6. Anesthesiologists, the state, and society
46. Triage in civilian mass casualty situations
Susan K. Palmer
A small community hospital located several hundred miles from any other hospital gets word that it is about to receive 100 casualties from a F-5 tornado that touched down five miles away. All elective surgeries are cancelled, and surgeons are encouraged to quickly complete ongoing procedures. An anesthesiologist is assigned to perform “front door triage” – deciding which casualties go directly to the OR, which can wait for treatment, and which can probably not be saved. At least 20 casualties are expected to need critical care or urgent surgery. There are five operating rooms. The ICU consists of eight beds, and is full. The local blood supply consists of 20 units of RBCs, including only four O negative units. Resupply of blood and other critical provisions is several hours away.
The American Medical Association’s Code of Medical Ethics states:
Individual physicians should take appropriate advance measures to ensure their ability to provide medical services at the time of disasters, including the acquisition and maintenance of relevant knowledge.1
In medical triage, a “disaster” is defined as an incident in which local response resources are overwhelmed by patient needs. Recent terrorist attacks, catastrophic earthquakes, and potential global pandemics have resulted in more discussion and effort towards planning for the next mass casualty situation.
General principles of civilian triage should be familiar to all physicians. Isolated instances of mass casualties can happen in a region with only one small hospital, and any physician may be called upon to act as a triage officer. Anesthesiologists in particular have special knowledge useful in triage – airway assessment and management, fluid and blood resuscitation, intensive care expertise and knowledge of surgical treatment and local operating room capabilities.
Principles of civilian versus military triage
Military triage is an example of a situation in which limited medical resources must be allocated among multiple casualties. The goals of combat medicine are to return the greatest number of soldiers to combat, and then to preserve life. Seriously wounded soldiers may be quickly stabilized, but then wait while attention turns to returning less seriously wounded soldiers to the battlefield. (For a discussion of military triage principles, see Chapter 47.) Combat triage principles do not appropriately address civilian mass casualty situations in which survival, not combat-readiness, is the main goal of medical treatment.
Ethical principles of civilian triage
Traditional medical ethics teaches that a physician should put their patients’ interests ahead of his or her own interests or preferences and also ahead of the interests of any other patients. In mass casualty situations traditional patient-centered ethical principles of medicine may have to yield temporarily to the consequentialist (or utilitarian) principle of “doing the most good for the greatest number.” Consequentialism was described by the British philosopher and socialist, Jeremy Benthamand, and was further developed by James Mill and his son John Stuart Mill. Consequentialism does not value an individual as much as the collective group of people affected in a mass casualty situation. Individuals may even be viewed as a “means to an end” when applying consequentialist principles in practice. In the words of Jonsen and Edwards,
This [disaster] is one of the few places where a “utilitarian rule” governs medicine; the greater good of the greater
Table 46.1. Catagories and color-coding for casualties in civilian disasters
number rather than the particular good of the patients at hand. This rule is justified only because of the clear necessity of general public welfare in a crisis.2
Patients’ trust in the medical profession is based heavily on the belief that physicians will do what is best for them individually. Utilitarian decision-making has the potential to erode that trust, if it is perceived that such decisions are made capriciously or are based on subjective judgments. Therefore, decisions about which patients will receive limited medical care resources in a disaster must be based on thoughtful criteria that are agreed upon and transparent to the community of patients. A number of models of medical triage in civilian mass casualty situations are available. For one example of triage criteria, see Table 46.1.
The principle of justice dictates that criteria for triage of civilian patients must be based on their medical condition and not on their social connections. Ethically acceptable criteria for withholding or withdrawing care from patients could include the likelihood of benefit from medical care, the urgency of need for care, and the availability of the resources needed to care for a particular patient. Unacceptable criteria might include social worth, patient contribution to their illness/injury, or the patient’s ability to pay for care. No patient group should receive special consideration in a disaster situation, other than that dictated by their physiology – including children.
