TRIAGE

Triage is the medical assessment of patients to establish their priority for treatment. When medical resources are limited and immediate treatment of all patients is impossible, patients are sorted in order to use the resources most effectively. The process of triage was first developed and refined in military medicine, and later extended to disaster and emergency medicine.

In recent years, it has become common to use the term triage in a wide variety of contexts where decisions are made about allocating scarce medical resources. However, triage should not be confused with more general expressions such as allocation or rationing (Childress). Triage is a process of screening patients on the basis of their immediate medical needs and the likelihood of medical success in treating those needs. Unlike the everyday practice of allocating medical resources, triage usually takes place in urgent circumstances, requiring quick decisions about the critical care of a pool of patients. Generally, these decisions are controlled by a mixture of utilitarian and egalitarian considerations.

History

Baron Dominique Jean Larrey, Napoleon's chief medical officer, is credited with organizing the first deliberate plan for classifying military casualties (Hinds, 1975). Larrey was proud of his success in treating battle casualties despite severe scarcity of medical resources. He insisted that those who were most seriously wounded be treated first, regardless of rank (Larrey). Although there is no record of Larrey's using the term triage, his plan for sorting casualties significantly influenced later military medicine.

The practice of systematically sorting battle casualties first became common during World War I. It was also at this time that the term triage entered British and U.S. military medicine from the French (Lynch, Ford, and Weed). Originally, triage (from the French verb trier, "to sort") referred to the process of sorting agricultural products such as wool and coffee. In military medicine, triage was first used both for the process of prioritizing casualty treatment and for the place where such screening occurred. At the poste de triage (casualty clearing station), casualties were assessed for the severity of their wounds and the need for rapid evacuation to hospitals in the rear. The emphasis was on determining need for immediate treatment and the feasibility of transport.

The following triage categories have become standard, even though terminology may vary:

1. Minimal. Those whose injuries are slight and require little or no professional care.
2. Immediate. Those whose injuries, such as airway obstruction or hemorrhaging, require immediate medical treatment for survival.
3. Delayed. Those whose injuries, such as burns or closed fractures of bones, require significant professional attention that can be delayed for some period of time without significant increase in the likelihood of death or disability.
4. Expectant. Those whose injuries are so extensive that there is little or no hope of survival, given the available medical resources.

First priority is given to those in the immediate group. Next, as time and resources permit, care is given to the delayed group. Little, beyond minimal efforts to provide comfort care, is given to those in the expectant category. Active euthanasia for expectant casualties has been considered but is almost never mentioned in triage proposals (British Medical Association, 1988). Those in the minimal group are sent to more distant treatment facilities or left to take care of themselves until all other medical needs are met.

From the beginning, the expressed reasons for such sorting were a blend of utilitarian and egalitarian considerations. Larrey stressed equality of care for casualties sorted into the same categories. On the other hand, one early text on military medicine advised, "The greatest good of the greatest number must be the rule" (Keen, p. 13). Over the years, it also became clear that the utilitarian principle could be interpreted in different ways. The most obvious meaning was that of limited medical utility: The good to be sought was saving the greatest number of casualties' lives.

But the principle could also be construed to mean doing the greatest good for the military effort. When interpreted this way, triage could produce very different priorities. For example, it was sometimes proposed that priority be given to the least injured in order to return them quickly to battle (Lee). An oft-cited example of the second use of the utilitarian principle for triage occurred during World War II (Beecher). Commanders of U.S. forces in North Africa had to decide how to use their extremely limited supply of penicillin. The choice was between battle casualties with infected wounds and soldiers with gonorrhea. The decision was made to give priority to those with venereal disease, on the grounds that they could most quickly be returned to battle preparedness. A similar decision was made in Great Britain to favor members of bomber crews who had contracted venereal disease, because they were deemed most valuable to the continuation of the war effort (Hinds, 1975).

