Historically, the triage of temporarily scarce health resources has served narrow utilitarian ends. The recent H1N1 pandemic experience provided an opportunity for expanding the theoretical foundations/understandings of critical care triage in the context of declared infectious pandemics. This paper briefly explores the ethics-related challenges associated with the development of modern critical care triage protocols and provides descriptions of some ‘enhanced fairness’ features which were developed through the use of an inclusive deliberative engagement process by a Canadian provincial Department of Health.
- Critical care triage
- scarce health resources
- vulnerable populations
- government/criminal justice
- philosophical ethics
- philosophy of the health professions
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- Critical care triage
- scarce health resources
- vulnerable populations
- government/criminal justice
- philosophical ethics
- philosophy of the health professions
In 2009/10, one of the significant challenges facing healthcare providers, health organisations and governments has been the development of triage protocols to guide the allocation of scarce critical care resources during pandemic incidents. The dominant ethics imperative driving existing processes for triaging health resources is a utilitarian version of consequentialism—that is, to distribute resources in order to provide the greatest good for the greatest number.1 In practical terms this means that, in circumstances of dire resource scarcity, individuals with a reasonably good probability of surviving a pandemic incident are privileged in their access to critical care over those with a very low probability of survival. In this paper the challenges associated with critical care triage are explored, including the inherent compromise of widely-valued individually-focused ethics principles. Relevant ethics considerations arising from consideration of a number of theoretical approaches are briefly explored, and some pragmatic ways in which modern triage practices could be constructively enhanced by incorporating elements of justice/fairness are proposed.
A brief history of triage
The first use of triage is attributed to Baron Dominique Jean Larrey, the surgeon general of Napoleon's armies, who developed a system of ‘prompt and methodical succor’ in response to his concern about the unnecessary loss of life caused by the haphazard management of battlefield casualties.2 In the egalitarian-influenced triage system developed by Larrey, field surgeons triaged the injured with the goal of treating the most dangerously wounded first without regard for rank or distinction.
The best known version of triage was introduced in the 18th century by the British military.3 Its development was influenced by two prominent physician hospitalists, John Aitken and Thomas Percival. The goal of British triage is to achieve maximal utility and efficiency in warfare. In this system, treatment priority is given to the health needs of medical personnel who can be returned to active duty and then to the seriously injured who are expected to survive. Those injured or ill for whom no available treatment is expected to be effective in preserving life receive the lowest priority in terms of access to critical care.
Typically, in modern healthcare settings where resources are intermittently limited under normal conditions, efforts are made to restrict admissions to the intensive care unit (ICU) and to accelerate the discharge of less severely ill patients in order to give critical care priority to very sick patients who are expected to benefit the most from such intervention. In this way, current ICU triage practice is closer to the historical French egalitarian version of triage than to the British military model.
Since the wake-up experience with severe acute respiratory syndrome (SARS) in 2002/3, the main focus of preparedness planning for circumstances of temporarily scarce critical care resources such as declared pandemic incidents has been systematic attention to the goals of utilitarianism—that is, putting into place triage protocols and health structures that are expected to produce the greatest benefits for the greatest number. Consistent with a modified British system of triage, the major clinical evaluative tools developed and promoted in the aftermath of SARS have, as their primary goal, the survival of as many people as possible from a pandemic incident.
Challenges and compromises
The allocation of scarce health resources poses significant challenges for decision makers. This is because there is no shared conception of justice for determining what health resources a person has a just claim to, and there is no existing social consensus regarding which ethics principles and values should inform health resource allocation.
Norman Daniels, in describing ‘the aggregation problem’, calls attention to one of the fundamental challenges to decision making about health resource allocation—that is, ‘when should we allow an aggregation of modest benefits to larger numbers of people to outweigh more significant benefits to fewer people?’4 There is no obvious ‘right’ answer to this question. Two polarised approaches are typically proposed and advocated—that is, provide ‘fair chances’ of deriving some health benefit(s) to ‘worst off’ individuals or give priority to whatever healthcare treatment(s) is anticipated to produce the ‘best outcomes’ (greatest net health benefit for all). Neither of these options provides much in the way of pragmatic guidance for decision making and, as Daniels has indicated, there is no satisfactory theoretical characterisation of an intermediary position.
