Photo Credit: Yossi Zeliger/Flash90
Sheba Medical Center team at the coronavirus isolation ward, June 30, 2020.

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 characterizing the triage scenario, but this entails the horror of selection. But the COVID-19 pandemic challenges this perspective and raises questions about the morality of triage.

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“A lack of intensive care ventilation units owing to rapidly increasing infection rates numbers among the most significant nightmare scenarios of the corona pandemic,” says Mathias Wirth, Head of the Ethics Department in the Faculty of Theology at the University of Bern, because: “Shortages of supply can result in triage of patients suffering from severe cases of COVID-19 and thus force a life or death decision.”

Here, triage means favoring some COVID-19 patients over others depending on urgency and prognosis. Together with experts from Yale University, King’s College London, Charité Berlin and Essen University Hospital, medical ethicist Mathias Wirth has prepared a statement on these difficult decisions. The statement was published in the American Journal of Bioethics (AJOB), the most frequently cited scientific journal in the entire field of ethics (The Meaning of Care and Ethics to Mitigate the Harshness of Triage in Second-Wave Scenario Planning During the COVID-19 Pandemic).

The experts warn against the possibility of prematurely implementing triage; even though triage allows for decisions based on fairness in extreme situations, it leads to significant strain on the affected parties, relatives and medical personnel. In order to avoid it, every effort must be made to transfer seriously ill patients to other hospitals without shortages of supply – across country borders in case of emergency, according to the authors.

In concrete terms, Mathias Wirth’s team of researchers recommend increased regional, national and even international collaboration in intensive care for COVID-19 patients in preparation for future waves of infection. “Just because triage is correct under some circumstances does not mean that it is correct under all circumstances,” says Wirth. “There is no real and legitimate triage situation as long as treatment spaces are available elsewhere.”

Secondly, a negative triage decision for individual people should not under any circumstances mean that their medical and psychological care is neglected. Quite the opposite: If they are deprived of a ventilator, maximum effort is required for their care and treatment, both for them and for their relatives.

The statement from Wirth et al. presents all stakeholders who advocate for more collaboration in the future situation with strong arguments. Because the judgments associated with triage give too little consideration to moral problems, according to medical ethicists.

“The suffering that triage decisions involved for patients, relatives and medical personnel in the epicenters of the first wave attests to this,” says Wirth. Thanks to the recommendations, triage planning can be classified more clearly as a last resort, meaning that alternatives must be afforded greater attention.

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