Points to Consider: Triage in the Perspective of Catholic Bioethics
I. Introduction
Over the past several months, the virus causing COVID-19 disease has been spreading silently throughout the world, infecting hundreds of thousands of people. COVID-19 already has killed over eighteen thousand people worldwide, and it threatens to hospitalize and kill countless more as well as to overwhelm systems of health care delivery. As the pandemic spreads in breadth and depth, people are beginning to call for programs of triage and rationing of health care. How should Catholic health care professionals and administrators address these issues?
Triage is an organized process of determining the priority of treating patients based on the severity of their condition. Closely linked to triage in times of crisis or during emergency events is rationing, the controlled allocation of medical equipment, services, or resources, including the time and attention of health care professionals.
Health care triage outside war or mass casualty events from accidents, terrorism, or extreme weather has been unusual in the United States. Some guidance for triage in pandemics was developed following the SARS outbreak in 2002–2004 and the H1N1 crisis in 2009. But little research has been done to determine whether this triage guidance leads to optimal outcomes. Implementing strict triage and rationing plans in the context of patient care can raise a number of ethical questions. Patients and families may wonder if they will be abandoned or whether decisions will be based on sound criteria and implemented in a fair and consistent manner. Overburdened health care professionals may suffer moral distress in denying life-saving care to some patients while offering it to others, and they may struggle to make impartial decisions.
Triage and rationing are specific protocols within a larger set of planning initiatives for situations of extreme medical needs and limited resources called “crisis standards of care.” The National Catholic Bioethics Center (NCBC) has utilized materials from several recognized sources on crisis standards of care (listed at the end of this resource), but this resource is focused primarily on the issue of triage and rationing.
The NCBC holds that triage and rationing protocols can be necessary and helpful measures in a pandemic if they are built on sound ethical principles. Catholic health care providers should support sound secular protocols for triage and rationing but also should strive to improve their design and implementation by drawing on resources in the Catholic moral tradition. Below, the NCBC provides some suggested ethical principles, considerations, and questions to assist in this effort.
II. Ethical Considerations on Triage and Rationing
A. Substantive Principles and Considerations
These substantive ethical goods should be addressed in the creation of standards for triage and rationing:
1. Human Life, Health, and Dignity. The ultimate standard and goal of triage and rationing should be to save human lives, and to serve human health and dignity, to the greatest extent possible consistent with the common good. In addition, it is important to serve the full range of human needs and to care for those who have been vulnerable or marginalized prior to the current pandemic. In particular, Catholic health care providers should advocate and care for disabled patients who already are oxygen or ventilator dependent.
Reflection Questions to Ask
Regarding objective standards for triage and rationing (see below), what steps are we taking to care for particularly vulnerable patients (e.g., the disabled) or marginalized (e.g., the poor) outside the context of this pandemic?
Apart from services and resources subject to triage and rationing, are we providing the full range of care to all patients, including personal support and palliative and spiritual care?
2. Objectivity, Justice, and Proportionality. Standards created for limiting or directing treatment (for example, in the allocation of ventilators and beds in the intensive care unit) should be based on objective measures that best serve human life, health, and dignity. They should be applied in a nonarbitrary, nondiscriminatory manner and only for as long as necessary. To the extent possible, they should be perceived as fair by all.
Reflection Questions to Ask
Are the triage and rationing protocols accurate, complete, and based on the best standards such as the Sequential Organ Failure Assessment (SOFA) Score?
In establishing objective standards, have we eliminated grounds for bias or partiality as much as possible?
Are triage and rationing protocols as specific and limited as possible in terms of the resources to be rationed and the duration of time in which the protocol is in effect?
3. Duty to Care. Health care professionals have an ethical duty to care for patients even in conditions of limited resources and risk. The community has an ethical duty to provide health care professionals with the resources they need, including resources essential for patient care, personal safety, and their own human needs.
Reflection Questions to Ask
What steps are we taking to make it possible for health care professionals to fulfill their vocation to care for patients? Are we providing adequate staffing, safety measures, and rest?
What steps are we taking to address the needs of health care professionals outside work, including the safety of family members?
4. Stewardship. Resources for patient care become increasingly valuable in times of crisis and shortage. Health care providers should use resources in the most efficient, effective ways possible, consistent with respecting human life, health, and dignity.
