continue to be tempting to import the widely accepted principles of triage for decisions about who gets what care. Indeed, whenever conditions of scarcity necessitate difficult decisions about the distribution of burdens and benefits, the language and tenets of medical triage may present an apparently attractive model. This is true for issues as far from medical care as world hunger and population control (Hardin; Hinds, 1976). The moral wisdom of appropriating the lessons of medical triage for such diverse social problems is doubtful and should be carefully questioned. Otherwise, utilitarian considerations often associated with triage may dominate issues better addressed in terms of loyalty, personal autonomy, or distributive justice (Baker and Strosberg).
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