The COVID-19 pandemic has been overwhelming public health-care systems around the world. With demand exceeding the availability of medical resources in several regions, hospitals have been forced to invoke triage. To ensure that this difficult task proceeds in a fair and organised manner, governments scrambled experts to draft triage guidelines under enormous time pressure. Although there are similarities between the documents, they vary considerably in how much weight their respective authors place on the different criteria that they propose. (...) Since most of the recommendations do not come with ethical justifications, analysing them requires that one traces back these criteria to their underlying theories of distributive justice. In the literature, COVID-19 triage has been portrayed as a value conflict solely between utilitarian and egalitarian elements. While these two accounts are indeed the main antipodes, I shall show that in fact all four classic theories of distributive justice are involved: utilitarianism, egalitarianism, libertarianism, and communitarianism. Detecting these in the documents and classifying the suggested criteria accordingly enables one to understand the balancing between the different approaches to distributive justice—which is crucial for both managing the current pandemic and in preparation for the next global health crisis. (shrink)

At the height of the Covid-19 pandemic, frontline medical professionals at intensive care units around the world faced gruesome decisions about how to ration life-saving medical resources. These events provided a unique lens through which to understand how the public reasons about real-world dilemmas involving trade-offs between human lives. In three studies (total N = 2298), we examined people’s moral attitudes toward the triage of acute coronavirus patients, and found elevated support for utilitarian triage policies. These utilitarian tendencies (...) did not stem from period change in moral attitudes relative to pre-pandemic levels–but rather, from the heightened realism of triage dilemmas. Participants favoured utilitarian resolutions of critical care dilemmas when compared to structurally analogous, non-medical dilemmas–and such support was rooted in prosocial dispositions, including empathy and impartial beneficence. Finally, despite abundant evidence of political polarisation surrounding Covid-19, moral views about critical care triage differed modestly, if at all, between liberals and conservatives. Taken together, our findings highlight people’s robust support for utilitarian measures in the face of a global public health threat, and illustrate how the dominant methods in moral psychology (e.g. trolley cases) may deliver insights that do not generalise to real-world moral dilemmas. (shrink)

The COVID-19 pandemic has generated an imbalance between the clinical needs of the population and the effective availability of advanced life support (ALS) resources. Triage protocols have thus become necessary. Triage decisions in situations of scarce resources were not extraordinary in the pre-COVID-19 era; these protocols abounded in the context of organ transplantation. However, this prior experience was not considered during the COVID-19 outbreak in Spain. Lacking national guidance or public coordination, each hospital has been forced to put (...) forth independent and autonomous triage protocols, most of which were, nonetheless, based on common ethical principles and clinical criteria. However, controversial, non-clinical criteria have also been defended by Spanish scientific societies and public institutions, including setting an age cut-off value for unilaterally withholding ALS, using ‘social utility’ criteria, prioritising healthcare professionals or using ‘first come, first served’ policies. This paper describes the most common triage criteria used in the Spanish context during the COVID-19 epidemic. We will highlight our missed opportunities by comparing these criteria to those used in organ transplantation protocols. The problems posed by subjective, non-clinical criteria will also be discussed. We hope that this critical review might be of use to countries at earlier stages of the epidemic while we learn from our mistakes. (shrink)

Some ethicists assert that there is a consensus that maximising medical outcomes takes precedence as a principle of resource allocation in emergency triage of absolutely scarce resources. But the nature of the current severe acute respiratory syndrome-related coronavirus 2 pandemic and the history of debate about balancing equity and efficiency in resource allocation do not support this assertion. I distinguish a number of concerns with justice and balancing considerations that should play a role in critical care triage policy, (...) focusing on discrimination and on fundamental egalitarian and social justice concerns. (shrink)

In today’s pandemic, many countries have experienced shortages of medical resources and many healthcare providers have often been faced with dramatic decisions about how to allocate beds, intensive care, or ventilators. Despite recognizing the need for triage, responses are not the same everywhere, and opinions and practices differ around what guidelines should be used, how they should be implemented, and who should ultimately decide. To some extent, triage issues reflect community values, revealing a given society’s moral standards and (...) ideals. Our goal is to study two countries which share many common features—Italy and France—as they deal with the pandemic, revealing the moral organization of medicine and healthcare, the power structures, and the nature of the disruptions in each context. (shrink)

