Utilitarianism is often cited as the guiding philosophy in disaster triage. “Doing the most good for the greatest number…” is the common refrain. Is that what people do in disasters? Is that what we should do? Are disaster triage systems fundamentally different that day-to-day triage?
Disaster triage tools often call us health care providers to declare people dead or dying and move on to salvageable ones. As everyone knows, or should know if they watched the Princess Bride, there’s a big difference between dead and mostly dead (mostly dead being somewhat alive). This would be the expectant, or black, category of disaster triage (1). Tag them as dead and move on to the next patient, right? Right???
“…it is difficult to walk away from a person who is on the verge of succumbing to severe injuries…” (2)
“Critically ill patients with minimal chance of survival are tagged as black...” (3)
“This mandates that some survivors should not be treated, even though possibly salvageable…” (4)
The help we get from the literature is not in making this decision, but in dealing with the subsequent moral injury. “[Debriefing] can also provide tangible support and foster group cohesion, potentially resolving the sacrificial harms necessitated by the utilitarian calculus of disaster triage” (3). Do we have to sacrifice provider (psychologically, spiritually, or morally) for patient (physically)? A protocol that puts all the health care providers off on mental health leave isn’t very utilitarian, is it?
Some of the controversy exists because excessive measures are sometimes taken in non disaster situations in the healthcare of patients, whether because of diagnostic or prognostic uncertainty, fear of litigation, preference of a patient’s loved ones, or the innate human desire to help one another. All of us in emergency medicine have seen resuscitations that went on too long, or shouldn’t have been started, treatments given that we knew were ineffective, or procedures performed that did more harm than good. All in the name of trying to save a life. Perhaps when people say utilitarianism when they just mean common sense, for example not starting chest compressions on the severely head-injured patient with no pulse. That's not “walking away from a person on the verge of succumbing,” that's recognizing the limitations of our tools. If that patient would have been treated more aggressively in a non disaster situation, it isn’t really a different philosophy of care, is it? Just more time to process our uncertainty and discomfort.
Triage exists because of a relative scarcity of resources. In disasters, sufficient resources are not available for an overwhelming demand. So disaster triage is necessary. But wait, we triage every day. That is because health care resources are limited, and health care demand is, if not unlimited, at least less limited. Perhaps in some utopia, there exists an abundance of health care resources and a healthy population with little illness and injury. But everywhere else (everywhere), resources need to be allocated, patients have to be prioritized. How do we ethically decide such matters?
I’ll skip the ethics of triage in general, which is not without controversy, literature, and research (see 5). As for triage in disaster, is utilitarianism universally accepted and practiced? Hardly. First of all, it’s not even defined. What does it mean to do the greatest good? Are we talking most lives saved? Most years of life saved? Most socially-valuable years of life saved? Most emergency responder years of life saved? Most disability-adjusted years of life saved? (See 6). To say that disaster triage is guided simply by utilitarianism is an oversimplification, and ignores fundamental ethical principles such as the Hippocratic oath, human rights, egalitarianism, and dignity (7).
In a systematic review of ethical principles guiding disaster triage, utilitarianism was specifically identified as the guiding principle in only a few of the 36 articles included (8). Medical measures were often used such as ‘sickest first’ and likelihood of benefit. Nonmedical measures included youngest first, saving function of society, protecting vulnerable groups, conservation of resources, and unbiased selection.
“If we are doubtful about the ability of the utilitarian scheme to save more lives (or promote other utilitarian goals) relative to other schemes, and if we cannot tell which utilitarian scheme is the most appropriate morally, the moral authority of utilitarianism shrinks considerably.” (Barilan)
Here’s an illustration. Let’s say a utilitarian approach saves 100 out of 100,000, a clinical approach only saves 30. “Is such a tiny bit of difference worth the utilitarian degradation of people into objects in a machine of care that keeps rejecting the weakest and trampling on traditional roles, professional boundaries, habits of care and the psychological distress of caretakers?" (9)
Triage is complicated, exponentially more so in disasters. There are no simple solutions. Maybe we should seek for guiding principles instead of perfect algorithms, like this one:
‘Que le respect de la vie soit le principe élémentaire de l’éthique et de la vraie humanité’
(‘Respect for life must be the ethical principle and the truth of humanity’).
-tableau in front of the Professor Schweitzer Hospital in Lambarene (Gaboon) (7)
References
1. Silvestri, MD S, Field, MD A, Mangalat, et al. Comparison of START and SALT triage methodologies to reference standard definitions and to a field mass casualty simulation. Am J Disaster Med [Internet]. 2017 Jan.
2. Lee CH. Disaster and mass casualty triage. AMA Journal of Ethics. 2010 Jun 1;12(6):466-70.
3. Wagner JM, Dahnke MD. Nursing ethics and disaster triage: applying utilitarian ethical theory. Journal of Emergency Nursing. 2015 Jul 1;41(4):300-6.
4. Frykberg, Eric R. MD, FACS. Medical Management of Disasters and Mass Casualties From Terrorist Bombings: How Can We Cope?. The Journal of Trauma: Injury, Infection, and Critical Care 53(2):p 201-212, August 2002.
5. Aacharya RP, Gastmans C, Denier Y. Emergency department triage: an ethical analysis. BMC emergency medicine. 2011 Dec;11(1):1-3
6. O'Laughlin DT, Hick JL. Ethical issues in resource triage. Respiratory care. 2008 Feb 1;53(2):190-200.
7. Petrini, C. Triage in public health emergencies: ethical issues. Intern Emerg Med 5, 137–144 (2010).
8. Ghanbari V, Ardalan A, Zareiyan A, Nejati A, Hanfling D, Bagheri A. Ethical prioritization of patients during disaster triage: a systematic review of current evidence. International emergency nursing. 2019 Mar 1;43:126-32
9. Barilan, Y., Brusa, M., Halperin, P. (2014). Triage in Disaster Medicine: Ethical Strategies in Various Scenarios. In: O’Mathúna, D., Gordijn, B., Clarke, M. (eds) Disaster Bioethics: Normative Issues When Nothing is Normal. Public Health Ethics Analysis, vol 2. Springer, Dordrecht.
Photos
Mario Wallner, pexels.com
Ankush Minda, unsplash.com
