Herding cats: ethics in prehospital triage

Objective: Triage can create an ethical slippery slope when providing prehospital emergency health care. In triage decisions, emergency management is like the idiom of “herding cats”, which refers to managing or controlling the chaos and organizing people toward common goals. The purpose of this literature review is to explore the ethical framework of prehospital triage and to provide a critical view of the subject.

Methods: Published materials related to “triage”, “ethics”, and “prehospital emergency medicine” were extracted from online databases and books from 1985 until February 2021. The papers were handled in seven themes including the historical basis, the importance of the triage, ethical considerations in prehospital triage, justice, assessment and decision-making, the variability of triage assessment criteria, and the reliability of triage decisions. Except for the historical basis and the importance of triage, the other five groups were discussed with an ethical critique of the content. The methodology in this article is based on a critical interpretation of discussions on triage through ethical approaches.

Results: There are three basic ethical approaches to triage: utilitarianism, beneficence, and justice. Due to the historical military basis of triage, results-focused approaches have become more prominent. Ethical values in prehospital triage include the issues of human rights, moral rights, social justice, and beneficence. Ethical difficulties in triage decision-making involve vulnerability, limited resources, the concern of safety, the urgency of the situation, and instability. Triage decisions may be affected by subjective approaches such as the personal values and beliefs of the decision-makers.

Conclusions: Three predominant ethical concepts in triage are utilitarianism, beneficence, and justice. The unique dynamics of the field influence triage decision-making in a variety of ways. The way triage is structured makes it more amenable to subjective influences. Considering the differences in prehospital triage models and approaches, there is an important need for an ethical framework that expresses clear values and principles that will guide prehospital emergency caregivers. In this paper, it is suggested that an ethical framework should include the following six headings: basic bioethical principles, distributing scarce resources, decision-making process, community support, assessment criteria, and promote the common good.

Prehospital emergency medicine; Triage; Management; Decision-making; Justice; Ethical theories

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