At the height of the Covid-19 pandemic, frontline medical professionals at intensive care units around the world faced gruesome decisions about how to ration life-saving medical resources. These events provided a unique lens through which to understand how the public reasons about real-world dilemmas involving trade-offs between human lives. In three studies (total N = 2298), we examined people’s moral attitudes toward triage of acute coronavirus patients, and found elevated support for utilitarian triage policies. These utilitarian tendencies did (...) not stem from period change in moral attitudes relative to pre-pandemic levels--but rather, from the heightened realism of triage dilemmas. Participants favored utilitarian resolutions of critical care dilemmas when compared to structurally analogous, non-medical dilemmas—and such support was rooted in prosocial dispositions, including empathy and impartial beneficence. Finally, despite abundant evidence of political polarization surrounding Covid-19, moral views about critical care triage differed modestly, if at all, between liberals and conservatives. Taken together, our findings highlight people’s robust support for utilitarian measures in the face of a global public health threat, and illustrate how hypothetical scenarios in moral psychology (e.g. trolley cases) should strive for more experiential and psychological realism, otherwise their results might not generalize to real-world moral dilemmas. (shrink)

In early 2020, a number of countries developed and published intensive care triage guidelines for the pandemic. Several of those guidelines, especially in the UK, encouraged the explicit assessment...

We often show a greater inclination to assist and avoid harming people identified as those at high risk of great harm than to assist and avoid harming people who will suffer similar harm but are not identified (as yet). Call this the identified person bias. Some ethicists think such bias is justified; others disagree and claim that the bias is discriminatory against statistical people. While the issue is present in public policy and politics, perhaps the most notable examples can be (...) found in medical ethics such as in ICU triage decisions made during the COVID‐19 pandemic. The Rule of Rescue, as the application of the identified person bias is sometimes called, states that spending large amounts of resources rescuing identifiable individuals who are in imminent danger is justified. In this paper, I show that our distorted attitudes toward time play a role in identified person bias. I claim that ICU triage decisions are better explained by a preference to treat people sooner rather than later, which is at least partially due to near bias (positive events are to be preferred to be near rather than distant), than by a preference to treat identified lives over statistical lives. Thus, another bias, near bias, is involved in the reasoning behind the identified person bias and the Rule of Rescue. (shrink)

On March 11, 2020 the World Health Organization classified COVID‐19, caused by Sars‐CoV‐2, as a pandemic. Although not much was known about the new virus, the first outbreaks in China and Italy showed that potentially a large number of people worldwide could fall critically ill in a short period of time. A shortage of ventilators and intensive care resources was expected in many countries, leading to concerns about restrictions of medical care and preventable deaths. In order to be prepared for (...) this challenging situation, national triage guidance has been developed or adapted from former influenza pandemic guidelines in an increasing number of countries over the past few months. In this article, we provide a comparative analysis of triage recommendations from selected national and international professional societies, including Australia/New Zealand, Belgium, Canada, Germany, Great Britain, Italy, Pakistan, South Africa, Switzerland, the United States, and the International Society of Critical Care Medicine. We describe areas of consensus, including the importance of prognosis, patient will, transparency of the decision‐making process, and psychosocial support for staff, as well as the role of justice and benefit maximization as core principles. We then probe areas of disagreement, such as the role of survival versus outcome, long‐term versus short‐term prognosis, the use of age and comorbidities as triage criteria, priority groups and potential tiebreakers such as ‘lottery’ or ‘first come, first served’. Having explored a number of tensions in current guidance, we conclude with a suggestion for framework conditions that are clear, consistent and implementable. This analysis is intended to advance the ongoing debate regarding the fair allocation of limited resources and may be relevant for future policy‐making. (shrink)

We distinguish and review aspects of the history of two models of triage: egalitarian and utilitarian. Egalitarian triage is widely and successfully practiced in battlefield medicine, as well as in the emergency room and the ICU. Utilitarian triage has been sporadically practiced and typically collapses under the pressure of public scrutiny. Unfortunately, the two models tend to be conflated, confusing our understanding of the past and confounding our ability to plan for the future.

