Dynamics and Ethics of Triage: Rationing Care in Hard Times, The

Military Medicine, Jun 2005 by Repine, Thomas B, Lisagor, Philip, Cohen, David J

Triage of medical care, whether necessary because of routine daily limitations or forced by exceptional circumstances, such as for soldiers injured in combat or civilians in mass casualty situations, is increasingly coming under scrutiny. The decisions that limit access to fundamental and even life-or-death treatments are fraught with controversy. These decisions are difficult for the medical provider to make and are even more difficult for the patient to understand. Medical providers are poorly trained to address the numerous factors involved in triage decisions under the pressure of limited time. Patients are understandably selfish and short-sighted regarding their own care. Both provider and patient can feel that triage is immoral. In contrast, when triage is taught proactively and reviewed relative to the situation, the ethical principles that guide triage are evident and intact. Both provider and patient must learn the considerations and consequences of triage.

Introduction

Combat, combat medical care, and triage are dynamic processes. Ethics is too, although the ethical principles themselves are not. During a time of war, and after an attack such as that on September 11, 2001, the need for all physicians and the community at large to learn about the process of triage and the surprisingly dynamic ethics around it could not be more evident.

When the demand for medical care exceeds the ability to provide it, care must be rationed. Chronic medical care has always operated on some basic premise of rationed care. The sickest patients are always treated first. This is obvious in emergency rooms across the United States and is just as prevalent, although not as obvious, in the daily decisions of all physicians. On a larger scale, the rationing of care has driven the emergence of health maintenance organizations (HMOs).1 Even ignoring their financial motives, the triage of resources followed by such organizations has been increasingly and publicly challenged.

People in the United States believe that medical care is a right. In fact, only prisoners have a right to health care. This technical misunderstanding aside, our society still views individual health care as at least an entitlement and not a privilege. This sense of entitlement leads to conflicts between patients, who are unwilling to settle for less than maximal care, and physicians, who must determine who can realistically receive care. The expectation that every patient can be treated in every situation cannot be met. We are faced, as a community, with deciding how we will divide the precious medical resources to do the most good for the most people.

Physicians in this uncomfortable position have typically deferred decisions of "who gets what" to inner personal judgment. These decisions are understandably fraught with controversy, because the motives behind them are not always clear to people inside, let alone outside, the situation. Compounding this ambiguity is the fact that there has been insufficient training, minimal oversight, and little formal discussion regarding basic ethical concerns such as fidelity, veracity, justice, autonomy, and even beneficence, to ensure that these principles are being addressed in these extreme circumstances. These ethical principles are just as important, if not more important, in triage situations in which decisions can affect life and death. Arguably, however, when the practice and principles of triage are examined within the context of the situation in which it is used, these ethical principles become evident as the foundations on which triage decisions are actually made.

Background

Before any discussion regarding the ethics of triage can be undertaken, we must understand the mechanics and typical driving factors involved. Triage is derived from the French word trier, which means to choose among several.2,3 It is a military term in origin, being used to describe the prioritization of wounded soldiers and the use of available medical resources for maximal efficiency. Commonly recognized examples of triage include (1) prehospital, (2) catastrophic, (3) emergency department, (4) intensive care, (5) waiting list (e.g., for lifesaving treatments such as organ transplants), and (6) battlefield situations.4

Battlefield triage is divided into two main scenarios that represent two ends of a spectrum of medical care: (1) when the number of patients and the severity of their injuries do not exceed the capability to render care and (2) when the number of patients and/or the severity of their injuries do exceed this capability.5 In the first type of situation, patients with the worst injuries are treated first. Individual patients normally recognize that their sprained ankle should wait when the doctor is treating a patient with a heart attack. Without this understanding of the bigger picture, some patients do not accept waiting and few, if any, accept being denied care if acutely ill. Again, anyone who has waited in an emergency department waiting room is intimately familiar with this common perception.