The role of social justice in triage guidelines: considering the context
While some have argued that an emergency is not the place to remedy structural injustices, others contend that social justice should play a direct and important role, since certain disadvantaged groups are negatively affected by common triage criteria. This commentary outlines the debate and suggests a specific perspective to further discuss the role of social justice.
Commentary
On 1 February 2023, the Council of Europe Committee of Ministers adopted recommendations on the “equitable access to medicinal products and medical equipment in a situation of shortage”. These recommendations emphasise several principles, including “non-discrimination” and “attending to systematically disadvantaged individuals and groups in matters of health”, where “disadvantages arise from economic and social conditions, legal status, disability, chronic illness, or age”. At the same time, the signatories maintain that priority should be given to minimising the risk of mortality and morbidity.
This position is echoed in several triage guidelines that contain both justice and efficiency as two separate guiding principles. While “justice’ is frequently spelled out as adhering to either non-discrimination or outcome equality for all social groups (or both), considerations of efficiency either relate to the maximisation of benefits or the minimisation of harms (Jöbges et al. made an international comparison of triage recommendation in the specific context of COVID-19 and outline the underlying goals and principles of guiding documents.).
But what precise role does social justice play in triage? While some have argued that an emergency is not the place to remedy structural injustices, others contend that social justice should play a direct and important role, since certain disadvantaged groups are negatively affected by common triage criteria. This commentary outlines the debate and suggests a specific perspective to further discuss the role of social justice.
Efficiency as the primary goal of triage
There is broad consensus that triage, often rooted in its historical context of war, involves some form of a “maximisation” rationale. The goal of triage is to uphold efficiency considerations, whether it be maximising the number of lives saved, maximising the number of quality-adjusted life years (QALYs) or optimising the use of resources. Many authors of guidelines and policymakers concur that “saving lives” represents the only acceptable interpretation of the “efficiency constraint” either for pragmatic reasons or if fairness considerations shall be sufficiently taken into account (Savulescu, Persson, and Wilkinson 2020; Emanuel et al. 2020). Notably, in most guidelines, the saving of lives is asserted as the primary concern and efficiency is therefore regarded as the primary goal of triage (Savulescu, Persson, and Wilkinson 2020; Christian et al. 2014; Emanuel et al. 2020; Vincent and Creteur 2020).
Still, it is commonly accepted that justice also plays a role in triage as some form of minimal constraint. Most commonly, justice is conceptualised as procedural justice (a fair and transparent process) that moreover finds expression in the demand of non-discrimination. Non-discrimination in the narrow sense implies that characteristics, such as ability, age, gender or socioeconomic status, should not influence a triage decision for an individual patient, as they are arbitrary and thus irrelevant to a decision. (We draw in our analysis on the accounts and concepts presented by Eidelson (2015) and Lippert-Rasmussen (2006). Eidelson in particular understands the concept of “direct discrimination” in a narrow sense as the absence of arbitrary unequal treatment and the absence of stereotypical attribution of characteristics based on group membership.)
Giving social justice and efficiency equal weight
Some have argued that “social justice” should also play a more prominent role in triage (Stone 2020; Reid 2020, Schmidt et al. 2021). This poses a more complex challenge, as social justice also delves into the broader context of health determinants and the constantly poorer outcomes of the vulnerable, including the elderly, individuals with disabilities and those facing socioeconomic disadvantages (Meier 2022). “Neutral” criteria like resource use or short-term prognosis can result in triage decisions that disproportionately affect socially marginalised groups.
To address this problem, Reid thinks that it is possible to strengthen the role of social justice and make it nevertheless compatible with the maximisation rationale: as a minimum requirement, triage should not deepen existing inequalities. She furthermore proposes what she calls a “balancing” approach, implying that we can “balance” values and principles of equal weight to resolve moral dilemmas without rendering the ethical dilemma “illusory [in view of] our commitment to values that we compromise”.
Social justice as the primary goal of triage
Then, there is the position that social justice should take precedence over efficiency. Advocates of this position not only think that persistent injustices of socially salient groups ought not be worsened (as a minimum requirement) but hold that they should be remedied (in a more demanding version). Any triage decision primarily driven by a maximisation rationale is likely to result in a situation where certain socially significant groups are left in a worse condition than before the triage decision was made. This disparity arises not only due to underlying comorbidities but also because preventive healthcare measures are often less effective in socioeconomically disadvantaged groups, and transmission rates tend to be higher among them (Tolchin et al., 2021). Thus, there is a need for proactive efforts by decision-makers to prevent disadvantages from accumulating within socially deprived groups and exacerbating existing disparities.