Shortages of life-saving medical resources caused by COVID-19 have prompted hospitals, healthcare systems, and governmentsto develop crisis standards of care, including 'triage protocols' to potentially ration medical supplies during the public health emergency. At the same time, the pandemic has highlighted and exacerbated racial, ethnic, and socioeconomic health disparities that together constitute a form of structural racism. These disparities pose a critical ethical challenge in developing fair triage systems that will maximize lives saved without perpetuating systemic inequities. Here (...) we review alternatives to 'utilitarian' triage, including first-come first-served, egalitarian, and prioritarian systems of allocating scarce medical resources. We assess the comparative advantages and disadvantages of these allocation schemes. Ultimately, we argue that while triage protocols should not exacerbate disparities, they are not an adequate mechanism for redressing systemic health inequities. Entrenched health disparities must be addressed through broader social change. (shrink)

The COVID-19 coronavirus pandemic raises a host of challenging ethical questions at every level of society. However, some of the most acute questions relate to decision making in intensive care. The problem is that a small but significant proportion of patients develop severe viral pneumonitis and respiratory failure. It now seems likely that the number of critically ill patients will overwhelm the capacity of intensive care units within many health systems, including the National Health Service in the UK. The experience (...) of Northern Italy—a couple of weeks ahead of the UK, suggests that it will simply not be possible to provide mechanical ventilation to every patient who might need it. When the crunch comes, the unpalatable question facing clinicians is which patient to save. There are some obvious strategies to avoid or reduce the problem—through measures to increase intensive care capacity, and via society-level interventions to reduce the spread of the virus. These are vitally important, but unfortunately they are unlikely to prevent the problem of demand outstripping supply from occurring. What, then, should clinicians do? How should they allocate the scarce resource of intensive care—particularly over the coming weeks as the crisis escalates? There are different values at stake in triage decisions, but at a basic level the key values are those of benefit and …. (shrink)

While triage protocols share a common goal—maximizing life by selecting patients who would most benefit from critical care—there are many variations in the selection of criterion to respond to situ...

One question that has sometimes cropped up in the debate on triage and the management of scarce healthcare resources concerns patients’ merits, demerits, and responsibility with regard to their own medical condition. During the current pandemic, some have wondered, when it comes to accessing healthcare, whether patients who have refused vaccination—despite the availability of vaccines and pressure to get vaccinated from the health authorities—should be given the same priority as patients who have diligently undergone vaccination in accordance with the (...) authorities’ recommendations. The issue of patients’ merits and demerits is not new, and it did not emerge with the pandemic for the first time. In the past, the question was often posed whether terrorists have the right to receive the same treatment as their victims, with the same degree of priority, all clinical conditions being equal. Another issue that has been raised concerns patients suffering from diseases caused by unhealthy lifestyles that they have freely adopted: drinking, smoking, eating fatty foods, practising extreme sports, etc. The conclusion reached in the present article is that it is indeed possible to identify certain general rules for cases of this sort, as is shown by the literature on the topic. However, slavishly following these rules, even in exceptional cases for which it is impossible to make detailed provisions, can lead to disastrous consequences. Therefore, following Aristotle, the article seeks to take account both of the rule of justice and of equity, which is a form of “situational justice” capable of filling the gaps of general norms in the light of concrete cases. (shrink)

The call for 'triage' as a specific policy for the selection of patients presenting with chronic renal failure, in the light of increasingly limited resources prompted us to question nephrologist on their bases for selection. We discovered no absolute criteria for rejection, but a consensus of opinion against those with additional and complicating factors to their renal disease such as age, hepatitis carriers and mental illness-a bias seen throughout the National Health Service. In this paper we discuss the validity (...) of such criteria, the implications of the currently pragmatic and often covert practice of selection, and in this potentially finite area of demand we question the rationale for the limitation of resources. (shrink)

Much of the ethical discourse concerning the coronavirus pandemic has focused on the allocation of scarce resources, be it potentially beneficial new treatments, ventilators, intensive care beds, or oxygen. Somewhat ironically, the more important ethical issues may lie elsewhere, just as the more important medical issues do not concern intensive care or treatment for COVID‐19 patients, but rather the diversion towards these modes of care at the expense of non‐Covid patients and treatment. In this article I explore how ethicists can (...) and should prioritize which ethical issues to deal with, and develop a method of triage for identification and prioritization of ethical issues both in the next public health emergency and in bioethics more widely. (shrink)

