Attending Anesthesiologist, Massachusetts General Hospital; Assistant Professor, Harvard Medical School
Black L, Cist AFM, Curran M, Dalal AN, Goodman AK, Le Roy A, Sunder N, Wilson MC
During a mass casualty disaster, the acute imbalance between need for treatment and capacity to supply care poses difficult rationing problems. It is common to assume that such disasters call for “utilitarian” procedures that deliberately prioritize saving the most lives over other considerations. A group of medical responders to the 2010 Haitian earthquake faced particular challenges in determining how to allocate limited treatment, time and other resources between existing patients and potential patients not yet under care. We identified that rationing dilemmas points occurred at three points: when care had to be limited, when care had to be completed prematurely, and when care had to be withdrawn. “Repeat triage” refers to rationing challenges occurring at all these points, where the allocation of care is between existing and potential patients. By contrast, “initial triage” designates the allocation of access to treatment among new arrivals, all of whom are potential patients. Repeat and initial triage differ significantly. Several considerations make repeat triage special by supporting limited priority to existing patients, in transgression of pure “utilitarian” procedures: (1) Pragmatically, often it is more efficient to complete treatment on existing patients, for whom prognosis can be established with greater certainty and without added time, than to attempt to save new patients; (2) A fiduciary trust relationship has been formed between care-giver and existing patients, which may make the moral obligation towards them somewhat stronger than the one to potential patients; (3) Existing patients will have often arrived earlier, so when needs are equal, the “first come, first served” principle prioritizes them for care; (4) Withdrawal of care during repeat triage may constitute active rather than passive harm, and more often a serious transgression of patient autonomy; (5) Health providers should normally not be asked to behave in ways that profoundly violate their personal and professional integrity, and abandoning existing patients may do so. For these reasons, responders can permissibly give a degree of priority to existing patients over newcomers in disaster.
The earthquake that struck Port-au-Prince, Haiti on January 12th 2010, killed and injured hundreds of thousands. With medical needs far exceeding available resources in this massive disaster, medical teams encountered severe ethical challenges. Rationing dilemmas in a mass casualty situation commonly evoke the initial triage of casualties, where whom to treat first is being decided. The triage decisions that posed the most difficult moral quandaries for some medical teams in Haiti, however, arose after the primary triage into treatment. These medical responders wondered when and how they should limit medical care for patients who were already under care with their team, in order to reserve resources for new casualties who were also in need of treatment.
In the first weeks after the earthquake, approximately eighty-five volunteers from the Massachusetts General Hospital (MGH) joined the relief efforts. These responders worked in MGH groups and non-governmental organizations based in small rural Haitian hospitals; with an International Medical and Surgical Response Team; and aboard the USNS Comfort, a US Navy hospital ship that served as the major referral hospital. Upon their return to Boston, a group met to discuss the ethical dilemmas that they had faced.
In order to clarify the differences in rationing method appropriate to different stages of care, we distinguish between primary and subsequent triage points. We use the term “initial triage” to describe the sorting of casualties on arrival into categories of priority for treatment - the primary rationing decision as to whom to treat first. We define “repeat triage” as rationing treatment between patients who had already been accepted into care and those who were not (yet) under care. While “initial triage” allocates care between new arrivals, “repeat triage” allocates care between existing and potential patients.
We identified three “cases”—types of situation in which group members had to consider limiting care for existing patients in order to maintain resources for new arrivals who were not yet within the medical system. We discuss the thought processes that went into clinical decision making before analyzing the ethical considerations that bear the most on these dilemmas, with reference to the relevant ethics literature.
In care rationing, several ethical considerations demarcate existing from potential patients and hence, the decision making appropriate for repeat triage from the one appropriate for initial triage. They include the pragmatic advantages to treating existing patients, the fiduciary relationship that links an existing patient to a care giver, the allocation principle of first-come first-served, the doing-allowing distinction linked to patient autonomy, and the rights and motivation of health care workers.