As military triage has evolved during the twentieth century, the goal of maintaining fighting strength has increasingly become the dominant, stated goal. In the words of surgeons Gilbert W. Beebe and Michael E. DeBakey, "Traditionally, the military value of surgery lies in the salvage of battle casualties. This is not merely a matter of saving life; it is primarily one of returning the wounded to duty, and the earlier the better" (p. 216).

The nuclear weapons used at the end of World War II introduced unprecedented destructive power. In the nuclear age, triage plans have had to include the possibility of overwhelming numbers of hopelessly injured civilians. In earlier days, it was not uncommon to plan for 1,000 or 2,000 casualties from a single battle. Now, triage planners must consider the likelihood that a single nuclear weapon could produce a hundred times as many casualties or more. At the same time a single blast could destroy much of a community's medical capacity. Such probabilities have led some analysts to wonder if triage would be a realistic expectation following a nuclear attack (British Medical Association, 1983).

Triage has moved from military into civilian medicine in two prominent areas: the care of disaster victims and the operation of hospital emergency departments. In both areas, the categories and many of the strategies of military medicine have been adopted.

The necessity of triage in hospital emergency departments is due, in part, to the fact that a number of patients needing immediate emergency care may arrive almost simultaneously and temporarily overwhelm the hospital's emergency resources (Kipnis). More often, however, the need for triage in hospital emergency departments stems from the fact that the majority of patients are waiting for routine care and do not have emergent conditions. Thus, screening patients to determine which ones need immediate treatment has become increasingly important. Emergency-department triage is often conducted by specially-educated nurses using elaborate methods of scoring for severity of injury or illness (Purnell; Wiebe and Rosen; Grossman).

Ethical Issues

The traditional ethic of medicine obligates healthcare professionals to protect the interests of patients as individuals and to treat people equally on the basis of their medical needs. These same commitments to fidelity and equality have, at times, been prescribed for the treatment of war casualties. For example, the Geneva Conventions call for medical treatment of all casualties of war strictly on the basis of medical criteria, without regard for any other considerations (International Committee of the Red Cross; Baker and Strosberg). However, this principle of equal treatment based solely on medical needs and the likelihood of medical success has competed with utilitarian considerations in military medicine. In such triage, healthcare professionals have sometimes thought of patients as aggregates and given priority to goals such as preserving military strength; loyalty to the individual patient has, at times, been set aside in order to accomplish the most good or prevent the most harm. The good that might have been accomplished for one has been weighed against what the same amount of effort and resources could do for others. The tension between keeping faith with the individual patient and the utilitarian goal of seeking the greatest good for the greatest number is the primary ethical issue arising from triage.

Triage generates a number of additional ethical questions. To what extent are the utilitarian goals of military or disaster triage appropriate in the more common circumstances of allocating everyday medical care, such as beds in an intensive care unit? If some casualties of war or disaster are categorized as hopeless, what care, if any, should they be accorded? Should their care include active euthanasia? Should healthcare professionals join in the triage planning for nuclear war if they are morally opposed to the policies that include the possibility of such war (Leaning, 1988)? What new issues arise for triage in a time of global terrorism (Kipnis)?

Triage is a permanent feature of contemporary medical care in military, disaster, and emergency settings. As medical research continues to produce new and costly therapies, it will continue to be tempting to import the widely accepted principles of triage for decisions about who gets what care. Indeed, whenever conditions of scarcity necessitate difficult decisions about the distribution of burdens and benefits, the language and tenets of medical triage may present an apparently attractive model. This is true for issues as far from medical care as world hunger and population control (Hardin; Hinds, 1976). The moral wisdom of appropriating the lessons of medical triage for such diverse social problems is doubtful and should be carefully questioned. Otherwise, utilitarian considerations often associated with triage may dominate issues better addressed in terms of loyalty, personal autonomy, or distributive justice (Baker and Strosberg).

gerald r. winslow (1995)

revised by author

SEE ALSO: Healthcare Resources, Allocation Of: Microallocation; Justice; Warfare: Medicine and War

BIBLIOGRAPHY

Baker, Robert, and Strosberg, Martin. 1992. "Triage and Equality: An Historical Reassessment of Utilitarian Analyses of Triage." Kennedy Institute of Ethics Journal 2: 103–123.