Objectives To characterize the prevalence and content of pediatric triage policies.Methods We surveyed and solicited policies from U.S. hospitals with pediatric intensive care units. Policies were analyzed using qualitative methods and coded by 2 investigators.Results Thirty-four of 120 institutions (28%) responded. Twenty-five (74%) were freestanding children’s hospitals and 9 (26%) were hospitals within a hospital. Nine (26%) had approved policies, 9 (26%) had draft policies, 5 (14%) were developing policies, and 7 (20%) did not have policies. Nineteen (68%) institutions (...) shared their approved or draft policy. Eight (42%) of those policies included neonates. The polices identified 0 to 5 (median 2) factors to prioritize patients. The most common factors were short- (17, 90%) and long- (14, 74%) term predicted mortality. Pediatric scoring systems included Pediatric Logistic Organ Dysfunction-2 (12, 63%) and Score for Neonatal Acute Physiology and Perinatal Extensions-II (4, 21%). Thirteen (68%) policies described a formal algorithm. The most common tiebreakers were random/lottery (10, 71%) and life cycles (9, 64%). The majority (15, 79%) of policies specified the roles of triage team members and 13 (68%) precluded those participating in patient care from making triage decisions.Conclusions While many institutions still do not have pediatric triage policies, there appears to be a trend among those with policies to utilize a formal algorithm that focuses on short- and long-term predicted mortality and that incorporates age-appropriate scoring systems. Additional work is needed to expand access to pediatric-specific policies, to validate scoring systems, and to address health disparities. (shrink)

During the COVID-19 pandemic, the number of patients who require intensive care treatment may outnumber the number of intensive care beds, even in industrialized nations. Consequently, triage may become necessary. In Italy, France, and Spain, age has been used as a leading parameter to decide who is admitted to the intensive care unit, and who receives palliative care. Although age is an objective and easy-to-use parameter, it is ethically not ideal to withdraw ventilator therapy from elderly people who suffer (...) from COVID-19. We have developed a simple and easy-to-use scoring system to allow for triage that is based upon scientific outcome data and, at the same time, fulfills ethical standards. (shrink)

The paper discusses the problem of triaging the elderly in the period of the COVID-19 pandemic crisis by analyzing the triage process, caused by lack of resources, in Germany, Holland, the Czech Republic, and Slovakia. We apply inductive, deductive, and normative bioethical methods, comment on various recommendations for the indication of intensive care during a crisis, and discuss the utilitarianism of benefit maximization. As it follows from the evaluation of the elderly by the frailty parameter, medically inappropriate treatment, as (...) a result of limited resources, is characterized by clinical and bioethical uncertainty. If the main bioethical objective of general bioethics for the COVID-19 pandemic is, in the case of limited resources, based on the non-utilitarian consequentialism paradigm, from the perspective of medical ethics, we face a borderline situation closely related to the topic of dying and death. Such a situation requires social, ethical, and professional reflection. An algorithm for intensive care indication in the situation of crisis and limited resources in the period of the pandemic requires a definition of criteria that identify an acceptable reason for abandoning the treatment in the context of the autonomy of the elderly and by respecting their human dignity and humanity. A global objective of general bioethics in the situation of the pandemic crisis should be based on the paradigm of social justice. (shrink)

In the first wave of the COVID-19 pandemic, healthcare workers in some countries were forced to make distressing triaging decisions about which individual patients should receive potentially life-saving treatment. Much of the ethical discussion prompted by the pandemic has concerned which moral principles should ground our response to these individual triage questions. In this paper we aim to broaden the scope of this discussion by considering the ethics of broader structural allocation decisions raised by the COVID-19 pandemic. More specifically, (...) we consider how nations ought to distribute a scarce life-saving resource across healthcare regions in a public health emergency, particularly in view of regional differences in projected need and existing capacity. We call this the regional triage question. Using the case study of ventilators in the COVID-19 pandemic, we show how the moral frameworks that we might adopt in response to individual triage decisions do not translate straightforwardly to this regional-level triage question. Having outlined what we take to be a plausible egalitarian approach to the regional triage question, we go on to propose a novel way of operationalising the ‘save the most lives’ principle in this context. We claim that the latter principle ought to take some precedence in the regional triage question, but also note important limitations to the extent of the influence that it should have in regional allocation decisions. (shrink)

In a previous paper, Dominic Wilkinson and colleagues argued in support of the British National Health System utility maximizing triage policies that allocate medical resources to ensure the...