Reflection Questions to Ask
Are we doing everything we can to identify and access additional essential resources and to focus health care delivery priorities on essential activities rather than on profit?
In decisions to transfer resources from hospitals not currently experiencing demand (e.g., rural or small facilities) to hospitals facing a shortage, are we taking steps to ensure that the “donor hospitals” will have the resources they need when demand rises?
B. Process Principles and Considerations
These principles of sound ethical process should be addressed in implementing standards for triage and rationing.
1. Consistency. Standards should be implemented on a consistent basis without granting exceptions or exemptions for reasons outside established substantive clinical and ethical principles. At the same time, reasonable efforts should be made to provide a channel for people to express their questions or concerns.
2. Accountability. The chain of authority to establish and implement protocols of triage and rationing should be clearly founded and communicated to all relevant parties, especially health care professionals, patients, and families.
Reflection Question to Ask
Do triage and rationing decisions take into account, as much as reasonably possible, the need for professional–patient communication and informed consent, particularly in decisions to withdraw life-sustaining treatment?
3. Transparency. Standards for and implementation of triage and rationing should be publicly accessible and proactively explained. As soon as reasonably possible, clinical and organizational leaders should engage the community to explain current standards and to gather input for improving them.
4. Regular Review. Ethical and clinical principles of triage should be reviewed on a regular basis and adjusted as necessary to save more lives, help more patients, reduce moral distress, and increase public trust and support.
C. Additional Considerations and Resources regarding Catholic Health Care Providers
1. Need for Prayer and Support. Health care providers in particular are facing scenarios of fatigue, danger to health and life, and moral distress. In addition to supporting the efforts of health care organizations and public authorities, Catholics should pray in particular for all those involved in direct clinical care during a pandemic, and they should seek additional ways to provide them with personal, social, and spiritual support.
2. Need for Prudence. Humans are unique in the range of their psychological and spiritual powers, above all reason and free will. The optimal state of these powers—their ability to work well individually and in an integrated manner consistently—is called virtue. Long discussed in classical and Christian ethical analysis, prudence was most influentially defined by Aristotle as “right reason about things to be done.” Prudence perfects the human ability to use reason to make practical, ethical decisions. Prudential decision making requires discerning the reality of a variety of goods and deciding how best to protect or promote these in practical situations. Prudential decision making is superior to making decisions in an ad hoc manner, based primarily on emotional considerations, or based upon incomplete standards of ethical good such as utilitarianism and consequentialism.
Making prudential decisions in triage situations is essential. Sound triage protocols are necessary but not sufficient to achieve ethical outcomes because there is more to making ethical decisions than the mere application of standards. Health care professionals, especially Catholics, must strive to recognize and serve the good of each human person while working within the parameters of the clinical and legal standards.
3. Need for Charity. Catholics believe that God revealed the true nature of love through his Son, Jesus Christ, and empowers us to exercise a deeper form of love in union with him. Charity is first and foremost a relationship of life and love between the Christian and God. But Catholics are called and empowered to share this transcendent love with others. In the context of health care, while affirming the legitimacy of triage standards and the requirements of clinical care, charity can empower Christian health care professionals to engage in distinctive efforts to serve others or to promote their dignity in ways that others might miss. Identifying the potential for such efforts will require prayer and discernment.
Sources of Guidance on Crisis Standards of Care and Triage
Centers for Disease Control and Prevention (CDC). 2007. Ethical Guidelines in Pandemic Influenza. Atlanta, GA: CDC.
CDC. 2009. Pandemic Influenza Triage Tools: User Guide. Atlanta, GA: CDC.
Hick, J. L., Hanfling, D., Wynia, M. K., & Pavia, A. T. 2020. Duty to Plan: Health Care, Crisis Standards of Care, and Novel Coronavirus SARS-CoV-2. Washington, DC: National Academy of Medicine.
Institute of Medicine. 2012. Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response: Volume 1: Introduction and CSC Framework. Washington, DC: The National Academies Press. doi: 10.17226/13351.
World Health Organization (WHO). 2016. Guidance for Managing Ethical Issues in Infectious Disease Outbreaks. Geneva, Switzerland: WHO.