Report of the Forum for Global Health Ethics webinar on the role of social justice in triage: balancing efficiency, equity and inclusion
Introduction
In November 2023, the Forum for Global Health Ethics and Swiss Medical Weekly jointly organised the eighth webinar in the series addressing ethical challenges in global health hosted by the Institute for Biomedical Ethics and History of Medicine. This collaboration brought together a diverse community, including practitioners, researchers, students and policymakers, and fostered discussion on relevant topics in global health ethics. The November webinar addressed the ethical question of the role of social justice in triage. Triage is the classification and prioritisation of injured or ill individuals based on available resources – a topic that was discussed during the COVID-19 pandemic, generating much controversy. Historically, the concept of triage was introduced on the battlefield in the 19th century and is nowadays used not only in the context of pandemics but also in everyday healthcare.
This forum, hosted by Holger Baumann and Tania Manríquez, was conceptualised by Holger Baumann and Felicitas Holzer and included experts who presented and discussed perspectives of triage: Aamir Jafarey (Sindh Institute of Medical Science, Pakistan), Carla Saenz (Pan American Health Organization [PAHO]), Harald Schmidt (University of Pennsylvania, US) and Dominic Wilkinson (University of Oxford, UK). The speakers’ expertise was the basis for a wide-ranging, constructive discussion with observations, learnings and questions from attendees. Some key points from the discussion are summarised below.
Classification and prioritisation: impact on discrimination and social justice – four complex perspectives
In the introduction, Harald Schmidt presented the triage principles that directly impact different populations. The “first come, first served” principle supports already well-connected individuals. The “sickest first” principle prioritises those with the worst outcome and high mortality so that resources for those with a prognosis of a favourable outcome are already exhausted. It is common practice in many countries to prioritise people with a short-term survival prognosis.
Harald Schmidt’s presentation outlined when health parameters lead to racial discrimination. Statistics on the COVID-19 pandemic in the US indicate that race and ethnicity serve as risk factors for increased disease cases, hospitalisations and mortality compared to white, non-Hispanic citizens. He observed significant discrimination against specific populations linked to the prioritisation of individuals with a short-term survival prognosis. This assessment is commonly connected with the Sequential Organ Failure Assessment (SOFA score), a classification based on the assessment of six organs or organ systems: lungs, nervous system, cardiovascular system, liver function, coagulation system and kidney function. If population groups are predisposed to dysfunction of a specific organ, they are categorised lower and have a reduced probability of receiving intensive care treatment when resources are scarce. Non-Hispanic black people in the United States have pathological kidney measures (creatinine) significantly more often. If individuals are categorised lower in the SOFA classification due to their kidney markers, they are less likely to be considered for triage. The search for alternative measures and rejection of the prevailing SOFA models would promote inclusion of disadvantaged groups in the triage decision-making process.
The experience in Pakistan, presented by Aamir Jafarey, provides insight into the prioritisation of healthcare workers and their relatives. He emphasised the foundational principles of justification; triage requires incorporation of values such as reciprocity, solidarity, fidelity, instrumental values, social utility and cultural expectations. The guidelines implemented in Pakistan adhere to established medical criteria for assessing the salvageability of all incoming patients when allocating limited resources equitably. When the healthcare system threatened to collapse due to the pandemic, priority was accorded to frontline healthcare workers, including doctors, nurses, paramedics, support staff and their first-degree relatives, to keep the system running. Qualitative research conducted in Pakistan during the COVID-19 pandemic reveals that frontline staff made decisions in alignment with these criteria despite being unaware of the formal guidelines. These decisions were predominantly influenced by sociocultural norms, specifically hierarchy and kinship. Aamir Jafarey underscored the significance of incorporating established practices and adopting a pragmatic approach in order to sustain the healthcare system and mitigate further moral distress.
Carla Saenz, a representative of PAHO, emphasised that the individual triage decision-making at each centre can lead to inequity in allocating treatment, such as prioritising treatment for wealthy individuals or excluding some groups from access due to race and skin colour. She argued that guidelines must be made from a country’s highest level and be clear, transparent and coherent. Further research is needed to analyse existing discrepancies that were exposed during the COVID-19 pandemic to avoid future discrimination.
Dominic Wilkinson focused on efficiency and saving the greatest number. Initially, he distinguished the allocation of resources in healthcare between weak and strong forms. Weak forms aim to eliminate unjust biases and ensure equal access, while strong forms prioritise allocation to disadvantaged groups. An ethical starting point often involves utilitarianism, where equal considerations for all individuals emerge, emphasising saving the most lives. Balancing saving more lives and aiding a disadvantaged group is challenging. An existing survey indicates that the survey participants do not urgently favour prioritising specific groups, emphasising that efficiency is the highest priority. Dominic Wilkinson suggested concentrating on efficiency first. Nevertheless, social justice can function as a tie-breaker for patients with equal chances of survival.