The World Health Organization defines a disaster as a state that occurs when normal conditions of existence are disrupted and the level of suffering exceeds the capacity of the hazard-affected community to respond to it.
None of the three cases described above falls into the category of initial triage. These “repeat triage” decision points—treatment limitation, premature completion of treatment, and treatment withdrawal—follow the primary decision about whether to initiate care. Individual care is rationed between existing patients and potential patients. Repeat triage can therefore differentiate individuals according not simply to medical necessity and prognosis, but also, potentially, to their status as patients under medical care or alternatively, as people who have not yet entered care.
Initial and repeat triage may look like two instances of the same basic dilemma—how to reconcile the conflicting needs of the individual for maximal care with other people’s similar needs. But are there ethical or practical differences? Might the propriety of “utilitarian” procedures vary between initial triage and repeat triage? In particular, does the existing patient in repeat triage have some priority a potential patients when prognoses are similar and give neither a higher chance of benefit from treatment?
The simplest reason to prioritize existing patients during disaster is that, other things being equal, it is often more efficient to prioritize existing patients than to discharge them and admit new patients.
One argument for prioritizing existing patients somewhat is that a special fiduciary relationship has developed between the care-giver and any existing patient. The moral obligation to any existing patient could thus be considered greater than the obligation to an individual with whom a strong relationship has not as yet formed. Ethicists have accounted for the practitioner’s special obligations to existing patients based, for example, on the trust that these vulnerable persons have placed in him or her and to which he or she agreed to be faithful.
An existing patient may be thought to command priority over new arrivals simply based on the blind and imperfect fairness of “first come, first served,” a prevalent approach to allocating medical care, which nearly every health system uses to some degree. While sometimes those who arrive first are those who have more resources, it is hard to identify an alternative that would completely displace that principle, especially in chaotic disaster situations. When applied consistently, this relatively impartial principle can also prevent gross discrimination.
Initial triage during a disaster asks whom to withhold resources from for the sakes of others. Premature completion of care and care withdrawal—cases of repeat triage during a disaster—ask whom to withdraw resources from for the sakes of others. To take resources away from a patient while she is using them only to serve others is hard to justify; much harder to justify than either taking resources away from a consenting patient for her own sake, or withholding resources from a patient for others’ sakes, before she begins using them. If you will, the synergetic combination of two elements that are individually benign—rationing and treatment withdrawal—makes some cases of repeat triage difficult to defend.
Let us look at the two elements individually. Rationing often disadvantages, and in that modest sense harms, nonrecipients of rationed resources. But in a world of scarce resources some rationing remains necessary.
Move to treatment withdrawal. In standard care, treatment withdrawal deliberately benefits a consenting patient and that makes it easy to justify. Even consensual withdrawal of life support (say, from a terminal cancer patient in pain) seems roughly as justifiable as consensually withholding life support from such a patient.
Either rationing or treatment withdrawal are clearly defensible on their own. Returning to repeat triage during disaster relief, however, premature completion of care and care withdrawal bring together both rationing and treatment withdrawal. That combination remains hard to justify, for two reasons.
First, when the impetus behind treatment withdrawal is rationing, not the interests of the patient from whom that treatment is taken, then any disadvantage that this patient consequently incurs may count as active harm done to her, insofar as withdrawal is active.
A second way in which care withdrawal pursuant to some cases of repeat triage differs from the mere withholding of care pursuant to initial triage surrounds patient authorization. Outside of disaster situations, care termination for a patient’s own sake (say, termination of pneumonia care in an aging patient with end-stage cancer) can only be withheld with the (advance) consent of the patient (or that of the patient surrogate), and when it is safe to presume that, if the patient could give or refuse rational consent, he or she would consent.
While legal recourse is scarcely available to disaster victims, at the extreme end, non-consensual withdrawal of treatment might theoretically be interpreted as assault and, when harmful, as a tort, perhaps especially when it involves the removal of tubes from inside a patient’s body.