This essay presents and defends a triage theory of grading: An item to be graded should get full credit if and only if it is clearly or substantially correct, minimal credit if and only if it is clearly or substantially incorrect, and partial credit if and only if it is neither of the above; no other (intermediate) grades should be given. Details on how to implement this are provided, and further issues in the philosophy of grading (reasons for and (...) against grading, grading on a curve, and the subjectivity of grading) are discussed. (shrink)

Critical care as a discipline has become so expensive that some have proposed extensive limitations on the amount of money devoted to it by society. In this paper that issue is examined with respect to pediatric and neonatal intensive care. Initially, a case is presented which includes many of the ethical and economic issues. The neonatal population at present has a tolerable median cost, with a distinctly higher average cost created by many special cases such as the one described with (...) very high costs. The pediatric population is served by an intensive care system costing approximately one billion dollars. This contrasts with the adult costs which are markedly higher and yet do not meet the total preceived need. Different theories of justice would concede differing allocations to individuals and to the problem of critical care as a whole based on their view of the obligations of societal membership. The authors argue that in fact critical care might be analyzed from the view-point of economics more effectively by breaking down the cost allocations for different components for that care, and argue that labor is the major cost in its provision. They then argue that that labor component may be a necessary and affordable cost for a post industrial society. It may be that libertarians, Rawlsians, and utilitarians could accept such an allocation of resources. Further, it is argued that triage is not an appropriate approach to limiting expenses, and that other methodologies such as cost effectiveness are the only appropriate ones to invoke in pediatric critical care. Recognition of the economic realities present in a given case may be the key to clinicians' demonstrated reluctance to participate in the gatekeeper role through the use of triage. (shrink)

This paper presents the most relevant criteria considered in the face of a lack of resources and medical infrastructure to prioritize the treatment of patients affected by the COVID-19 pandemic. From a systematic review, points of view have been collected considering the medical and social fields. Multiple divergences were found in these views depending on the countries, resources, religious approaches, and political aspects that have been adapted according to the circumstances of each nation. Keywords: Triage, COVID-19, public health.

In this paper I discuss what triage is and how it might be applied to the preservation of endangered species. I compare the suggested application oftriage to endangered species with its application to wartime military practice, distribution of food aid, and human population control to show that the situation of endangered species is not analogous to these other suggested uses. I argue that, as far as species preservation is concemed, triage starts with the wrong norms and values: it (...) is “human chauvinistic,” giving primacy to economic, political, and sociocultural aspects that emphasize human interests without recognizing the connection between the survival of other species and the survival of humans. (shrink)

In this paper I discuss what triage is and how it might be applied to the preservation of endangered species. I compare the suggested application oftriage to endangered species with its application to wartime military practice, distribution of food aid, and human population control to show that the situation of endangered species is not analogous to these other suggested uses. I argue that, as far as species preservation is concemed, triage starts with the wrong norms and values: it (...) is “human chauvinistic,” giving primacy to economic, political, and sociocultural aspects that emphasize human interests without recognizing the connection between the survival of other species and the survival of humans. (shrink)

A mass casualty (MASCAL) event is different to a major incident. The crux of this difference is that in a major incident, by the adoption of special measures, normal or near-normal standards of care can be maintained. In a MASCAL, irrespective of what special measures are instituted, standards of care inevitably drop. This is a, currently unmet, challenge for medical planning and planning policy. Twenty-First century weaponry is capable of producing thousands of causalities a day over a period of several (...) days in peer-on-peer conflict. In this chapter, we propose that medical planning for military events on this scale should include the following: explicit acceptance that ‘gold standard’ care cannot be given to patients who are triaged for treatment, a better understanding how to identify those patients who will not be triaged for treatment, a focus on ensuring patient flow (which includes diversion, self-care and remote monitoring), and implementation of the principle that care should be given by the lowest capable provider. We attempt to begin to develop some principles for planners to consider drawing on historical precedents and explore some of the ethical implications of our proposals. (shrink)