Discussion
The complexity of triage was illustrated by the discussion, which was based on the questions and answers that followed the presentations and is summarised in the following paragraphs:
- While it is fundamental to ensure the continuity of healthcare services and to recognise the sacrifices that health workers make for the community, prioritising healthcare workers and their first-degree relatives can inadvertently lead to a system of preferential treatment. As indicated by Aamir Jafarey, this preferential treatment is implemented in Pakistan to prevent staff from being absent when caring for relatives, thereby ensuring ongoing healthcare delivery. Harald Schmidt stated that in the United States, where the issue has not been extensively discussed, it was essential to consider the implications of disguised discrimination. If priorities were to be set, other systemically relevant groups would also have to be prioritised, and not every healthcare worker is exposed to the same risks. Dominic Wilkinson argued that emergencies demand equal treatment, emphasising that the more complex the situation, the less time there is for deliberation. According to Dominic Wilkinson, triage was not the best place for fixing social justice.
- How can we incorporate social justice in emergencies, such as a massive accident or earthquake, where there is no time to identify discriminating factors? The assumption of an accident differs from a pandemic, where it is impossible to consider where a person comes from. However, using the “first come, first served” principle also involves injustices for those who have been identified as priority patients secondarily. According to Carla Saenz, who cites an earthquake as an example, the impact hits the poor much harder than the wealthy population, who have the resources to rebuild.
- Including disadvantaged groups in prioritisation raises the question of fairness when individuals from a non-disadvantaged group are affected: Can fairness in resource allocation incorporate considerations like social factors, even if this means that individuals who are not personally responsible for their situation may be affected? Harald Schmidt sees no alternative than to include as many tools as possible to avoid discrimination of specific groups. Globally, Dominic Wilkinson refers to inequity in the allocation of resources, as seen in the example of vaccine allocation: The allocation of vaccinations demonstrates global inequity, where more-disadvantaged countries are vaccinated later.
In conclusion, addressing allocation questions at the national level poses significant challenges. Further exploration and in-depth discussions on the global allocation of resources are warranted, particularly in anticipation of future pandemics.
Beatrix Göcking, Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland, beatrix.goecking[at]ibme.uzh.ch
Suggestions for further reading
Kappes A, Zohny H, Savulescu J, Singh I, Sinnott-Armstrong W, Wilkinson D. Race and resource allocation: an online survey of US and UK adults’ attitudes toward COVID-19 ventilator and vaccine distribution. BMJ Open. 2022 Nov;12(11):e062561. https://doi.org/10.1136/bmjopen-2022-062561.
Savulescu J, Persson I, Wilkinson D. Utilitarianism and the pandemic. Bioethics. 2020 Jul;34(6):620–32. https://doi.org/10.1111/bioe.12771.
Savulescu J, Vergano M, Craxì L, Wilkinson D. An ethical algorithm for rationing life-sustaining treatment during the COVID-19 pandemic. Br J Anaesth 2020; 125(3): 253–8. https://doi.org/10.1016/j.bja.2020.05.028.
Schmidt H. Opinion: The Way We Ration Ventilators Is Biased. The New York Times 2020 Apr 15.
Schmidt H, Roberts DE, Eneanya ND. Rationing, racism and justice: advancing the debate around ‘colourblind’ COVID-19 ventilator allocation. J Med Ethics. 2022 Feb;48(2):126–30. https://doi.org/10.1136/medethics-2020-106856.
Schmidt H, Roberts DE, Eneanya ND. Sequential organ failure assessment, ventilator rationing and evolving triage guidance: new evidence underlines the need to recognise and revise, unjust allocation frameworks. J Med Ethics. 2022 Feb;48(2):136–8. https://doi.org/10.1136/medethics-2021-107696.
Shekhani SS, Moazam F, Jafarey A. Fighting the COVID-19 pandemic: A socio-cultural insight into Pakistan. Dev World Bioeth. 2023 Jul;dewb.12413. https://doi.org/10.1111/dewb.12413.
Smith MJ, Ahmad A, Arawi T, Dawson A, Emanuel EJ, Garani-Papadatos T, et al. Top five ethical lessons of COVID-19 that the world must learn. Wellcome Open Res. 2021 Jan;6:17. https://doi.org/10.12688/wellcomeopenres.16568.1.
White DB, Lo B. Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic. Am J Respir Crit Care Med. 2021 Feb;203(3):287–95. https://doi.org/10.1164/rccm.202010-3809CP.
Wright K, Aagaard N, Ali AY, Atuire C, Campbell M, Littler K, et al. Preparing ethical review systems for emergencies: next steps. BMC Med Ethics. 2023 Oct;24(1):92. https://doi.org/10.1186/s12910-023-00957-2.
Forum for Global Health Ethics
View the whole webinar on Role of Social Justice in Triage: