Updated: Jan 24
By: Connor Brenna, University of Toronto
Connor Brenna is a senior medical student in the University of Toronto MD Program. Prior to joining the University of Toronto he studied a combination of philosophy and the basic sciences at the University of Saskatchewan, and continues to search for the interface between these disciplines in the field of bioethics. The COVID-19 pandemic impacted virtually all Canadians in some way, and a uniquely high caseload in Toronto inspired Connor to think about the medical profession’s conceptions of justice and their implementation in triage protocols. These protocols ought to be able to withstand moral scrutiny, because they are being created and used in real time to guide life-and-death decision-making when resources are scarce. Connor hopes that this brief can engage others to think critically about how we make clinical decisions with potentially great consequences, and what basic values we want these decisions to reflect.
Under ordinary circumstances, medical systems aim to deliver high-value care to all patients in part through the adherence to a governing code of ethical principlism. Medical decisions are typically guided by four principles: beneficence (“do good”), non-maleficence (“do no harm”), autonomy (patients make decisions about their care), and justice (fairness in every sense of the word).(1) Classically, decision-making should satisfy all four, but ethical tension arises when principles come into conflict with each other—for instance, a patient may willfully choose a treatment approach that will harm them (such as opting not to amputate a gangrenous limb), bringing autonomy and nonmaleficence into conflict. Medical triage perfectly illustrates the tension between principles because by its very nature, optimal care cannot be provided to all patients due to the overwhelming imbalance of needs and resources.(2) When patients outnumber hospital beds, triage protocols employ the concept of “distributive justice”, which focuses on the fair distribution of limited resources.(3) In these settings, distributive justice governs practice and existing triage guidelines,(4) reflecting the concept that patients with equal need should have equal rights to healthcare resources.
While the concept of distributive justice dominates straightforward triage, the problem of how to best allocate scarce resources is further complicated by situations which invite the consideration of blame or responsibility. For example, imagine a hypothetical circumstance where an individual protesting pandemic lockdown measures subsequently contracts COVID-19. One may argue that this person bears some degree of responsibility: they contracted the virus while opposing a policy intended to protect themselves and others, whether their protesting was an expression of ignorance (misunderstanding the utility of lockdown measures), arrogance (assuming a greater knowledge than public health officials), or something else entirely. Whether or not triage should consider any possibility of individual responsibility, however, is contentious: should an individual who falls ill after protesting against lockdown legislation receive lower priority during the allocation of scarce medical resources?
In 2017, Gold and Strous offered insight for this sort of decision-making by exploring an extreme example: suppose both the victim and the perpetrator of an act of terror (say, a killing spree) simultaneously arrive at the same hospital with similar injuries—who should the clinician treat first?(5) The authors identify two ethical frameworks for such a scenario: the conventional “no exceptions” approach to distributive justice, and a justice-oriented “victim-first” approach.(5) Substantiating the latter, they argue that distributive justice can be balanced against retributive justice (“those who commit crimes deserve punishment”) and corrective justice (“those trespassed by another deserve rectification at the cost of that other”), proposing that treating their scenario’s victim first is a legitimate triage policy.(5) Extending their rationale to the hypothetical lockdown protester, it seems that the principles of retributive and corrective justice would favour prioritizing another individual who obeyed lockdown measures but contracted the virus nonetheless. I contend that the magnitude of personal responsibility is important, though, and it is challenging to draw comparisons between a peaceful protester and a terrorist: the former is presumably exercising their freedom of assembly to advocate for what they believe to be improved policy (albeit in the process putting themselves and their subsequent contacts at risk, during an infectious disease pandemic), and the latter is acting with intentional violence toward the innocent.
Softening the scenario presented by Gold and Strous, we can instead consider a closer parallel to the lockdown protester. Suppose that two cyclists collide, and sustain similar and grievous injuries: they are then taken in the same ambulance to an emergency department with only one available bed. Prior to the crash, one patient operated a blog through which they posted furiously about the ineffectuality of bicycle helmets, and the other was guilty of riding without a bell. Both patients here can be thought to bear a sliver of responsibility for the accident or its outcomes, but neither deserves to be punished for that—especially not in the emergency department. In such a situation, it is more defensible to defer to standard “no exceptions” triage criteria to guide their treatment, rather than pause to consider and weigh the actions of each patient leading up to the crash. This is an important criticism of the terror-triage scenario presented by Gold and Strous, too: even in situations where there are elements of justice that rely on responsibility for one's own condition, it is not the role of the physician to act as an agent of retributive or corrective justice.(6)
Between the terror-triage and bicyclist-mishap scenarios, a lockdown protester seems to be closer to the latter. There are many reasons for which one could attend a lockdown protest, including ignorance, taking a wrong turn in the park, or even—I must admit—knowing something I do not. It is unlikely that they are intentionally trying to harm anyone else. Perhaps there is an appropriate punishment for willful actions that inadvertently put others at risk, but it is determined neither by clinicians nor at the point of triage. Returning to the four core ethical principles, these situations represent an ethical tension best resolved by first adhering to the principles of beneficence, non-maleficence, and autonomy—at least as far as immediate care goes. In the context of the COVID-19 pandemic, there are several emerging suggestions about how we can best allocate limited resources,(7) but they do not and should not recognize individual responsibility for illness as a factor in determining priority for care.
Beauchamp TL, Beauchamp P of P and SRSTL, Childress JF, Childress UP and HP of EJF. Principles of Biomedical Ethics. Oxford University Press; 2001. 470 p.
Domres B, Koch M, Manger A, Becker HD. Ethics and Triage. Prehospital and Disaster Medicine. 2001 Mar;16(1):53–8.
Gillon R. Justice and allocation of medical resources. Br Med J (Clin Res Ed). 1985 Jul 27;291(6490):266–8.
Beveridge R, John S, Clarke B, John S, Janes L, John S, et al. Implementation Guidelines for The Canadian Emergency Department Triage & Acuity Scale (CTAS). :32.
Gold A, Strous RD. Second thoughts about who is first: the medical triage of violent perpetrators and their victims. Journal of Medical Ethics. 2017 May 1;43(5):293–300.
Wicclair MR. Second thoughts about ‘second thoughts.’ Journal of Medical Ethics. 2017 May 1;43(5):303–4.
Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. New England Journal of Medicine. 2020 May 21;382(21):2049–55.