Beebe, Gilbert W., and DeBakey, Michael E. 1952. Battle Casualties: Incidence, Mortality, and Logistic Considerations. Springfield, IL: Charles C. Thomas.

Beecher, Henry K. 1970. "Scarce Resources and Medical Advancement." In Experimentation with Human Subjects, ed. Paul A. Freund. New York: George Braziller.

British Medical Association. 1983. The Medical Effects of Nuclear War. Chichester, UK: John Wiley and Sons.

British Medical Association. 1988. Selection of Casualties for Treatment After Nuclear Attack: A Document for Discussion. London: Author.

Burkle, Frederick M. 1984. "Triage." In Disaster Medicine: Application for the Immediate Management and Triage of Civilian and Military Disaster Victims, ed. Frederick M. Burkle, Jr., Patricia H. Sanner, and Barry W. Wolcott. New Hyde Park, NY: Medical Examination.

Childress, James F. 1983. "Triage in Neonatal Intensive Care: The Limitations of a Metaphor." Virginia Law Review 69: 547–561.

Grossman, Valerie G.A. 1999. Quick Reference to Triage. Philadelphia: Lippincott Williams and Wilkins.

Hardin, Garrett. 1980. Promethean Ethics: Living with Death, Competition, and Triage. Seattle: University of Washington Press.

Hinds, Stuart. 1975. "Triage in Medicine: A Personal History." In Triage in Medicine and Society: Inquiries into Medical Ethics, ed. George R. Lucas, Jr. Houston, TX: Institute of Religion and Human Development.

Hinds, Stuart. 1976. "Relations of Medical Triage to World Famine: A History." In Lifeboat Ethics: The Moral Dilemmas of World Hunger, ed. George R. Lucas, Jr., and Thomas W. Ogletree. New York: Harper and Row.

International Committee of the Red Cross. 1977. "Geneva Conventions: Protocol I, Additional to the Geneva Conventions of 12 August 1949, Relating to the Protection of Victims of International Armed Conflicts (1977)." In Encyclopedia of Human Rights, ed. Edward Lawson. New York: Taylor and Francis.

Keen, William W. 1917. The Treatment of War Wounds. Philadelphia: W. B. Saunders.

Kilner, John F. 1990. Who Lives? Who Dies?: Ethical Criteria in Patient Selection. New Haven, CT: Yale University Press.

Kipnis, Kenneth. 2003. "Overwhelming Casualties: Medical Ethics in a Time of Terror." In After the Terror: Medicine and Morality in a Time of Crisis, ed. Jonathan D. Moreno. Cambridge, MA: MIT Press.

Larrey, Dominique Jean. 1832. Surgical Memoirs of the Campaign in Russia, tr. J. Mercer. Philadelphia: Cowley and Lea.

Leaning, Jennifer. 1986. "Burn and Blast Casualties: Triage in Nuclear War." In The Medical Implications of Nuclear War, ed. Fredric Solomon and Robert Q. Marston. Washington, D.C.: National Academy Press.

Leaning, Jennifer. 1988. "Physicians, Triage, and Nuclear War." Lancet 2(8605): 269–270.

Lee, Robert I. 1917. "The Case for the More Efficient Treatment of Light Casualties in Military Hospitals." Military Surgeon 42: 283–286.

Lynch, Charles; Ford, J. H.; and Weed, F. W. 1925. Field Operations: In General View of Medical Department Organization. Vol. 8 of The Medical Department of the United States Army in the World War. Washington, D.C.: U.S. Government Printing Office.

