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Posted on June 3, 2020 at 9:00 AM

by Mathias Wirth, Ph.D.; Laurèl Rauschenbach, MD; Brian Hurwitz, MA, MSc, MD, FRCP, FRCGP; Heinz-Peter Schmiedebach, MD; Jennifer A. Herdt, Ph.D

Although the number of severely ill people is declining in some epicenters, there is a risk of a second wave of COVID-19 infection with a large number of patients who are likely to require ventilation or other forms of intensive care. In the current state of the pandemic, second-wave scenario planning should give consideration to alternatives to triage. The shortage of ventilators showed that despite the existence of triage guidelines, moral questions remain. Care ethics suggest that considerations of justice offer incomplete responses to moral dilemmas. Based on this we offer a perspective for second-wave scenario planning. The most significant recommendation is that future patients should be taken to other regions or countries for ventilators, or ventilators should be flown to where they are needed. This would help to avoid – at least partially – the harshness of triage for patients and medical staff.

Art by Craig Klugman

Triage is designed as a strategy for exceptional circumstances and is associated with intricate ethical dilemmas. Where medical personnel, equipment, or medicines do not suffice, the principles of triage determine how they will be allocated. Sufficient resources and rescue equipment must therefore be kept on standby to prevent triage from becoming a necessity. It is only by de-emphasizing the perspective of the individual patient that one can refuse care for those in need of it. Positive justice connotations make consistency in allocation of scarce resources the dominant value in characterising the triage scenario, but this entails the horror of selection. The COVID-19 pandemic challenges this perspective and raises questions about the morality of triage. It would be counterintuitive to abandon triage in times of a pandemic, because one must choose how to allocate scarce resources and the alternatives, such as selecting which patients to help at random or according to first come first served, which are morally unconvincing due to their blindness to relevant medical and moral differences. However, triage as a last resort conceals a broader set of ethical considerations capable of expressing the core principle that each person matters equally. It is unbearably difficult for a patient and their families and friends not to interpret a classification based on specific triage criteria as a moral judgment about the worth of an individual life. How can the unsubstitutable dignity of each and every individual be affirmed even as resources are given to some people and not to others? This is where the ethics of care comes into play, by framing the problem of the scarcity of medical resources as one not adequately solved by triage alone. Second-wave scenario planning during the COVID-19 pandemic presents an opportunity to prepare and implement alternative strategies to better avoid the need for triage procedures. The care perspective justifies medical, political, and economic action to avoid the need for triage during second waves of the current pandemic.

The imperative of medical aid provision within every emergency department is compromised as soon as a large number of patients are in need of treatment. Ethicist Judith Shklar articulates the associated problem very pointedly: “If the victims of catastrophes refuse to accept their misfortune and cry out in anger, then we hear the voice of the feeling of injustice.” The dark side of triage is not trivial; it is comprised of harms and injuries that exist as a direct result of proclaimed ‘acts of justice’. As such, triage can mean not providing comprehensive care to seriously ill COVID-19 patients, and to many other patients too.

For ethicist Joan C. Tronto, care ethics involves a critique of the ways in which justice is invoked to resolve moral dilemmas in medical contexts.  She avoids a theoretical resolution to the dilemmas posed by competing interests. Instead, she challenges regularism (‘it is not unjust because it corresponds to accepted rules’) and principlism (‘it is not unjust because it corresponds to the principles of age, prognosis etc.’). Justice provides an incomplete ethical lens on the situation; what needs to be addressed is its claim to completeness, especially in relation to triage’s claims to meet or solve all justice problems. Tronto wants to focus on the persistence of suffering. She calls the unconditional recognition of the needs of others the main focus of care ethics. Tronto is realistic enough not to conceptualize care activities without the criterion of justice in mind. In this respect, the intended repertoire of care is more comprehensive than that of justice, and helps to make it “more moral”. Such encompassing moral concern is becoming increasingly necessary even for criteria-based triage concepts, since moral qualms about saving one COVID-19 patient’s life over another’s cannot not be easily forgotten, even when such decisions are deemed fair by triage guidelines.  The psychological burden borne by medical personnel who must make such decisions is significant and long-lasting.

To address the serious problem of another possible shortage of ventilators or Extracorporeal membrane oxygenation (ECMO) for COVID-19’s second wave of patients with severe progression, where ventilators or ECMO may do more good than harm, two concrete recommendations for triage, from the perspective of this analysis, can be made which minimise the harmfulness of triage’s regularism and principalism:

Firstly, just because triage can determine who gets priority based on a fair system of criteria does not mean alternative options should be ruled out. When the number of patients requiring ventilators in a city or region increases enormously, everything possible must first be done to bring affected patients to other hospitals, cities, or even countries where ventilators are readily available. Based on the principle of caring and solidarity, elaborate cross-border coordination of unused ventilation equipment, be that the borders of cities, regions, or countries, along with the coordination of all available medical means of transport, must begin urgently in order to avoid the ethical problem of triage. The use of a triage that is designed according to fair criteria should be deemed immoral if there has not been every political and logistical effort made to fly out COVID-19 patients who are seriously ill but well enough to be relocated. Such a procedure leads to further questions: What if other cities or countries that lag temporally behind on the virus curve wish to hold off supplying their ventilators, to build up and conserve their resources for their population’s likely future needs? They could be reluctant to commit them to meeting the needs of others? These questions show the complexity of the current situation. However, from the perspective of care, including the fact that even well-prepared regions might need help in times of exploding numbers of patients, narrow and rigid understandings of justice do not allow for the “more moral” which these extraordinary circumstances require, to avoid the death of patients where neighboring regions have medical capacities available. Unlike in an earthquake or volcano the effects of which are confined the pandemic has not given rise to much sign of international cooperation. There is the anxiety that taking in additional patients during a second wave might compromise a country’s capacity to cope with its own patient needs, so planning for second wave must take account of the political and international context of the virus’s global spread. The co-operative element is not just about national borders which are shut but about other sorts of socio-economic borders. More cooperation in preparing a possible second-wave-scenario could significantly mitigate isolationist actions taken during the first wave of the pandemic, and allow an ethics of care to be followed much more closely than in the first wave.

Secondly, a negative triage decision for a COVID-19 patient must not mean that other medical attention, including psychological care, is neglected, and this should also extend to the patient’s relatives. On the contrary, maximum efforts must be made for medical and psychological care in spite of a triage decision to offer less medical treatment to a particular patient, which is labor intensive and expensive. Possible second-wave scenarios of the COVID-19 pandemic require implementations of measures that were undertaken either only minimally or not at all during the first wave of the pandemic.

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