Triage of critical care resources in COVID-19: a stronger role for justice

Abstract

Some ethicists assert that there is a consensus that maximising medical outcomes takes precedence as a principle of resource allocation in emergency triage of absolutely scarce resources. But the nature of the current severe acute respiratory syndrome-related coronavirus 2 pandemic and the history of debate about balancing equity and efficiency in resource allocation do not support this assertion. I distinguish a number of concerns with justice and balancing considerations that should play a role in critical care triage policy, focusing on discrimination and on fundamental egalitarian and social justice concerns.

Promoting racial equity in COVID-19 resource allocation

“…Others have also recently voiced the importance of ‘balancing justice and outcomes in [COVID-19] emergency triage’ and demonstrate how values pluralism is already embedded within accepted clinical practice. 10 We agree and we shun a ‘“single principle” distributive view’ 11 in favour of one that can account for both MLS and racial equity. This paper dismantles the arguments against the confrontation of racial inequity within COVID-19 triage protocols, highlights concerns related to existing proposals and proposes a new paradigm to grant more patients of colour access to scarce COVID-19 resources.…”

Evolving an ethical framework for Covid-19 management in India

“…These included a failure to considering alternatives to conventional triage, especially when allocating lifesaving intensive care resources to multiple patients having similar prognosis and life expectancy in case of recovery. Globally, ethicists have struggled to reconcile the utilitarian, egalitarian, and social or instrumental value-based approaches towards pandemic triage that favour maximisation in terms of lives saved, social justice, and recognition of social utility, respectively (8,26). In developing countries including India, the challenge and necessity for establishing an ethically robust pandemic triage model are [4] ostensibly supporting public health measures can be abused by authoritarian governments for imposing punitive measures against political dissidents (37).…”

“…We would like to thank the two peer reviewers whose insightful and critical comments greatly [7] Indian Journal of Medical Ethics Published online first on March 27, 2021. [8]…”

“…Globally, pandemic ethics has reflected tensions arising from the failure of consensus-building towards the most effective means for controlling the pandemic, reducing the loss of lives, and minimising the negative economic impact on the community (8). In the Indian context, the health, sanitation, and housing systems' preexisting vulnerability, high burden of comorbidities, widespread nutritional deprivation, and the global economic downturn further increase the population's susceptibility to a pandemic (9).…”

Prioritizing critical-care resources in response to COVID-19: lessons from the development of Thailand's Triage protocol

“…In normal circumstances, health workers observe four basic ethical principles in patient care: (i) maximum patient benefit (beneficence); (ii) do not expose the patient to any additional harm (nonmaleficence); (iii) respect for autonomy; and (iv) justice. However, in a scenario of scarce medical resources brought about by a public health emergency in Thailand, consensus was reached in the stakeholder consultation meetings that there is a need to prioritize “maximizing total benefits for the society” over “the good of the individual patient.” Deciding how to ration access to critical care brings with it grueling ethical dilemmas; for instance, a utilitarian model of triage can compromise egalitarian principles and vice versa (19). This complexity necessitates a transparent and inclusive protocol development process that ensures ethical allocation decisions are grounded in societal values as well as expert input.…”