O'Donnell, Thomas J. 1960. "The Morality of Triage." Georgetown Medical Bulletin 14(1): 68–71.

Purnell, Larry D. 1991. "A Survey of Emergency Department Triage in 185 Hospitals." Journal of Emergency Nursing 17(6): 402–407.

Rund, Douglas A., and Rausch, Tondra S. 1981. Triage. St. Louis, MO: Mosby.

Vickery, Donald M. 1975. Triage: Problem-Oriented Sorting of Patients. Bowie, MD: Robert J. Brady.

Wiebe, Robert A., and Rosen, Linda M. 1991. "Triage in the Emergency Department." Emergency Medicine Clinics of North America 9(3): 491–503.

Winslow, Gerald. 1982. Triage and Justice. Berkeley: University of California Press.

TRIAGE

The metaphor "triage" (a French word meaning "to pick or sort according to quality") gained entry into medical parlance from a military context in which Napoleon's chief surgeon, Jean Larrey, found it necessary to categorize wounded soldiers needing treatment according to a utilitarian principle: those whose wounds, even if left untreated, were such as not to preclude a return to the battlefield; those sustaining mortal wounds for whom treatment would be futile; those needing immediate attention for whom there would be hope for survival and eventual return to active duty. Only the last group would be given medical attention when human, medicinal, and facility resources had to be rationed. Strategies for "triaging" in times of warfare, natural disasters (e.g., earthquakes, famines, etc.), and civil defense planning have marked the modern era. Similarly and more routinely, contemporary health care practice necessitates the application of triage where patients must be sorted or prioritized because of restricted medical resources. Hospital emergency rooms often designate a triage nurse whose task it is to order those seeking treatment according to greatest need and best potential for benefit.

Medical Care. The highly technical nature of modern medicine has further contributed to the complexity of selecting patients for treatment. For example, advances in organ transplant technology utilizing both natural and artificial organs offer new hope to patients with life threatening vital organ failure, but the supply of transplantable organs remains limited and the selection of recipients presents an ethical as well as a logistical dilemma. In organ allocation the utilitarian questions of "Who has greatest need?" and "Who might benefit most?" are further complicated by possible considerations of social worth and equality of persons. Should younger patients with as yet untapped potential for social contribution be chosen over the retired, or those with disabling mental or physical handicap? If three patients are equal in need and in their potential to benefit from treatment, and there are resources for treating only one, what criteria or selection principle will accord with the traditional Christian belief in a fundamental obligation in justice to recognize the irreducible, inalienable equality of all persons?

Some ethicists (e.g., Joseph Fletcher), appealing to a pragmatic distributive or allocative justice, propose that we choose on the basis of the good of the greatest number or the social interest. Thus, a bank president and father of four children would be chosen to receive treatment over an unemployed single person or a prison inmate. Paul Ramsey, and most Roman Catholic moral theologians, espousing a principle of the absolute equality of persons (commutative justice), argues that selection among medically equal and suitable patients be by random choice (e.g., lottery, choosing straws, or "firstcome, first-served") so as to avoid reducing the value of persons to their social worth. To do otherwise, it is argued, is to enter upon a "slippery slope" with implications unacceptable in a Christian ethic. Decisions based on social worth criteria are highly relative and rooted in a value system in which power and material things take precedence over persons. Further, the power entrusted to selected decision or policy makers, who would be calculating and evaluating the social value of another, raises disturbing ethical questions about who decides and who decides who decides.

The power at stake here is not just power for persons but power over persons. Ramsey and others object that there are some things we can do which we ought not to do, things which in the extended calculus hold potential for disproportionate harm to the humanum which is to be sustained by a Christian ethic. In a more positive vein, Ramsey observes that blind or lottery selection of persons to benefit from rationed medical resources emulates God's own indiscriminate care for us.