Further to the lack of a clear answer to this fundamental question of resource allocation, important ethics principles that guide the delivery of healthcare services in normal circumstances are compromised in the interests of the necessary shift in focus from meeting the health needs of individual patients to population health and promotion of the ‘common good’ in the development and implementation of critical care triage protocols.5 One of these is ‘respect for individual autonomy’, which is the basis for the modern widely-valued practices of informed consent and patient-centred care. During declared pandemic incidents, some of those presenting for care who would be offered critical care services in circumstances of normal limited resources are not eligible for such care in circumstances of scarce resources in which a critical care triage protocol constitutes the temporary standard of care. Two other widely-held ‘patient welfare’ ethics principles may be compromised during pandemic incidents. The principle of beneficence refers to the obligation of healthcare providers and health organisations to provide health benefits to persons presenting for care, and the principle of non-maleficence refers to the obligation of healthcare providers and health organisations to do as little as possible harm to such persons. During pandemics, healthcare providers and health organisations are hampered/constrained in their fulfilment of these usual obligations. Some persons presenting for care do not receive critical care treatment benefits that they would receive in normal circumstances, and predictable harms/burdens resulting from such lack of critical care intervention accrue to them.
Other relevant theoretical considerations
In addition to concern about the compromising of ethics norms/standards, there has been some limited attention in the triage literature to the ‘tension between the individualistic basis of bioethics and the utilitarian ethos of triage’.6 Practising healthcare providers are challenged to think and act differently when actively engaged in public health work such as the triaging of scarce health resources. The shifting of focus and attention from the individual patient directly in front of the health practitioner to considerations of the rather nebulous ‘common good’ does not come naturally to most providers. For example, through their clinical training, exposure to role models/mentors and subsequent practice experience, doctors become comfortable and confident with operating within a dyadic fiduciary relationship that is founded on well-understood duties of care arising from their obligation ‘to put the interests of the patient first’. Although some health professional codes of ethics make brief reference to members’ obligations to support public health initiatives and to use health resources prudently, healthcare providers receive little training and practical guidance about how to actualise these responsibilities. While health practitioners may understand and accept the need for coercive public health measures, such as the temporary quarantining of those with difficult-to-treat infectious illnesses, they are usually not required to be (and avoid being) directly engaged in enforcing ‘constraints on the liberty of others’ that are associated with such public health initiatives.
Some triage authors have drawn a parallel between the deontological foundations of the Hippocratic tradition and the philosophy of personalism which places persons squarely at the centre of theory and practice. For Carlos Petrini, a personalist conception of solidarity ‘promotes the collective good by safeguarding and giving value to the well-being of each individual’.6 This is at odds with the usual public health understanding of solidarity which acknowledges that providing ‘fair chances’ of receiving health benefits to all individuals is likely to interfere with promotion of the well-being of the majority. As such, some of the goals of personalism are in fundamental tension with those of utilitarianism in that, for the former, obligations to individual persons supersede utility considerations. Despite this, most forms of personalism, as opposed to rigid conceptions of individualism, take seriously the moral importance of interpersonal relationships and the co-responsibility obligations that arise from these relationships.
In applying a relational social justice lens to public health, Francoise Baylis, Nuala Kenny and Susan Sherwin have drawn attention to the limits of an individualistic approach to public health and pandemic planning. In their view, ‘it is a mistake to simply import the familiar bioethical perspective of concerns that were designed to address conflicts between interests … into a discourse that really calls for … a framework that is attentive to the communal aspects and values of public health ethics’.7 In their attention to relationships and their particularities of context, Baylis et al argue for a conception of public health that is informed by relational notions of autonomy, justice and solidarity.
Other authors have suggested that a shift in the framing of critical care triage from consequentialism to virtues may make some room/space for ethics considerations beyond mere utilitarian calculations of ‘the greatest good for the greatest number’. Linda Good has proposed a set of relevant virtues, including fidelity and veracity, which she believes those engaged in critical care triage should possess.8 Gregory Larkin and Jeffrey Arnold contend that having a set of seven virtues (ie, prudence, courage, justice, stewardship, vigilance, resiliency and charity) should ‘empower [healthcare] providers … to vertically integrate principles of safety, public health, utility and medical ethics at the micro [doctor–patient], meso [provider–provider] and macro [doctor–society] levels’ in their management of mass casualty events.9
In addition to his foundational contribution to virtue theory, Aristotle was one of the first articulators of another influential ethics conception—that is, formal justice. In my view, this version of justice is helpful in framing and sorting through some of the important ethics questions/issues of relevance to pandemic critical care triage. Formal justice requires us to treat individuals and groups of persons the same unless we can demonstrate a relevant difference(s) between/among them that justifies different treatment. So, in order to justify the different treatment/management of groups of persons during a pandemic incident, there must be an identified, legitimate relevant difference(s) between them. Historically, developers of triage systems have assumed that there are important relevant differences between (1) having an anticipated very low probability of survival of the pandemic incident and having a better-than-this probability of survival; and (2) having a pre-existing very poor prognosis and not having such a prognosis prior to the incident. These two differences are the usual rationales for not offering critical care services to those presenting for care who meet one or more established medical exclusion criteria while providing such treatment to those whose health conditions do not fall within any of these criteria. For example, in alignment with assumption (1), one could argue that there is a relevant difference between the having of an advanced age and the having of a younger-than-this age if there is good evidence to demonstrate that, for a person presenting for care, being of an age above the age threshold means that he or she has a very low probability of survival of the incident while being of an age lower than the age threshold is associated with a greater probability of survival.
