Principles of Medical Ethics

Western medical ethics have been traditionally guided by 4 broad principles: autonomy (respecting the decision-making capacity of individual patients through informed consent), beneficence (balancing risks and benefits of a given action), nonmaleficence (avoiding the causation of harm), and justice (distributing risks and benefits fairly).Reference Beauchamp and Childress17 Within the context of these ethical norms, triage is the “well-established process of finding the most appropriate disposition for a patient based on an assessment of the patient's illness and its urgency.”18 As commonly used in clinical and public health settings, triage aims to guarantee that limited resources are justly allocated to some patients, while attempting to avoid direct, intentional harm to other patients in need of treatment or therapeutic interventions. Triage assumes that not all persons requiring care can be readily accommodated.Reference Kessel19

Ethical triage decisions consider and appropriately balance the 4 tenets of Western medical ethics. In making triage decisions the clinician is not expressly violating patient autonomy, but the patient is not engaged in an active process of informed consent. Instead, consent to “be triaged” is implicit in consent to receive medical care. This implicit consent is founded on societal norms that have come to accept clinical triage as a reasonable and ethical means to distribute scarce medical resources. Although triage has been challenged as an acceptable model for rationing medical care because of its presuppositions based on utilitarian and salvage ability principles,Reference Bell20 to date no serious alternative has been proposed.Reference Hardin21 Triage remains widely accepted as the preferred model for the ethical distribution of scarce medical resources in everyday clinical settings.

Expected Clinical Benefit

The foremost clinical criterion underpinning ethical triage decisions is expected outcome in survival and function.18 For triage decisions to be considered fair, just, and ethical, the medical resource must be allocated with prudence.Reference Winslow Gerald22 Patients with injuries that are so severe that treating them would be medically futile are not considered appropriate candidates for receiving scarce resuscitative resources.

Triage is applied in various contexts of medical resource scarcity: routine clinical care, military operations, and public health or population-level emergencies. Therefore, the goals of triage in different environments and contexts can lead to divergent perspectives of what constitutes ethically sound triage decision making. Military battlefield medicine explicitly allocates scarce resources by giving priority to soldiers based not only on greatest clinical need but also on an evaluation of which soldiers should be treated first to accomplish specific strategic or tactical operational goals (ie, winning the war), often without attention to the principles of justice that buttress ethical civilian triage.Reference Winslow Gerald22 This often implies giving priority to soldiers who are most likely to rapidly return to duty. In the civilian sector, intensive care units (ICUs) are the most familiar sites of inpatient triage. In ICUs, where utilization of highly specialized, advanced acute care has increased and bed space has decreased, rationing by triage is a fundamental reality of daily operations.Reference Sinuff, Kahnamoui and Cook23 However, neither the military nor the ICU models of triage provide entirely appropriate prototypes of lifeboat triage for the creation of inpatient hospital surge capacity in the context of a high-consequence event. Triage decisions in these extreme cases do have life-and-death consequences.Reference Hartman24

Utilitarian Perspective

Triage decisions in routine clinical care and during a high-consequence event are made from a utilitarian, population perspective, that is, “the greatest good for the greatest number.”Reference Hartman24, Reference Rubinson, Nuzzo and Talmor25 The well-being of the affected population is the highest priority. This approach maximizes the number of saved lives, while minimizing the number of deaths in those who will “probably live only if treated.”Reference Winslow Gerald22 This utilitarian perspective diverges from the egalitarian principle guiding daily life, which states that “the rights of people to have their needs met are essentially equal.”Reference Winslow Gerald22 Potential inequalities in the distribution of resources could occur but should be bound within the parameters of providing the greatest benefit to society as determined by the specific, immediate needs of the affected population during a high-consequence event.

Proportionality

Discharging patients prematurely is a cornerstone of the lifeboat principles outlined here and requires a discussion of the ethical principle of proportionality. In the case of inpatient discharge triage decisions in a disaster, proportionality requires a balancing of risks and benefits for all patients under an entity's jurisdiction affected by triage decisions. A minimal threshold of benefit that exceeds risk must be reasonably expected. In other words, the potential medical benefits to incoming patients should be at least equal to, but ideally greater than, the potential risks of not receiving care for discharged patients. Proportionality best represents the lifeboat in crises. The needs of all, those “in the boat,” and those still “in the water” are considered on equal terms. More specifically, the medical needs and thus access to limited resources of individual victims of the disaster are considered equal to the needs of those already using the resource. Because some patients will inevitably be discharged or have a medical resource reassigned to another, this principle assumes that the risk of adverse events to patients who have care suspended does not exceed the risks to victims of the disaster if care is denied or delayed.

Providers acknowledge the valid expectation on the part of patients and families that care, once commenced, will continue. There is an expectation that inpatients are receiving some benefit from their hospital admission. Cessation or withdrawal of treatment represents an unexpected breach of implied obligation.Reference Beauchamp and Childress17 In critical care settings it has generally been considered unethical to cease life-sustaining therapy for the benefit of another.Reference Truog26 The standards of care would be altered in a disaster scenario,4, Reference Wise27 however, allowing for the imposition of lifeboat ethics.

