It was Dominique-Jean Larrey, a rugged French military surgeon in Napoleon’s Grande Armée, who came up with the system of triage. On the battlefield Larrey, who tended to the wounded at the battle of Waterloo, had to determine which soliders needed medical attention most urgently, regardless of their military rank. In doing so he came up with the concept of distinguishing between urgent and non-urgent patients. Triage, from the French trier (“separate out”) remains as useful today as it was in the Napoleonic campaigns.
Yet most doctors today have rarely been in battlefield conditions.
Most physicians are not trained as wartime medics.
We have never before faced these battlefield triage decisions.
The covid-19 pandemic has changed that.
The coronavirus pandemic is upon us. This novel virus has disrupted lives, killed people, and wreaked havoc with our economy. COVID-19 has also raised novel ethical questions and generated ethical duties for the public, health professionals and the government. Just as our health system has been caught off guard, so have our ethics.
As our society struggles to come to terms with the COVID-19 pandemic, for which our resources to treat the ill may well prove inadequate, difficult and heart-wrenching decisions may have to be made by physicians and nurses.
We owe them as much guidance as possible, and we should want that guidance to be framed in ways that protect our society—and each of us individually—from temptations that will come all too readily to mind.
In cases where decisions must be made about who shall be saved when not all can be saved, we also decide what sort of culture we want ours to be—we are constituting ourselves as a certain kind of people, a “Bayanihan Nation”.
When faced with scarcity, some will be tempted simply to pass by those who are older, the physically disabled or cognitively impaired, those who seem to have little to contribute to our common life. Indeed, some of the proposals for treatment allocation that have been made in different Western countries may already reflect a yielding to that temptation.
The general principles that guide care for individual patients are the duty to help the sick and respect their autonomy.
The general principles that guide public health ethics are concern for the common good and justice.
In the current crisis, these principles all come into play.
We are all in this together.
Even if the personal risk for an individual is not great, the risk to the common good is immense.
But the measures taken to mitigate the effects of the virus must be just and fair.
“A basic tenet of ethically conducted triage is that the degree of rationing through triage is proportionate to the anticipated or realized shortfall in resources.”
- * Barnett DJ , Taylor HA , Hodge JG, Jr. Resource allocation in the frontlines of public health preparedness and response: Report of a Summit in Legal and Ethical Issues . Public Health Rep . 2009 ; 124 ( 2 ): 295 – 303 .
* Published in the United States after the lessons they learned in 9/11 and SARS.
Therefore, the rationing of critical care should be held as a LAST RESORT, and only implemented when all attempts have been made to optimize the use of resources, augmentation to include all efforts to acquire scarce critical resources or to transfer patients to other health-care facilities that are able to provide care.
Ideally, to enable timely decisions and avoid duty-to-care conﬂicts, triage oﬃcers should not be involved in triage and direct care of patients requiring triage simultaneously.
Using a triage team comprising a senior intensivist and another senior physician from an acute care background may have advantages.
This ensures that at least two perspectives are provided on each case, one estimates the probability of good outcome with intensive care and the other without intensive care.
Furthermore, a team approach may mitigate some of the emotional burden associated with sole decision-making.
In limited resource settings, particularly in middle-and low-income countries, (which is us! The Philippines, a very third world country where Health Services are on the lowest priority of both gov’t and individual families) triage and refusal of ICU admission are everyday occurrences.
In these settings, well-established triage systems may exist; therefore, it is suggested that it is most appropriate to continue using the existing model for triage decision-making rather than implementing a new process during a disaster or pandemic.
But if worse comes to worst. We need to formulate some guidelines in the allocation of scarce resources during this pandemic.
But first let us address the elephant in the living room, or as in Spain they say the octopus in the garage:
One point of contention that is particularly intriguing is whether health care workers should be prioritized.
Many feel that they should.
Medical professionals are a scarce resource, the logic goes, akin to N95 face masks.
We must do everything we can to conserve them.
Others argue based on morale. Fighting a pandemic with limited resources is hard enough—doctors and nurses may mutiny if their well-being isn’t considered paramount. And then there is the issue of competing obligations. Sure, health care workers are responsible for caring for the sick, but they also have commitments to their own families and neighbors.
Medical ethics emphasizes that physicians have a duty to care for patients, even in crisis. Should we doctors be willing to serve, no matter the cost, and to put ourselves last?
For some of us, the answer is yes, even if the personal protective gear proves inadequate. Some are not afraid to die, and it doesn’t seem too much to ask. But this isn’t the case for everyone.
Massive teams are involved in caring for patients—not least, those who provide meals, security, and environmental services. Consider this last group. The hospital would completely fall apart if the cleaning crew went on strike—especially now, with our unprecedented guidelines for deep sanitization of public spaces. Janitorial staff are as critical to the care of patients as doctors.
All of us in health care depend on an even wider circle of essential workers in grocery stores, pharmacies, delivery services, public safety, and transportation.
As with frontline health care workers, large numbers of people in all of these groups are falling sick. Would my physician colleagues agree that they also should receive priority for ventilators?
The truth is that there is an ordinary sort of heroism—that of doing one’s work well and resisting fear. Every day at the hospital, we encounter ordinary heroes.
In the midst of this crisis, we need to call one another to ordinary heroism.
- *Moral Guidance on Prioritizing Care During a Pandemic – Public Discourse = A Joint Statement
- *Respirators, our rights, right and wrong: Medical ethics in an age of coronavirus – New York Daily News
- *A Call to Ordinary Heroism | L. S. Dugdale | First Things
JOSEPH A. CORDERO, MD, FPCS, FPALES, FPSGS Husband and Father; General Surgery; Minimally Invasive Surgery and Surgical Endoscopy; Breast and Soft Tissue Surgical Oncology; Surgical Education and Training; Medical Ethics and Bioethics