Ethical Dilemmas in Triage - Balancing Medical Need, Resource Allocation, and Fairness

Introduction

Mass casualties like pandemic situations, epidemic diseases, and terror attacks take so many lives at stake, which makes the decision-making for triaging difficult and challenging as the mortality and disability rates in that chaotic situation cannot be controlled. Hence, ethical principles should be devised well in advance and executed when needed, prior to the disaster, to carry out the triaging without any bias or ethical breach, saving many lives and contributing to better outcomes. The planning should involve an open and transparent approach, which should be easily applicable, accountable, and reasonable, especially in decision-making at the time of disaster for balancing between careful utilization of scarce resources and providing medical needs. Improper planning can lead to poor triaging, causing increased mortality rates and mistrust of the healthcare delivery systems.

What Are the Steps Taken to Solve Ethical Dilemmas in Triaging?

The guidelines for catering to the medical needs and allocation of scarce resources in public health emergencies rely on the following integral aspects:

A. To Reduce Morbidity and Mortality Rates: The first and foremost step is to reduce the morbidity and mortality rates by providing quick medical care to the affected.

B. To Have a Well-Equipped Medical Team: A medical team should be made ready in advance to serve the public in need by all means, like providing health care, social services, and infrastructure during the time of casualties. The team should strive to promote transparency, trust, and understanding among the public about the decisions taken regarding the allocation of scarce resources.

C. To Ensure Fairness: The decision-making in catering medical care and allocation of scarce resources should ensure fairness and equality.

D. Ethical Considerations: Ensuring fairness and the allocation of resources becomes challenging and difficult without paying attention to the ethical considerations that guide the process without bias. They include:

• Beneficence: The obligation to treat and save life, and the course should follow the benefit of the patient.

• Utility: The main goal is to achieve the greatest benefit for the patient by resource utilization.

• Fairness: Doing what seems morally right.

• Transparency: Showing openness with regard to decision-making.

• Accountability: Being answerable or responsible for the actions.

• Veracity: Telling the truth.

• Respect for Others: Respecting the patient’s integrity, decisions, dignity, and bodily integrity.

• Proportionality: Making proportionate decision-making, which makes the benefits outweigh the burdens.

• Solidarity: Showing unity.

• Reciprocity: Compensating for the actions of others.

• Stewardship: Preserving the resources to the best of their efficacy.

E. Allocation Criteria: Based on the condition of the patient and the situation, guidelines have been devised for the allocation of resources, which include:

F. Acceptable Allocation Criteria: The decision to allocate medical services is based on two categories:

• Medical Prognosis: The decision is taken based on the severity of the injury, the chances of getting a positive response to the treatment offered, the relative risk for delaying the treatment, and other chances of survival, which will dictate the allocation of services to the ones who are in need of it.

• Essential Social Functions: The priority for accessing scarce resources and medical care is given to the ones who play an important role in performing essential services of society, like:

Healthcare workers (doctors, nurses, paramedical staff) who work in emergencies save many people’s lives.

• Public health scientists whose role is important in addressing public health emergencies.

• Public safety personnel (police, fire engine staff, military personnel).

• Personnel playing a role in critical infrastructure (telecommunication staff).

G. Applying the Allocation Criteria:

1. Tier 1 ( Given the Highest Priority):

• A person with a highly morbidity and mortality condition but having a favorable prognosis.

• A person with high occupational exposure has a favorable prognosis.

• A person whose role is irreplaceable and has a better prognosis.

2. Tier 2 (Elevated Priority): A person with moderate mortality and morbidity rate but falls into having a better prognosis.

3. Tier 3 (Lowest Priority): Other than the ones who come under tier 1 and tier 2 categories.

H. Situation Dependent Allocation Criteria: Although the selection criteria based on medical prognosis and essential social functions eased the decision-making in service and resource allocation, challenges arose again when people could not be differentiated based only on the above-mentioned criteria. Hence, three more criteria are added, which include:

• Age: Priority is granted to have access to scarce medical resources based on age, quality-adjusted life years, and disability-adjusted life years. A young patient is given priority over the old as the prognosis is better in the young.

• Lottery System: This involves picking a person on a random basis through a lottery system. This enables an equally random chance to avail the scarce medical services. This is opted when health professionals are left with no other choice as the recipients match all requirements, and the scarcity makes it difficult to decide.

• First Come / First Served: It is acceptable in non-emergency situations as access to medical care is granted to the one who comes first as it favors the one who has social, informational, and economic advantages.

I. Unacceptable Allocation Criteria: The guidelines also include unacceptable criteria during the allocation decision-making, which exhibit a lack of fairness, discrimination, and inefficiency in catering to the service. They include:

J. Social Characteristics: Social characteristics like gender, ethnicity, nationality, religion, etc., should not be considered as they may indicate discrimination and offer irrelevant selection in allocating the services.

K. Social Worth: Criteria like job status, education, social status, family background, and political influence should not be considered and are termed unacceptable by providing access to scarce medical needs during public emergencies.

L. Implementation: The guidelines stress on implementing the steps to eliminate the scarcity before doing the allocation process, which include:

1. Supplying Adequate Medical Resources: Efforts to be made to supply medical resources and services to overcome scarcity during public health emergencies. This effort should be initiated at all levels of decision-making, including the state government and individual health institutions.

2. Prior Judgment Of Scarcity: The chances of impending scarcity should be assessed priorly, and efforts should be made to eliminate the scarcity.

3. Apt Usage Of Allocation Criteria: The allocation criteria and prioritization process should be used only during the scarcity, depending on the nature, severity, and time duration of the scarcity.

4. Fair and Transparent Decision Making: The allocation criteria selected should be fair enough and transparent, leading to maximum utilization of resources and saving many lives without any bias.

5. Periodic Assessment of Guidelines Promoting Allocation: The guidelines should be scrutinized on a regular basis, and the criteria for judging the individual’s inclusion or exclusion to avail the scarce medical resources to be reassessed periodically.

6. Consistent Implementation of Prioritization Guidelines: The allocation guidelines should be followed consistently under all circumstances to avoid favoritism or nepotism and to ensure a smooth process of the prioritization process.

7. Decision-Making to be Done By People Outside the Clinical Team: To avoid bias, conflicts between the caregivers and the patients, and to avoid confusion, the decision made regarding the allocation of scarce resources and medical services is to be made by decision-makers outside the clinical team.

8. Palliative Care Services to be Provided Consistently: People suffering from serious illness should be provided palliative care (necessary specialized care) based on the decision of allocation throughout the public emergency situation. Priority should be given to those who do not have access to scarce medical resources and should not be curbed from it.

Conclusion

Triaging in public health emergencies plays an important role in minimizing the death rates by allocating scarce medical services to the needy. However, failure in proper planning leads to a lot of confusion and improper allocation. Hence, prior evaluation of the ethical dilemmas should be carried out and solved by implementing necessary steps in supplying adequate resources and analyzing the scarcity well in advance, contributing to better treatment outcomes.