From a formal justice perspective, the determination of what does not constitute a relevant difference for the purposes of resource allocation decision making during a pandemic incident is of equal importance to what does constitute one. Most would likely agree that the list of factors/variables that should not constitute a relevant difference between/among individuals for the purposes of allocating scarce health resources include: gender, race, ethnicity, religion, sexual orientation, income and disability (the latter considered independently of health-related exclusion criteria). There is currently an ongoing debate about whether social utility factors such as vocational and parental status provide legitimate bases for relevant differences among individuals in the critical care triage context. Further, if one assumes that one of the primary goals of resource allocation during pandemic incidents is the survival of as many people as possible regardless of their disability status, differences in the pre-existing quality of life of those presenting for care (independent of the meeting of exclusion criteria) should not be considered relevant for the purposes of critical care triage.
In my view, exploring and expanding the justice dimensions of critical care triage is a good starting point for a broader conceptual re-examination of pandemic practices. Triage systems were initially established (and subsequently modified over time) within a distributive justice framework for the explicit purpose of developing and implementing a better than ad hoc way of temporarily distributing scarce health resources—that is, to define in pragmatic terms what is proper or fair in terms of resource allocation in this context. The well-established utilitarian mechanism for distributing scarce health resources sanctions certain disparities whereby individuals with the worst prognosis are excluded from access to critical care services. To date, no professional and social consensus around a competing practical way of distributing scarce health resources has emerged. Although personalist conceptions acknowledge the importance of solidarity and co-responsibility in decision making that will affect society as a whole, personalism in and of itself does not provide an obvious easily-adjudicated mechanism for choosing which legitimate health needs should be met when the needs of all individuals cannot be addressed due to resource constraints. With regard to virtues theory, while the having of certain virtues such as those suggested by Good and by Larkin and Arnold may predispose an individual to act in fair/good ways, it does not guarantee that the allocation choices made by virtuous persons will resonate within, and be supported by, diverse modern societies that are informed by a rich plurality of values. In my view, an evaluative approach based on exploration of social and formal justice considerations can promote the development and incorporation of ‘enhanced fairness’ features that have the potential to temper the rigid and impersonal utilitarian calculations that primarily inform the content of existing pandemic critical care triage protocols.
Augmenting the fairness of critical care triage
In this section, some pragmatic ways to enhance the fairness of critical care triage are briefly described. These ‘enhanced fairness’ features were developed by an inclusive, dynamic working group that was tasked with the creation of a pandemic critical care triage protocol for a Canadian province of Nova Scotia.
Getting the protocol development process ‘right’
As Ruth Malone has indicated, ‘there is a lot of ethics in the process’ of developing health policies.10 In a socially just policy/protocol development process described by the author and Christy Simpson elsewhere,11 protocols are established from the ground up by a protocol development working group which collaboratively functions as the ‘author’ of the protocol's content and the ‘steward’ of its development process. The membership of the working group consists of primary/core stakeholders, relevant resource persons and health organisational leads. Attention is paid to the recruitment of members from those social and vocational groups that will be directly affected by implementation of the protocol including, in the context of critical care triage, those who have been intensive care patients (‘care receivers’), frontline healthcare providers and the public.
One of the first foundational tasks of the working group is to collaboratively develop a set of procedural/process values that are to (1) inform the development of the protocol's substantive content and (2) be dynamically incorporated into its internal processes and procedures. Examples of these are: inclusiveness, collaboration, openness/transparency, consistency, accountability, responsiveness and revisability. In addition, the working group establishes a set of understandable relevant substantive principles and values that are to (1) act as criteria for decision making and (2) inform the balancing of competing obligations that arise in the development of the content of the protocol. Examples of these that are of particular relevance to pandemic planning and critical care triage are: efficiency and promotion of the common good, health equity, justice, proportionality and trust and reciprocal obligation to care (Nova Scotia Pandemic Critical Care Triage Protocol Development Working Group, unpublished report, 2010). Once these values and principles are established, the working group, using a deliberative engagement approach,12 progressively builds the protocol's content while paying careful attention to the existing and evolving evidence bases of important and controversial elements such as proposed critical care exclusion criteria.
