DISASTER TRIAGE FOR ALLOCATING SCARCE RESOURCES
Lifeboat ethics
The time to prepare the lifeboats is before leaving the harbour. Making such decisions while capsizing during the storm is obviously too late to be of much help. Allocation of scarce resources, then, is a planning (rather than response) issue and is a very ethically-loaded topic. Disaster ethics is a peacetime pursuit (see Naomi Zack, Ethics for Disaster). The original lifeboat example (Hardin, 1974) was an analogy of world economy, rich nations in the lifeboat, poor nations floundering in the sea. How many do we let in the lifeboat? And how do we decide which ones? Letting everyone in is not an option, as much as we would like it to be. The boat can only hold so many, if we are indiscriminate in assisting our fellow sufferers, the boat capsizes, we all drown. “Complete justice, complete catastrophe” (Hardin, 1974).
We had plans in place for when we might have to allocate scarce resources prior to the pandemic. We have also had an abundance of research, experience (SARS, MERS, influenza, regular outbreaks of various infections throughout the world), and planning in place for years if not decades prior to this pandemic. So we planned to run out of resources? As the scales of health care will always be tipped in favor of limitless demand (the unstoppability of sickness and death) over limited supply (finite resources), this is acceptable. Acceptable if planned with transparency and ethics.
Not easy
A survey by Gray et al (2022) in Disaster Medicine and Public Health Preparedness and their qualitative analysis of the factors that should go into decision-making around allocating scarce resources, show that it’s not a simple decision. 27 items made the final cut. It would be nice to have a simpler tool, maybe one with a neat four letter acronym. SOFA, for example. But alas, numerous studies have shown this tool to not accurately predict who should or shouldn’t be offered, or withdrawn from, critical care (Cuartas et al, 2022: a quarter of the people that would have qualified for withdrawal of ventilatory support survived hospitalization; Fink citing Blumhardt, 2010: 67 percent of H1N1 flu patients who survived would have been considered for exclusion from the ICU or for triage to “expectant” care with extubation and withdrawal from ICU support; Fink citing Guest et al, 2009: 46 percent of patients who would have been denied or withdrawn from intensive care treatment under the protocol, 61 percent actually survived to hospital discharge). In fact, though widely accepted, SOFA is not a tool for disaster triage (Wynia & Sottile, 2020). And a triage system based on something that is not able to predict who will benefit more than random, or first-come, first-served allocation of limited resources, is unethical (Wynia & Sottile, 2020). Better to have no triage system than a bad one.
Decisions have to be made as resources will always be finite. “The focus on potentially beneficial treatments is appropriate because virtually no treatment in medicine offers certain benefit for an individual patient and because a central point of controversy is whether the potential benefit is large enough or likely enough to occur in order to justify the expense” (