Still, this is not an easy transition, even during a critical event. Although the clinical outcomes may be similar and even ethically equivalent, withholding and withdrawing medical care may not be considered the same in an inpatient setting.Reference Levin and Sprung28, Reference Vincent29 In a clinical setting the termination or suspension of ongoing care is difficult. At least 1 survey suggests that physicians have greater difficulty withdrawing than withholding treatment.Reference Tallgren, Klepstad, Petersson, Skram and Hynninen30 The withdrawal of care from 1 group of patients to favor another group of patients (however justified) during a disaster is a foreign concept to most clinicians because such action does not focus on the welfare of individual patients,Reference Koenig, Cone, Burstein and Camargo31 as it does in routine practice. The principle of proportionality requires that bed allocation and policy be based on suitability.Reference Kalb and Miller David32

Justice and Empirically Based Triage

It may be argued that augmenting surge capacity through premature discharge would result in unacceptable rates of adverse medical events. However, even under routine conditions, there is a considerable risk for adverse events in the postdischarge period. Up to 19% of patients in the 2-week postdischarge period from inpatient medical units experience adverse events.Reference Forster, Murff, Peterson, Gandhi and Bates41 The probability of adverse events among patients whose inpatient care is suspended to create hospital surge capacity could be greatly reduced by the development of evidence-based, empirical clinical criteria to predict which patients are at the least risk for an adverse event upon discharge at any given point during their inpatient stay.Reference Kelen, Kraus and McCarthy7, Reference Kelen and Kraus34

The process of establishing objective inpatient triage decision processes is not only important in reducing clinical risks associated with improper discharge but it is also an important step in protecting the ethical principles that guide a just, fair process of lifeboat triage. Without guidelines, lifeboat decisions will be left to the individual judgment of bedside providers, hospital administrators, or public health officials. As evidenced in the aftermath of Hurricane Katrina, ad hoc lifeboat triage decisions expose both patients and providers to the potential chaos caused by ethical dilemmas made under duress and clouded by emotion during a high-consequence event. Ad hoc decisions also exacerbate the potentially subjective and ambiguous definitions of futility and benefit and could make the provider more vulnerable to legal liability, given that case law suggests that such decisions be conducted in a “medically reasonable manner.”Reference Hartman24 Unfortunately, perhaps the greatest limitation of ad hoc decision making is providers' unconscious or overt bias. Racial and ethnic disparities in care remain real for health care providers and patients alike. An objective system of comparing risk and benefit, as has been proposed,Reference Kelen, Kraus and McCarthy7 neutralizes such bias and restores equity and fairness.

By using an objective, methodological approach to lifeboat triage for the creation of hospital surge capacity, the potential biases of the subjective terms triage, benefit, and utility are minimized and the focus is placed on maximizing medical benefit for as many patients as possible. In addition, an objective, structured decision-making process for the triage of inpatients is requisite so that public health professionals, clinical care providers, third-party payers, and, most important, patients have a common language they can use in the discussion of resources allocation in the face of dire scarcity.18 The acceptability of risks in medical decision making should be determined using the most objective estimates available.Reference Beauchamp and Childress17 Risk-stratifying patients using empirical data provides these objective estimates. The development of objective criteria for the early discharge of inpatients makes the process of lifeboat triage legitimate and helps to ensure ethical decision making when the capacity of the lifeboat must be expanded.

Autonomy and Consent

Lifeboat triage policies should be transparent and publicly communicated. Arguments have been made for full-scale public debate regarding the balance between efficiency and equity in disaster triage policy.Reference Veatch38 Community values and expectations regarding the use and distribution of medical resources during a disaster are fundamental in the formulation of triage guidelines. In essence, lifeboat triage, as presented here, should be acceptable to the community at large.Reference Winslow Gerald22 Community consent will be more likely if community input and inquiry are sought during the disaster triage policies' development process. Input from the community could be garnered through a variety of mechanisms, including the appointment of community representatives to lead local discussion groups and larger town hall meetings. These mechanisms have proven successful in guiding population-level health decisions that are ethically challenging.Reference Hines42

To respect patient autonomy through the process of informed consent, hospitals should inform patients during the admission process that there is the possibility that their care will be terminated or suspended in the unlikely occurrence of a high-consequence event so that resources can be reassigned to other patients who are in need of more urgent or intensive medical care. Assuming that evidence-based protocols are available, patients should be informed that decisions will be based on actuarial risk-potential data. Rehearsing and training in lifeboat triage decisions in concert with other disaster and emergency response efforts would be advisable. Training should create awareness among all of the stakeholders (eg, clinical providers, administrators, patients, community) of how and why certain triage decisions could be made during a disaster. Similarly, methods to ensure accountability and analysis of triage outcomes to ensure fairness should be part of health system planning. Without an open discourse with patients, surrogates, and the larger community about the processes of lifeboat triage, there is the possibility of the perpetuation of patient suspicion and distrust, as occurred post-Katrina.