If, as a number of writers have predicted, the computers of the future will possess intelligence and capacities that exceed our own then it seems as though they will be worthy of a moral respect at least equal to, and perhaps greater than, human beings. In this paper I propose a test to determine when we have reached that point. Inspired by Alan Turing’s (1950) original “Turing test”, which argued that we would be justified in conceding that machines could think (...) if they could fill the role of a person in a conversation, I propose a test for when computers have achieved moral standing by asking when a computer might take the place of a human being in a moral dilemma, such as a “triage” situation in which a choice must be made as to which of two human lives to save. We will know that machines have achieved moral standing comparable to a human when the replacement of one of these people with an artificial intelligence leaves the character of the dilemma intact. That is, when we might sometimes judge that it is reasonable to preserve the continuing existence of a machine over the life of a human being. This is the “Turing Triage Test”. I argue that if personhood is understood as a matter of possessing a set of important cognitive capacities then it seems likely that future AIs will be able to pass this test. However this conclusion serves as a reductio of this account of the nature of persons. I set out an alternative account of the nature of persons, which places the concept of a person at the centre of an interdependent network of moral and affective responses, such as remorse, grief and sympathy. I argue that according to this second, superior, account of the nature of persons, machines will be unable to pass the Turing Triage Test until they possess bodies and faces with expressive capacities akin to those of the human form. (shrink)

The COVID-19 pandemic has occasioned a great deal of ethical reflection both in general and on the issue of reverse triage; a practice that effectively reallocates resources from one patient to another on the basis of the latter having a more favourable clinical prognosis. This paper addresses a specific concern that has arisen in relation to such proposals: the potential reallocation of ventilators relied upon by disabled or chronically ill patients. This issue is examined via three morally parallel scenarios. (...) First, the standard reallocation of a ventilator in accordance with reverse triage protocols; second, the reallocation of a personal ventilator from a chronically ill patient ordinarily reliant on it; and, third, the reallocation of a personal ventilator owned by a financially privileged individual but who is not ordinarily reliant on it. This paper suggests that whilst property rights cannot resolve these scenarios in a satisfactory manner, it may be possible to do so if we draw on the resources of phenomenology. However, in contradistinction to a recent paper on this topic, we argue that ethical claims to ventilators are not well grounded by the overly demanding notion that they are embodied objects. We suggest that the alternative phenomenological notion of homelikeness provides for a more plausible resolution of the issue. The personal ventilators of individuals who commonly rely upon them become part of their ordinary, everyday or homelike being. They are a necessary part of the continuation or maintenance of their basic state of health or wellbeing and the reallocation of such objects is unethical. Keywords: Phenomenology, COVID-19, Pandemic, Triage, Reverse triage, Ventilation, Chronic illness, Allocation of resources. (shrink)

The Covid-19 pandemic has led to severe shortages of many essential goods and services, from hand sanitizers and N-95 masks to ICU beds and ventilators. Although rationing is not unprecedented, never before has the American public been faced with the prospect of having to ration medical goods and services on this scale.

The coronavirus pandemic has brought to public attention a variety of questions long debated in medical ethics, but now given both added urgency and wider publicity. Among these is triage, with its origins in deciding which individual lives are to be saved on a battlefield, but now also concerned with the allocation of scarce resources more generally. On the historical battlefield, decisions about whom to treat first – neither those who would survive without treatment, nor those who would not (...) survive even with treatment, but those who needed treatment to survive – was facilitated by military discipline and the limited effectiveness of treatments available. In the allocation of scarce resources today, by contrast, such decisions are subject to intense public and political scrutiny, and the range of effective treatments available has immeasurably diminished the proportion of ‘those who would not survive even with treatment’. If triage decisions are to be made, they now need to be justified in the arena of public opinion by moral arguments which are also politically persuasive. A number of different aspects of what is required for this endeavour are examined in the first five contributions to this issue of the Journal. In ‘Should age matter in COVID-19 triage? A deliberative study ’1, Kuylen and colleagues report on a deliberative study of public views in the UK, in which participants ‘generally accepted the need for triage but strongly rejected ’fair innings’ and ’life projects’ principles as justifications for age-based allocation,…preferring to maximise the number of lives rather than life years saved’; and concerned that in any resolution ‘utilitarian considerations of efficiency should be tempered with a concern for equality and vulnerability’. A similar concern to temper utilitarian considerations, in this case with an Aristotelian view of the common good as ‘the good life for …. (shrink)

Some patients in intensive care units are too sick to derive much benefit from being there, while others are too well to require the technology and skills offered. When ICU resources are scarce, they may ethically be withdrawn from either sort of patient in favor of one more likely to benefit from the care.

