DISASTER TRIAGE FOR ALLOCATING SCARCE RESOURCES
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.
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 But alas, numerous studies have shown this tool to not accurately predict who should or shouldn’t be offered, or withdrawn from, critical care (Cuartas et al, 2022: a quarter of the people that would have qualified for withdrawal of ventilatory support survived hospitalization;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and withdrawal from ICU support; Fink citing Guest et al, 2009: 46 percent of patients who would have been denied or withdrawn from intensive care treatment under the protocol, 61 percent actually survived to hospital discharge).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” (Scheunemann & White, 2011). And just like letting everyone into the lifeboat would, in the end, benefit no one, so too do medical decisions have to be made with the big picture in mind. Whether or not this single patient in front of me will benefit from ventilatory support is not a decision that can be made in isolation of others who would benefit, perhaps more, from the same, limited, resource. “This is not paternalism. Unilateral authority overrides individual autonomy but does so to prevent the impermissible harm to other patients from irresponsibly managed unacceptable opportunity costs” (McCullough, 2020). Though some professionals claim to be somehow excluded from the need to ration in medicine, the reality exists (Scheunemann & White, 2011). Better than ignoring reality, would be to inform ourselves in order to conscientiously provide medical care.
Ways of deciding
So how do we decide who to haul into the lifeboat, and who to push apologetically away with the oars? Fundamental philosophies to guide rationing include utilitarianism, egalitarianism, and the rule of rescue:
Utilitarianism seeks to maximize overall benefits at the societal level
Egalitarianism emphasizes the equal moral status of individuals by trying to provide equal opportunity to have the basic goods in life.
Prioritarianism attempts to help those who are considered the worst off by giving them priority in situations in which all cannot receive a particular resource
Rule of rescue describes a powerful psychologic impulse to attempt to save those facing death, no matter how expensive or how small the chance of benefit. The philosopher Albert Jonsen coined the term and describes it as “the moral response to the imminence of death [which] demands that we rescue the doomed” (Scheunemann & White, 2011).
Here’s an uncomfortable idea, not at all new, but certainly relevant to the issue of resource allocation. Do we delude ourselves into believing that we make the policies, but that it is nature that creates the victims?
“…individuals collectively attempt to deny moral responsibility for their role in choices—no matter how ethical or necessary—that consign individuals to death. This denial involves creating the illusion that the suffering arises out of nature rather than from conscious choices” (Calabresi G, Bobbitt PC, 1978. Tragic Choices. New York: Norton).
Of course, suffering and death cannot be universally avoided. Policies will (hopefully) make life better in some way, reducing excessive suffering and preventable death. But not for everyone, and not all the time. Can we recognize and reconcile that?
Until the perfect predictive tool for rationing our limited health care resources is found (and I hope it forms a pleasant acronym), transparency in these decisions seems the best way.
“In morally pluralistic societies, reasonable people may be unable to agree about which principles should guide rationing” (Scheunemann & White, 2011). “Fair processes” to guide allocation of scarce resources involve:
"...oversight by a legitimate institution"
"...transparent decision making"
"...reasoning according to information and principles that all can accept as relevant"
"...procedures for appealing and revising individual decisions"
"...meaningful public engagement" (Scheunemann & White, 2011).
Alberta Health Services - one example
I was prepared to be critical of this policy. Maybe I am annoyed at the fact that I am rudely interrupted twice daily in my hospital by an overhead announcement that there is a pandemic (still going as of March, 2022), on the same system that would announce a bomb threat, code blue’s, fires, trauma team activations, and any other urgent announcements. But this document is well-crafted.
Many of the principles of fair process are reflected here. It is thoroughly utilitarian and egalitarian. This framework strives to be “an objective process to guide health care professionals in making the difficult determination of how to allocate resources to critically ill adult and pediatric patients when there are not enough critical care resources for everyone. Triage is not about withholding care from patients, it is about providing the best care to the greatest number of people. These protocols ensure that such decisions are made in an ethical, fair, and structured way and not ad hoc” (AHS, 2022). Nice.
I cringe a little at the responsibility thrust upon (and eagerly accepted by) “health care professionals”. This neglects the fact that decisions at the macro level (Scheunemann & White, 2011), that is to say, far removed from the average bedside clinician, have set the stage for many issues that arise around resource allocation. How much funding goes to health care, hospital staffing, bed capacity, supplies, etc. I resist the narrative that allocating health care resources is solely a health care team’s responsibility, made solely at the end of life or during critical illness. But otherwise, I leave this AHS document as a commendable example.
But to conclude on a really discouraging note, let us not forget that the pandemic did not create the ethical challenges we face, only amplified them. The inequalities that create scarcity will still be there whenever this current crisis is officially no longer a crisis.
There is much talk now about returning to “normal,” or a “new normal.” For bioethicists, such language should send up a red flag. Normal life is and has been unfairly unhealthy for too many of us for too long.
All health problems are affected by funding priorities, socioeconomic inequalities, health insurance, policies affecting employment and education, the availability (or lack thereof) of public and social services, and lack of access to the services and professionals adjunctive to medical care. Focusing only on fixes to the distribution of technologies and treatments – even when we argue that more “reserve capacity” is needed and should be provided and funded – falls far short of the goal of helping make society as a whole better able to deal with the imperfections of the human body and mind” (Churchill et al, 2020).
I had the perception that a disaster triage protocol would be instructions for front-liners, made by back room administrators, to tell us who to throw from the lifeboat. Who to withdraw care from, or deny it in the first place. There are certainly plans that are disturbingly close to that (Fink, 2020). I was pleased to see that was not the version created in my jurisdiction. Nor is it ethically justified elsewhere. The underlying problems that Churchill et al refer to above, mean that this is not strictly a pandemic issue, either. We're not in a lifeboat, we're in the only boat.