Such principles of justice may be difficult to strictly follow, however, since judgments of social worth are nearly inevitable sometimes. For example, if some of the survivors of a tsunami are healthcare workers with minor injuries, they might be given priority for treatment because of their value in then being able to help others. Physicians might be given the first doses of protective vaccine in a pandemic, so that they will not become infected and will be able to care for those who are. Such decisions amount to prioritization based on social worth, but may be justified in this very restricted context if the individual’s abilities are indispensable to the larger goal of this disaster’s containment. The decisions should be strictly limited to only those skills that are essential to the successful management of the disaster, and not to general social assessments.3
The risks of consequentialism
When physicians are forced into mass casualty situations where they must temporarily abandon the usual ethical principles of medicine, then they must recognize that what they are doing is distinctly different from what would be acceptable in the normal course of patient care. Consequentialism, especially when it is not recognized as distinctly different from usual medical ethics, can subvert the patient-centered values that form the bedrock of medical professionalism.
A historical example of the subversion of patient-centered ethical values by consequentialist arguments can be found in the “Nazification” of the medical profession in pre-WWII Germany.4 In a decades-long process, German physicians were gradually convinced to adopt consequentialist principles in medical decision-making in order to serve the interests of the “state” as the highest “good” and to bring the “greatest happiness” to the greatest number of people. The process began with the replacement of academic physicians at universities with patriotic doctors who were not qualified as teachers or researchers and were less likely to question the shift in ethical decision-making. Physicians were promoted to positions of power on the basis of their political beliefs, and became increasingly involved in judgments regarding the “social worth” of certain groups of patients. They were then recruited to research “humane” methods of killing persons whose social worth was questioned. Consequentialist-type reasoning was offered to convince physicians that they were doing what was best for the “greatest number” of Germans. Ultimately, refusal by physicians to participate in these activities was branded as “unpatriotic,” and therefore harmful to society.
Consequentialism may be a legitimate ethical framework in which to make decisions regarding how resources should be allocated when mass casualties overwhelm the traditional delivery of medical care, but is not the ethical framework applied to usual medical care.
Once initial triage is performed to decide which patients do not need immediate care (the walking wounded, and the dead or near-dead), another set of decisions face providers in facilities to which the survivors are evacuated. During public health disasters, hospitals perform as “lifeboats,” with finite capacity to “surge” to meet the medical needs of arriving casualties. The extent of a hospital’s ability to “surge in place” depends on ability to acutely increase staff, the current status of critical supplies, the number of available beds, and the capacity to “create” available beds, among other things.
One consideration is the re-allocation of hospital beds from current inpatients to future ones, in a process sometimes called “reverse triage.” In reverse triage, patients who are capable of being cared for in lower acuity beds or at home are discharged to make room for incoming casualties.
The primary principle in disaster triage is utilitarian in aiming to provide the most benefit for the most people. Therefore reassignment of resources away from existing patients must meet a test of proportionality – there should be at least as much, and preferably significantly more potential benefit expected for the incoming casualties, than there is potential for harm to those hospital patients who are reassigned. Kraus and colleagues describe such considerations as “lifeboat ethics.” The needs of all – those in the lifeboats and those still in the water – are treated equally.5
Lifeboat ethics create concerns about breach of expectations to existing patients. Inpatients expect that they are benefiting from the hospitalization, and may therefore be harmed by early discharge. Some argue that in a public health disaster, all patients are equal, and therefore the priority of any existing patient, in the lifeboat or outside of it, is re-triaged in the setting of the mass casualty event. By this reasoning, it might be ethical to balance the likelihood that discontinuing “futile” care to an inpatient and reallocating resources to a “more salvageable” casualty will result in greater benefits than continuing critical care to a moribund patient while the casualty is denied the resource. Thus, a terminally ill ICU patient might be transferred to comfort care measures – in much the same way as a “black” listed pre-morbid casualty might be – so that another injured patient whose survival is more likely can occupy the bed.
As with other forms of triage, “lifeboat” triage should be transparent, and based on empirical data and community approval. In promoting disaster preparedness, hospital administrators who consider developing lifeboat triage policies should do so with considerable community input.
Several measures have already been taken to prepare for the arriving casualties. An assessment of the current status of all operating rooms has been made, and the operating rooms are being freed as soon as possible to accept casualties. All available staff have been contacted and asked to report to the hospital. The hospital, in other words, is preparing to “surge” as much as possible. The available blood has been inventoried, as well as an assessment of when resupply is likely to be possible. All of this information is helpful to the triage officer in allocating resources.