When working group members are comfortable with an initial draft protocol, it is electronically distributed to an inclusive relevant list of secondary stakeholders who are asked to review the protocol and provide comments and suggestions for revision. The working group subsequently considers this collated feedback and incorporates add-value input into the draft protocol while maintaining careful stewardship of the protocol's development right up to its final approval.
One important way to ensure fairness and mitigate potential discrimination is to anonymise the triage process—that is, to have a triage officer make decisions on the basis of the content of a triage form which is completed by the treating emergency department (ED) physician. The triage officer does not ‘lay eyes on’ the patient and the triage form contains no patient-identifying or personal information. In this way, the conscious and unconscious biases of decision makers—for example, the human tendency to be influenced by a variety of social utility factors—do not influence triage outcomes. For example, a triage officer would not be able discern whether the patient he or she is triaging is a member of a disadvantaged social group or, if there is an incorporated age-related exclusion criterion, what the patient's age is if he or she is younger than the established age threshold. ‘Blinded triage’ also reduces the significant psychological burden of treating ED physicians who, if required to assume a direct triage role, would be forced to make difficult and emotionally wrenching bedside-rationing decisions.
Reducing disparities between urban and rural access to critical care
An effective way to address the usual disparity in access to critical care resources between rural and urban residents13 is to establish a central triage committee (Nova Scotia Pandemic Critical Care Triage Protocol Development Working Group, unpublished report, 2010) which, among other crucial functions during a declared pandemic incident, has ‘command and control’ over access to critical care beds within a defined geographical jurisdiction such as a province, state or district. This central triage committee, which electronically monitors the availability of appropriately-staffed critical care beds in real time, makes equitable decisions about how such resources are to be utilised (which treat rural and urban patients the same), and ensures that there is a medical transportation system in place to support the safe and efficient transfer of patients between and among the rural and urban areas of the defined jurisdiction.
One of the basic tenets of procedural justice is that, for a process to be considered fair, it must have an appropriate appeals mechanism.14 The development of appeals mechanisms for pragmatic application during pandemic incidents is particularly challenging because of the need for real time (or as close to this as possible) decision making about critically ill patients' access to care. For this reason, most existing critical care triage protocols do not incorporate appeals mechanisms. In my view, two types of appeals are possible and workable in this context: (1) process appeals15 where there is a claim of error in the implementation of the procedures of the triage protocol; and (2) substantive appeals16 where there is a claim that the application of established triage tools, such as inclusion/exclusion criteria and Sequential Organ Failure Assessment (SOFA) scoring, misrepresents the patient's actual health status and/or prognosis for functional recovery. The adjudication of substantive appeals requires the timely submission and evaluation of additional medical evidence. Given the requirement for appeals to be independent, they are best handled through a central triage committee by an on-call (physician) appeals officer who, as appropriate, receives support from a healthcare ethics consultant or ethics committee member.
Meaningful attention to vulnerable populations
From a social justice perspective, there are a number of possible ways to enhance the fairness of critical care triage for members of vulnerable populations during pandemic incidents (in addition to eliminating/mitigating potential discrimination through ‘blinded triage’):
Participants from relevant disadvantaged/oppressed ‘communities of meaning’ are recruited (and supported) as members of the critical care protocol development working group and are meaningfully engaged in the secondary stakeholder review phase of the development of the protocol.
Emergency department responders adjust the time of presentation for care for those with demonstrated disadvantage (who tend to present later in their course of illness than privileged others17) to correspond to the time in their illness trajectory that most persons present for care (when time of presentation determines queue positioning).
Frontline triage teams include psychosocial support workers who are trained to address and reduce language, educational and cultural barriers.
Incapable persons presenting for care without an available/accessible substitute decision maker become the subjects of an automatic process appeal if they are not initially triaged for critical care.
In this paper I have briefly described some theoretical and practical considerations of relevance to exploring the ethics-informed development of a critical care triage protocol. Despite the significant challenges that it posed, the recent H1N1 pandemic provided a meaningful opportunity for beginning a conversation about enhancing the fairness of existing critical care triage processes.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.