The Hard Question of memory is the following: how are memory representations stored and organized so as to be made available for retrieval in the appropriate circumstances and format? In this essay, I argue that philosophical theories of memory should engage with the Hard Question directly and seriously. I propose that declarative memory is a faculty performing a kind of cognitive triage: management of information for a variety of uses under significant computational constraints. In such triage, memory representations (...) are preferentially selected and stabilized, but also systematically modified and integrated into generalized, model-like representational structures. Further, I propose a hybrid theory of remembering, which takes into account both the nature of the cognitive processes underlying remembering and the norms that govern representational success in relevant cognitive/epistemic contexts. (shrink)

Volume 20, Issue 7, July 2020, Page 75-77.

International Humanitarian Law mandates that all wounded in war, no matter which party they belong to, shall receive aid in accordance with their medical condition, and that “there shall be no distinction among them founded on any grounds other than medical ones.” This principle of impartiality is endorsed by various other military and civilian institutions worldwide to include the ICRC, the US Department of Defense, and the American Medical Association. In this essay, I argue that in some cases, we ought, (...) morally speaking, to triage based on factors beyond one’s medical condition. More specifically, I argue that in these cases, we ought to triage, at least partly, based on one’s moral responsibility for one’s current medical predicament. I call this view Triage by Moral Responsibility (TMR). I support my argument for TMR by demonstrating its plausibility when applied to cases of medical treatment and disaster relief, and by drawing parallels between these situations and those considered in the ethics of defensive harming. I conclude by discussing the practicality of my moral conclusion for the practice of medical triage in pandemics and war. (shrink)

We report here an emerging dispute in Italy concerning triage criteria for critically ill covid-19 patients, and how best to support doctors having to make difficult decisions in a context of insufficient life saving resources. The dispute we present is particularly significant as it juxtaposes two opposite views of who should make triage decisions, and how doctors should best be supported. There are both empirical and normative questions at stake here. The empirical questions pertain to the available level (...) of evidence that healthcare professionals would rather not be left alone with their ‘clinical judgments’ to make triage decisions, and to the accounts of distributive justice that doctors and healthcare professionals rely on, when making triage decisions. The normative questions pertain to how this empirical evidence should inform guidelines on how prioritisation decisions are made in a context of emergency, and who gets to have the authority to do so. This debate goes beyond the discussion of the care of critically ill patients with COVID-19 and has broader implications beyond the national context for the discussion of how to relieve moral distress in contexts of imbalances between healthcare resources and clinical needs of a population. (shrink)

Zusammenfassung. Der Beitrag diskutiert die ethischen Grundlagen der sogenannten Triage (der Sortierung von Behandlungsbedürftigen in Dringlichkeitskategorien beim Massenanfall Verwundeter) und prüft, inwieweit eine Übertragung dieser Praxis auf eine unter Rationierungsdruck geratende Alltagsmedizin begründbar bzw. zu erwarten ist. Insbesondere wird der ethische Status der sog. Maximierungsregel („rette so viele Menschenleben wie möglich”) erläutert, und es werden die bereits in der katastrophenmedizinischen Praxis nicht ganz unwirksamen Grenzen der Orientierung an dieser Regel deutlich gemacht.

The coronavirus disease-2019 (COVID-19) has caused shortages of life-sustaining medical resources, and future waves of the virus may cause further scarcity. The Yale New Haven Health System developed a triage protocol to allocate scarce medical resources during the COVID-19 pandemic, with the primary goal of saving the most lives possible, and a secondary goal of making triage assessments and decisions consistent, transparent, and fair. We outline the process of developing the protocol, summarize the protocol, and discuss the major (...) ethical challenges encountered, along with our answers to the challenges. These challenges include (1) the role of age and chronic comorbidities; (2) evaluating children and pregnant patients; (3) racial, ethnic, and socioeconomic disparities in health; (4) prioritization of healthcare workers; and (5) balancing clinical judgment versus protocolized assessments.We conclude with a review of the limitations of our protocol and the lessons learned. We hope that a robust public discussion of such protocols and the ethical challenges they raise will result in the fairest possible processes, less need for triage, and more lives saved during future waves of the pandemic and similar public health emergencies. (shrink)

Volume 20, Issue 7, July 2020, Page 207-209.

This paper provides a general framework for conceptualizing triage for intensive care unit admissions in public health emergencies such as the COVID‐19 pandemic. It applies this framework to some of the guidelines issued during the pandemic and addresses some controversial issues, including the role of age, the use of lives or life years, and the relevance of quality of life considerations. The paper defends a view on which triage protocols for public health emergencies should aim to maximize the (...) number of life years saved, may take into account age as a proxy, and should ignore quality of life considerations. (shrink)