In terms of the setting of priorities for resource allocation, two general principles are important. These are equity and utility. Based on these two concepts, there are two historically discrete models for triage of limited resources. These are the French egalitarian model based on equity and the British military model based on utility. Modern paramedic and emergency room care in multiple casualty situations favors the triage model based on utility. Modern ICU care favors the triage model based on equity. There are issues to be addressed in both triage responses. In a pandemic, both the utilitarian model and the equity model are active, and their applicability changes as the trajectory of the pandemic progresses.
Keywords: Pandemic, triage, equity, utility
Antommaria, A. H. M., T. S. Gibb, A. L. McGuire, P. R. Wolpe, M. K. Wynia, M. K. Applewhite, A. Caplan, D. S. Diekema, D. M. Hester, L. S. Lehmann, R. McLeod-Sordjan, T. Schiff, H. K. Tabor, S. E. Wieten, and J. T. Eberl. 2020. “Ventilator Triage Policies During the COVID-19 Pandemic at U.S. Hospitals Associated With Members of the Association of Bioethics Program Directors. ” Ann Intern Med 173 (3): 188–194. https://doi.org/10.7326/m20-1738.
Baker, Robert, and Martin Strosberg. 1992. “Triage and Equality: An Historical Reassessment of Utilitarian Analyses of Triage. ” Kennedy Institute of Ethics Journal 2 (2): 103–123.
Bazyar, Jafar, Mehrdad Farrokhi, and Hamidreza Khankeh. 2019. “Triage Systems in Mass Casualty Incidents and Disasters: A Review Study with A Worldwide Approach.” Open Access Macedonian Journal of Medical Sciences 7 (3): 482–494. https://doi.org/10.3889/oamjms.2019.119.
Beecher, Henry K. 1969. “Scarce Resources and Medical Advancement.” Daedalus 98 (2): 275–313. www.jstor.org/stable/20023879.
Churchill, Edward D. 1952. “Surgical Implications of the Evacuation and Distribution of Battle Casualties.” In Battle Casualties: Incidence, Mortality and Logistic Considerations, edited by Beebe Gilbert W and Michael E De Bakey, 242–257. Springfield, Ill.: Charles C. Thomas.
Clarkson L, and Mollie Williams. 2020. “EMS Mass Casualty Triage.” StatPearls [internet]. StatPearls Publishing. Last Modified 2020 Sep 8. https://www.ncbi.nlm.nih.gov/books/NBK459369/.
Egan, T. M., S. Murray, R. T. Bustami, T. H. Shearon, K. P. McCullough, L. B. Edwards, M. A. Coke, E. R. Garrity, S. C. Sweet, D. A. Heiney, and F. L. Grover. 2006. “Development of the New Lung Allocation System in the United States.” American Journal of Transplantation 6, no. 5p2: 1212–1227. https://doi.org/10.1111/j.1600-6143.2006.01276.x.
Fiest, Kirsten M., Karla D. Krewulak, Kara M. Plotnikoff, Laryssa G. Kemp, Ken Kuljit S. Parhar, Daniel J. Niven, John B. Kortbeek, Henry T. Stelfox, and Jeanna Parsons Leigh. 2020. “Allocation of Intensive Care Resources During an Infectious Disease Outbreak: A Rapid Review to Inform Practice.” BMC Medicine 18, no. 404: 1–17. https://doi.org/10.1186/s12916-020-01871-9.
Jonsen, Albert R. 1990. The New Medicine and the Old Ethics. Cambridge, Mass.: Harvard University Press.
Kant, Immanuel. 1956. Critique of Practical Reason. Translated by Lewis White Beck. New York: Liberal Arts Press.
Kass, Nancy, Jean Otto, Daniel O’Brien, and Matthew Minson. 2008. “Ethics and Severe Pandemic Influenza: Maintaining Essential Functions through a Fair and Considered Response.” Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 6: 227–236. https://doi.org/10.1089/bsp.2008.0020.
Kirby, Jeffrey. 2010. “Enhancing the Fairness of Pandemic Critical Care Triage.” Journal of Medical Ethics 36 (12): 758–761. https://doi.org/10.1136/jme.2010.035501.
Marsh, Richard. 2006. “Hard Decisions Will Have to Be Made: View from Intensive Care.” BMJ (Clinical research ed.) 332 (7544): 790–791. https://doi.org/10.1136/bmj.332.7544.790.
NYTFLL (New York State Task Force on Life and the Law). 2015. Ventilator Allocation Guidelines. New York State Department of Health (New York, USA). https://www.health.ny.gov/regulations/task_force/reports_publications/docs/ventilator_guidelines.pdf.
O’Mathúna, Dónal. 2016. “Ideal and Nonideal Moral Theory for Disaster Bioethics.” Human Affairs 26 (1): 8–17. https://doi.org/doi:10.1515/humaff-2016-0002.
Truog, Robert D., Christine Mitchell, and George Q. Daley. 2020. “The Toughest Triage—Allocating Ventilators in a Pandemic.” New England Journal of Medicine 382 (21): 1973–1975. https://doi.org/10.1056/NEJMp2005689.
Verweij, Marcel. 2009. “Moral Principles for Allocating Scarce Medical Resources in an Influenza Pandemic.” Journal of Bioethical Inquiry 6 (2): 159–169. https://doi.org/10.1007/s11673-009-9161-6.
Walker, Paul, and Terence Lovat. 2019. “Dialogic Consensus in Medicine—A Justification Claim.” The Journal of Medicine and Philosophy 44 (1): 71–84. https://doi.org/10.1093/jmp/jhy038.
White, Douglas B., and Scott D. Halpern. 2020. “Allocation of Scarce Critical Care Resources During a Public Health Emergency: Executive Summary. ” University of Pittsburgh School of Medicine (Pittsburgh: University of Pittsburgh School of Medicine). https://bioethics.pitt.edu/sites/default/files/Univ%20Pittsburgh%20-%20Allocation%20of%20Scarce%20Critical%20Care%20Resources%20During%20a%20Public%20Health%20Emergency.pdf.
White, Douglas B. and Bernard Lo, “A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic,” Journal of the American Medical Association 323, no. 18 (2020): 1773–1774, http://jamanetwork.com/article.aspx?doi=10.1001/jama.2020.5046.
Legal constraints are beyond the scope of this contribution but are discussed in the New York State Task Force on Life and the Law, Ventilator Allocation Guidelines (NYTFLL 2015, 61-71).
Cite as: Paul Walker, “Triage in a Pandemic: Equity, Utility, or Both?,” Ethics & Medicine 36, no. 3 (2020): 147–152.
About the Author
Paul Walker, OAM, MBBS, PhD, FRACS, FACS
Paul Walker, OAM, MBBS PhD, FRACS, FACS, is a Surgeon and Conjoint Professor in Surgery and the Clinical Unit in Ethics and Health Law, in the Faculty of Health and Medicine, University of Newcastle, NSW, Australia.