Various normative models are discussed as “fitting” the demand for social justice as the primary goal. One proposal is to consider social justice and enhance diversity in processes, such as introducing a system with bonus points for the socioeconomically deprived (Schmidt et al. 2021). An even more demanding claim involves the use of a lottery as a normative model for making triage decisions in health emergencies (see Schmidt 2020; Tolchin et al. 2020). However, even more demanding normative models are conceivable. Tolchin et al., for instance, discuss the model of the so-called “prioritarian triage”. This approach entails allocating scarce resources to the sickest patients first or, alternatively, prioritising resource allocation to minorities or individuals with lower socioeconomic status. The goal is to reduce or even eliminate the disproportionate disadvantages experienced by members of marginalised populations. (Indeed, article 6.1 of the “Recommendations on the equitable access to medicinal products and medical equipment in a situation of shortage” and particularly the formulation that “the severity of the health condition of the individual concerned and the healthcare needs” should be taken into account for prioritisation could be interpreted in the sense of a prioritarian model.)
However, there is an important counter-argument. When considering a broader conception of justice as “social justice”, Vogelstein and Krishnamurthi (2023) argue that injustices at a structural level do not necessarily imply that it is ethical to employ any means to rectify that unfairness in a triage situation, especially if doing so comes with significant moral costs. More specifically, the authors contend that moral costs would arise in relation to the efficiency constraint. Given that the allocation applies to life-saving treatment, more people will die if efficiency is neglected in favour of remedying justice concerns.
Contextualising triage
The positions described above lead to a major challenge that triage guidelines often fail to resolve because they attempt to include both efficiency and social justice considerations without explaining their precise role and status. This difficulty arises furthermore because both goals inevitably come into conflict with each other. Achieving a more inclusive distribution with a focus on “social justice” may lead to less efficient outcomes in terms of maximising saved lives or utilising limited resources, and vice versa. (See Ehni and colleagues (2020) who identify a similar conflict between the “maximisation rationale” and the concept of “justice”.) So, is there a way out of this dilemma?
Rather than advocating for any of the positions outlined above, we propose that triage and its objectives should be contextualised. One option is to consider triage in emergencies, such as during the COVID-19 pandemic, as a pure state of emergency, similar to car accidents that can randomly affect people regardless of their socioeconomic status. For example, let’s consider a situation where an individual experiences direct discrimination that violates a local fairness norm. We might view this discrimination as an isolated incident. However, unlike accidents, this decision can have broader implications. It not only harms individuals at an individual level but can also perpetuate systemic injustices that contributed to the initial discriminatory act.
This brings us to the second option: we could consider triage as a phenomenon linked to some sort of background structure, where social justice concerns become most visible. In other words, we could think of triage not as a singular event but as embedded in a context of structural injustice, perhaps itself contributing to disparities in outcome equality and socioeconomic standing. This second scenario invites us to consider the inherent connection between local and global justice considerations. It emphasises that the local should not be viewed in isolation from the broader context of structural injustice (Young, 2008). Scholars like Tolchin et al. argue that this recognition calls for local rules to contribute to the development of more-just social structures.
This reasoning may also be influenced by a mid- or long-term perspective. As Tolchin et al. (2021) argue, it is imperative even in an emergency to adopt a long-term view that considers future epidemic waves, as an accumulation of local injustices over time can worsen social justice. While efficiency considerations are predominant in the short term for single epidemic events, social justice certainly gains more prominence when events endure or repeat.
There might be valid reasons to consider triage in both ways. We hold that it is essential to examine evidence on how triage decisions during the COVID-19 pandemic have contributed to structural disparities between groups or whether the missing consideration of vulnerable groups (for the sake of efficiency) has remained a “local injustice’ without broader implications for the background structure. Triage guidelines should provide clarity about this contextualisation and explicitly state the consequences of these considerations for triage decisions.
Felicitas Holzer (felicitas.holzer[at]ibme.uzh.ch), Holger Baumann, Tania Manriquez Roa, Nikola Biller-Andorno
Institute of Biomedical Ethics and History of Medicine, University of Zurich