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In exceptional circumstances where the demand for care exceeds the supply, how do you decide who to start with? Triage is necessary where there is exceptional demand, leading to the use of a specific procedure to establish priorities.
Interview of Jean-Hervé Bradol conducted by Elba Rahmouni based on the article “In a disaster situation: get your bearings, triage and act” published in the book La médecine du tri. Histoire, éthique, anthropologie edited by Céline Lefève, Guillaume Lachenal and Vinh-Kim Nguyen.
What is this procedure?
The triage procedure as formulated by the World Health Organization is as follows: “Patients must be split into groups based on the seriousness of their injuries and decisions must be made about the treatments they can be given according to the resources available and their chances of survival. The principle on which these decisions are based is one of allocating resources to benefit the health of as many people as possible.” In theory, triage offers a mathematical demonstration of its superiority over the usual form of organisation by securing a better quantitative match between supply and demand for care, which in turn translates into a lower number of deaths.
For healthcare workers the triage procedure is the requirement to switch from one set of ethics to another. The first, the set that applies ordinarily, is presented as being centred on the individual interests of the sick or injured patient. When the situation is extraordinary, because demand exceeds supply in a much more marked way than usual, there is a perceived risk of wasting meagre resources and precious time by paying too much attention to cases with too good, or conversely, too poor a prognosis. The ethical approach that is then recommended is described as utilitarian. The objective becomes “the greatest good for the greatest number”, to the point where a small number of individuals are sacrificed for the general interest.
The tension between individual interests and the collective interest is already present outside exceptional situations, in the routine administration of care. But events that are seen by society as disasters give an unusual degree of visibility to discrimination in access to care, which is ordinarily more readily accepted because it is lost in the banality of day-to-day living.
Where does this procedure come from and what is its evolution?
Widespread use of the term triage and the clarification of its objectives date back to the First World War: sorting out the injured to send those whose state of health allowed it back to their regiment as quickly as possible and organising care effectively in the hope of avoiding as many deaths and severe functional deficits as possible among those who remained in the care of the medical services. Since the First World War, the uses of triage have diversified and become more extensive.
Today, triage is most frequently used outside of its original context: so-called wars of position such as the First World War. It has found a place in the response to natural disasters, epidemics and famines and in managing more day-to-day situations associated with a scarcity of resources, as well as for determining the order in which patients in the waiting area of an accident and emergency department are seen or patients are selected for admission to intensive care.
To whom does the triage procedure apply?
Triage is supposed to be applied to everyone based on the same medical and health criteria, with the aim of being effective at a collective level and treating all individuals fairly. However, the idea of considering individuals as equal, as a matter of principle, during the triage procedure and only distinguishing one from the other according to a small number of defined medical criteria, also has its medical limitations. For example, the consequences of a chest trauma are different based on whether it occurs in a patient who was previously healthy or a patient suffering from a chronic respiratory condition.
Beyond medical limits, other criteria come into consideration. There are some legitimate exceptions to the rule of a fair distribution of care between individuals. For example, we have to recognise that not prioritising care for some leading figures in society would magnify the disaster and the social unrest accompanying it.
More concerning are those circumstances when emergency assistance can also be used to the benefit of partisan interests, for example those of certain combatants or a certain political class. Particular economic interests can also prevail: those of war profiteers in the context of an armed conflict or more generally, those of crooks inside and outside aid organisations, for whom a disaster represents an opportunity to do good business.
Much more common phenomena are also at work. In France, for example, in spite of the existence of precise medical criteria, a request for admission to an intensive care unit has less chance of being satisfied if it is made over the phone rather than as the result of direct physical contact and similarly if it occurs during certain periods of the day. Patient selection often comes down, in reality, to the ordinary kinds of discrimination commonly found in society and which are drawn from a list that is both traditional and endlessly updated: a language (or pronunciation), a lifestyle...
How does it apply?
In an idealised view of disaster medicine, assuming that individuals are treated equally, the second assumption put forward is the existence of a single cause of harm (or a small number of causes) leading to an unusual number of cases of the same kind, differing only in terms of their seriousness. The hope that the supply of care can be rapidly adjusted to demand is based on the fact that the small number of causes of harm will make it possible to simplify treatment, which in turn favours a rapid, mass deployment of assistance. Re-establishing the balance between supply and demand for care is achieved at the cost of reducing the variety of clinical scenarios to a small number of categories, based on seriousness, usually two to five depending on the different triage systems.
However, in reality, the idea of a single cause of harm has its limitations. For example, two patients with a bullet wound in the same part of their body might, at the precise moment when they come into triage, present in exactly the same way depending on the few criteria selected to decide in a minute where the patient should be sent to, although in reality their prognoses are very different. These depend on which organs the bullet has hit when it entered their bodies. These could be identified through a proper clinical examination but in the usual conditions there is no time to do it.
Behind their apparent rationality, disaster response protocols rely to a large extent on reasoning deduced from physiological knowledge and on clinical know-how acquired through practice. When scientific studies are carried out in spite of the precarious circumstances, their results show the practical limitations of triage procedures. If the resources available are fairly generous, the professional in charge of the triage process will tend to want to avoid prejudicing the individual in front of them at a given time. The temptation is then, too often, to assign priority to cases whose treatment could be deferred based on a rigorous application of the criteria. If, on the other hand, resources are very limited, the desire to protect the interests of the wider community prevails. The risk is then that patients are disregarded when they could have been saved had they been seen as a priority.
Rationing care to the benefit of some and the detriment of others is often presented in the literature as a source of significant ethical dilemmas. The most frequently cited example is the decision, when there is a massive influx of people who are sick or injured, not to attempt to change the life prognosis of those who are judged to be too seriously ill. Their treatment is reduced to palliative care so that the end of their life is as painless as possible. In reality, the chances of survival of people who are dying, which are poor even in normal times, are appalling once a disaster occurs, because of the precariousness of their living conditions and care. When these types of patients receive medical treatment, the carer’s anxiety has more to do with the difficulty they face in accepting their own powerlessness in light of the scale of the disaster than cruelly exercising power over life and death during triage.
How can this procedure be accepted?
The explanation given by carers to justify the choices made in triage is expressed in terms that emphasise that not everyone will be treated in the same way but that it will reduce the number of deaths across the population as effectively as possible. Believing that such a justification will be acceptable to an individual in distress is based on the hypothesis that they will bear their suffering patiently for the good of the many. Experience shows that invoking the collective interest is not always sufficient to calm either people in a precarious situation, or those close to them. The use of – at best dissuasive – force is often inevitable, for example to prevent a pharmacy or food warehouse being pillaged by an angry crowd of people who have been deprived of goods that are essential for their survival.
In this sense, an emergency operation is successful when it results in exceptional social and political mobilisation that is capable of producing a consensus in terms of the distribution of aid and care, in order to prevent social and political unrest on too large a scale. Triage is thus shown to be what it is in essence: an essential stage in an operation based on rationing and the maintenance of order. Once it is seen as an affirmation of a new social norm of distributing scarce resources, triage becomes meaningful and useful.
Every operation bears the mark of one or a small number of people who have controlled the distribution of care and assistance. They play their role best when they bear in mind that triage is not simply a technique but also marks the switch, for better or worse, from one form of distributive justice to another. The new norm is not there to be followed blindly but to serve as a pointer towards the creation of an aid policy that changes every time, in order to respond as effectively as possible to an exceptional situation and the specific needs of its victims.