When casualties arrive, all patients who do not need immediate attention, either because they are not seriously injured, or because they are not expected to survive their injuries, should wait for resource-intensive treatment. Seriously and critically injured patients who have a potential to survive will receive first intensive treatment. The anesthesiologist should continue to reassess casualties even after they arrive, to “re-triage” if they later fit a different triage category, or as supplies arrive and more resources become available and can be extended to them. An assessment should also be made regarding how many hospital beds are available, and whether any inpatients can be allocated to lower acuity beds, or discharged home.
The recent earthquakes in Haiti and Chile underscore the need for physician and hospital preparedness should a natural disaster strike. Merin and colleagues describe the process of inventorying and managing limited resource, including the formation of triage consult committees to aid in difficult on the ground decision-making. Knowledgeable and prepared physicians are desperately needed in times of mass casualties, to have the best chance of providing life-saving care to as many people as possible.6
• During mass casualty situations, the goals of medical management change from those focusing on individual patient benefit, to more utilitarian principles of “doing the most good for the most people.”
• Civilian casualty triage differs from military triage. In military triage, a primary goal is returning the less severely wounded to combat. In civilian triage the goal is overall survival. Thus, victims not expected to survive may be allocated to lower treatment priority than those who have survivable injuries.
• Consequentialism is not philosophically supportable as an ethical basis for the best medical care because it approves of using individual patients as a means to achieve certain ends for others.
• Triage in mass casualty events should be based on principles of justice that treat all patients equally, and from the perspective of their medical condition rather than social worth.
• However, “social worth” may be applicable in very limited interpretations, when the particular skills of the individual are critical to managing the disaster itself. One example is allocation of vaccines to physicians in pandemics so that they remain well and continue to treat victims.
• “Lifeboat” ethics may lead to decisions to reallocate resources away from existing hospital patients in order to provide capacity to treat disaster victims.
• Triage should be based on ethically sound principles, should be transparent, should include public input, and should be developed before disaster strikes.
1 American Medical Association Code of Medical Ethics, Opinion 9.067. Physician obligations in disaster preparedness and response. Adopted June, 2004. AMA, Chicago, IL.
2 Jonsen, A. and Edwards, K. Resource allocation in Ethics in Medicine, University of Washington School of Medicine. http://eduserv.hscer.washington.edu/bioethics/topics/resall.thml.
3* Beauchamp, T.L. and Childress, J.F. (1994). Justice in Principles of Biomedical Ethics, 4th edn. NY: Oxford University Press, pp. 386–7.
4* Lifton, R. J. (1986). The Nazi Doctors, Medical Killing and the Psychology of Genocide. New York, NY: Basic Books.
5* Kraus, C.K., Levy, F., and Gabor, K. (2007). Lifeboat ethics; considerations in the discharge of inpatients for the creation of hospital surge capacity. Disaster Med Public Health Prep, 1(1), 51–6.
6* Merin, O., Nashman, A., Levy, G., et al. (2010). The Israeli field hospital in Haiti – ethical dilemmas in early disaster triage. New Eng J Med, published online, March 3.
Code of Medical Ethics of the American Medical Association. (2006). Council on Ethical and Judicial Affairs, current opinions with annotations 2006–2007 edition. AMA, USA.
Devereaux, A.V., Dichter, J.R., Christian, M.D., et al. (2008). Definitive care for the critically ill during a disaster: a framework for allocation of scarce resources in mass critical care. Chest, 133, 51S–66S.
Moreno, J.D. (2004). In the Wake of Terror. Medicine and Morality in a Time of Crisis. The Cambridge, MA: MIT Press.
Trotter, G. (2007). The Ethics of Coercion in Mass Casualty Medicine. Baltimore: The Johns Hopkins University Press.
VA Office of Public Health and Environmental Hazards: www.vethealth.cio.med.va.gov/
Veterans Health Administration – Central Office:Pandemic influenza in general, www.pandemicflu.gov.
National Center for Ethics in HealthCare.www.ethics.va.gov.