The social distribution of health care also invokes the ethical consideration of triage when a choice must be made between providing for a few patients whose need is critical and those for whom there is immediate, though limited, potential for benefit; expensive, even esoteric, treatments (e.g., the artificial heart); and supplying a large number of persons, especially the poor and underprivileged, with more routine medical care and preventive medicine (e.g., vaccines, dietary supplements). Many Christian ethicists maintain that in public policy concerning health care

priority ought to be given to that kind of preventive medicine or treatment of acute disease which will raise the general standards of health, especially for the young, over elaborate modes of treatment for the aged or seriously handicapped (Ashley and O'Rourke, 240).

A factor in this position is a recognized distinction between Biblical justice and the justice prevalent in secular society. The latter is avowedly impartial and favors individualistic opportunism. Those who find access and the financial means to pay have a right to benefit. Biblical justice, on the other hand, is not impartial and individualistic, but biased in favor of the poor and decidedly social in its thrust (see option for the poor).

Social Triage. The "lifeboat ethics" conundrum is yet another example of the metaphor of triage, here, social triage. The world population explosion, with attendant world hunger, confronts the developed nations with a disturbing specter: providing medical aid and food to underdeveloped countries will insure burgeoning population growth and, ultimately, increased starvation, unless such aid is contingent upon compulsory population control. Garrett Hardin (1980) argues for such contingencies in his "lifeboat ethics" proposal, cautioning the developed countries against lowering their own standards of living and health care lest their children, who ensure the future of the human race, become similarly deprived and lose their edge. Hardin contends that no amount of aid can reverse the plight of the underdeveloped nations. His utilitarian ethic effectively dictates that one save oneself even at the cost of sacrificing the other.

Hardin's assessment of the imminence of the over-population crisis is disputed by others who, nonetheless, do acknowledge a significant socio-economic and political problem confronting the world community. Some Catholic ethicists contend that

the advanced countries by introducing modern medicine [into underdeveloped nations] … upset the ecological balance and produced a rapid population growth, without at the same time producing the standard of living which in developed countries motivates and facilitates responsible parenthood (Ashley and O'Rourke, 241).

Rather than "sailing away," the developed nations are bound by principles of distributive and Biblical justice to restore the balance which they helped to destroy by raising the standards of living and education in the underdeveloped world. When resources are scarce those who stand to benefit most from enhanced opportunity are those whose need is greatest.

Bibliography: b. m. ashley and k. d. o'rourke, Health Care Ethics: A Theological Analysis (rev. ed. St. Louis 1982). j. f. childress, "Who Shall Live When Not All Can Live?" Readings on Ethical and Social Issues in Biomedicine, r. w. wertz, ed. (New Jersey 1973) 143–153. r. a. mccormick, "Justice in Health Care," Health and Medicine in the Catholic Tradition (New York 1984) 75–85. g. outka, "Social Justice and Equal Access to Health Care," On Moral Medicine: Theological Perspectives in Medical Ethics, s. lammers and a. verhey, eds. (Michigan 1987) 632–642. a. verhey, "Sanctity and Scarcity: The Makings of Tragedy," ibid., 653–657. p. ramsey, The Patient as Person (New Haven, 1970); Ethics at the Edges of Life (New Haven 1977).

[r. m. friday]

tri·age / trēˈäzh; ˈtrēˌäzh/ • n. 1. the action of sorting according to quality.2. (in medical use) the assignment of degrees of urgency to wounds or illnesses to decide the order of treatment of a large number of patients or casualties.• v. [tr.] assign degrees of urgency to (wounded or ill patients).ORIGIN: early 18th cent.: from French, from trier ‘separate out.’ The medical sense dates from the 1930s, from the military system of assessing the wounded on the battlefield.

triage (tree-ahzh) n. a system whereby a group of casualties or other patients is sorted according to the seriousness of their injuries or illnesses so that treatment priorities can be allocated between them. In emergency situations it is designed to maximize the number of survivors.