Earlier we mentioned that abandoning an existing patient with whom a deep and a compassionate care relationship has (hopefully) been formed tends to be emotionally more taxing on medical teams than refusing new admissions is. Because repeat triage is being conducted by health practitioners, the importance of their typical emotional response may support some priority to existing patients.
It is tempting to dismiss practitioners’ emotional responses as mere emotional responses with little relevance to fair resource allocation—as we would dismiss the emotions of a bigoted practitioner who fears treating HIV-positive patients. Especially during disaster, some may conclude, surely the extreme urgency of rescuing many patients’ lives overrides protecting practitioners’ emotions. On that view, practitioners should simply learn to prioritize public health needs over their own feelings and prejudices.
However, within limits, practitioners’ normal emotional responses do matter—especially during disaster. First, there are simple pragmatic reasons to avoid extreme emotional distress and protect personnel morale, certainly when stemming not from stigma but from commendable compassion that we generally encourage among medical workers. Preventing emotional burnout and preserving team unity may protect nearly everyone’s prospects, including some untreated patients who rely on future care in a functional care team. Taxing demands on relief workers—including being regularly forced to discharge vulnerable people onto the streets, to remove a critically ill patient from life support, or to amputate a child’s limb against their own sense—can result in worker attrition, system failure, and compromised care during disaster.
Though the argument can rely on pragmatic considerations alone, we should bear in mind that care-givers also have rights, and usually we do not insist that they provide care when that would violate their personal and professional integrity.
Thus, short of transferring more decisions to computers, mechanized decision algorithms, or independent teams who have no part in these patients’ care
Our experiences and deliberation suggest not only that many triage points fall beyond the primary allocation of treatment, but that initial and repeat triage differ in the ethical challenges that they pose. In repeat triage, a moderate priority to existing patients over new admissions is often acceptable.
As planned responses to disaster become more frequent, the expanding academic study of disaster response is providing insights into disaster epidemiology that may guide response patterns. Planners and coordinators of disaster relief efforts should recognize the multiple triage points they involved. Such recognition may allow prior preparation of the infrastructure and guidelines for transfer, discharge and follow-up that check repeat triage challenges.
During relief work, the formation of ethics committees and discussion support groups may further help individuals consider all options, improve decision making, decrease psychological tensions, and diffuse the responsibility for choice with profound consequences from the individual practitioner to the group.
We do not advocate an about-face in disaster relief practices, but a modification of the ethos. This moderate priority may turn out to be more closely aligned with what many relief workers already practice. If this analysis is correct, future commentaries should characterize in greater detail the appropriate degree of priority for existing patients.
Other commentaries could examine further questions. Does repeat triage in which both candidates for medical resources are existing patients differ from initial triage (that is, from triage between two new admissions)? Is repeat triage in which the existing patient was admitted before the disaster took place, with the expectation of normal fiduciary relations,
During disaster relief, a moderate priority to existing patients over new admissions is often acceptable. While absolute or very high priority is unwarranted, pragmatic considerations; the need to respect and preserve the fiduciary trust relationship; the first come, first served principle; distinctions between withholding and withdrawing treatment and their confluence with the notions of active and passive harm and patient autonomy; and the rights and morale of health care providers support a moderate priority for existing patients in repeat triage. Some of these considerations, such as the need to prevent responder team attrition by prioritizing existing patients, are especially acute during disaster—precisely because life and death hang in the balance for many. By inviting deliberation on factors beyond maximizing medical benefits and the number of lives saved, our argument questions the propriety of shifting fully to so-called utilitarian procedures.
The authors have declared that no competing interests exist.
We wish to thank Professors Ed Lowenstein, MD, Robert Truog, MD, and Leah Price, PhD, as well as the editor and anonymous referees, for their insightful suggestions during the preparation of this manuscript. *The Members of the MGH Disaster Relief Ethics Group are: Black L, Cist AFM, Curran M, Dalal AN, Goodman AK, Le Roy A, Sunder N, Wilson MC