Centre for Military Ethics: Ethics Playing Cards

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4 4 4 4

How do you decide the first person to treat or the allocation of single resources between two casualties with the same triage score?

Specific Topic(s):

• This scenario covers the ethics of triage and then the practical aspects of triage decision-making.

• This is linked to the scenario in 8 Clubs and Ace Clubs.

Key references:

‘Ethical principles of health care in times of armed conflict and other emergencies’ –

3. The primary task of health-care personnel is to preserve human physical and mental health and to alleviate suffering. They shall provide the necessary care with humanity, while respecting the dignity of the person concerned, with no discrimination of any kind, whether in times of peace or of armed conflict or other emergencies.

Geneva Conventions:

Protocol Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts (Protocol I), 8 June 1977. Article 10

Protocol Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of Non-International Armed Conflicts (Protocol II), 8 June 1977. Article 7

In all circumstances they (wounded, sick and shipwrecked) shall be treated humanely and shall receive, to the fullest extent practicable and with the least possible delay, the medical care and attention required by their condition. There shall be no distinction among them founded on any grounds other than medical ones.

Customary IHL:

Rule 87. Humane Treatment. Civilians and persons hors de combat must be treated humanely. https://ihl-databases.icrc.org/customary-ihl/eng/docs/v1_cha_chapter32_rule87 - specific categories of persons: the wounded, sick and shipwrecked, persons deprived of their liberty, displaced persons, women, children, the elderly, the disabled and infirm.

Ethical principles:

WMA INTERNATIONAL CODE OF MEDICAL ETHICS - https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/

A PHYSICIAN SHALL strive to use health care resources in the best way to benefit patients and their community.

WMA Declaration of Lisbon on the Rights Of The Patient: https://www.wma.net/policies-post/wma-declaration-of-lisbon-on-the-rights-of-the-patient/#:~:text=Every%20person%20is%20entitled%20without,with%20his%2Fher%20best%20interests.

1. Right to medical care of good quality:

e. In circumstances where a choice must be made between potential patients for a particular treatment that is in limited supply, all such patients are entitled to a fair selection procedure for that treatment. That choice must be based on medical criteria and made without discrimination.

Discussion:

Review of the question: The question considers triage as a process of clinical decision-making in order to allocate medical resources according to the needs of the patient.

Interpretation of the principles/policy from the references:

• There is a clear obligation under International Humanitarian Law and ethics to provide emergency treatment for acute injury or illness in accordance with their clinical priorities without discrimination.

• Triage is a process for allocation of resources according to the needs of an individual patient within a group.

• Triage processes place casualties into generic categories, but clinical judgement is needed to prioritise casualties within the categories.

Framework for answering the scenario/question:

• What is the triage score? [there is a big difference between two T1 casualties and two T3 casualties]

• Although the triage score is the same, are the injuries the same; does one obviously take priority?

• What is the resource that has to be allocated? [e.g. resuscitation bed, blood, surgical time, ICU bed, evacuation bay, etc.]

• Are there any other clinical discrimination factors beyond the triage score that apply at the individual level?

• Can the decision be discussed/shared?

Further discussion points

• What types of medical capabilities might be in short supply in an emergency situation? – [facilities, evacuation spaces, beds, blood, drugs, oxygen, etc.]

• What are the different systems for triage? What is the difference between a Major Medical Incident and a Mass Casualty Incident?

• How does this compare with triage in pandemics? [consider King Spades as well]

Author: Professor Martin Bricknell