A Catholic Perspective: Triage Principles and Moral Distress in Pandemic Scarcity

The Moral Core of Medicine

The moral core of allopathic medicine emerges with the Hippocratic tradition which melds the Aesculapian (priestly) and scientific roots of medicine. For centuries, in a public oath, the doctor committed, “I will use regimens for the benefit of the ill in accordance with my ability and my judgment, but from (what is) to their harm or injustice, I will keep (them)” (Miles 2004, p xiii). The focus is on altruistic commitment to individual patient benefit and scientific integrity and also includes issues of civic responsibility and public health.

As this tradition encountered early Christianity, the ethics recognized patient vulnerability and focused intently on the character of the doctor as a moral agent and the virtues of medicine: fidelity to trust, compassion, phronesis (prudence or practical wisdom), justice, fortitude, temperance, integrity, and self-effacement (Pellegrino and Thomasma 1993). However, by the end of the seventeenth century, the sick experienced rampant entrepreneurial medicine as a crisis of trust. Modern professionalism was developed with Codes of Ethics again identifying the core elements of scientific competence and an altruistic commitment to the patient’s interest. It clearly articulated medicine as a public trust with other obligations to society (Pellegrino and Thomasma 1988). The 2018 Canadian Medical Association (2018) Code of Ethics is in continuity with this tradition. It emphasizes the centrality of trust in the patient–doctor relationship and identifies core duties and responsibilities. Key duties identified in the Code that are under challenge in the condition of scarcity of resources and in situations of crisis include:

“Consider first the well-being of the patient” (p. 1). In a severe scarcity of medical resources, the primary duty to the individual patient remains but may be balanced by the health systems’ duty for the stewardship of shared resources and attention to prevention and population health. This requires a protocol that will protect the trust essential to the patient–physician relationship as far as possible while discharging responsibilities to the population at large.

In the late nineteenth and early twentieth centuries, public heath made a positive impact on the health of communities and populations as it focused on issues of poverty, sanitation, and disease prevention. However, as modern medicine developed from the late nineteenth century, it progressively focused on scientific and technological advances to individual patients (Kenny 2010). Medical ethics was largely replaced by principle-based bioethics dominated by respect for autonomy (Beauchamp and Childress 2001). Public health ethics became separate and distinct focusing on social justice (Powers and Faden 2006).

Catholic Physicians and the Ministry of Healing

A leper came to him and pleaded on his knees: “If you want to” he said, “you can cure me.” Feeling sorry for him, Jesus stretched out his hand and touched him. “Of course, I want to!” he said, “Be cured! (Mark 1, 29:40–41)

The Process of Clinical Triage in Scarcity

When patients present for emergency care under ordinary circumstances, they will be assigned a level of priority corresponding to their medical condition, but with expectation that they will receive the treatment most appropriate for their condition in a timely manner and that the waiting for care will not seriously affect their health status. Even patients whose condition is so grave that survival seems unlikely are given (with their consent or consent of a surrogate) trials of aggressive interventions that could possibly rescue them.

However, when truly massive numbers of sick people are seeking emergency care, a healthcare facility may be overwhelmed, and such ordinary prioritization of care becomes unworkable. Such a predicament occurred in past influenza pandemics and was one of the reasons why nations engaged in pandemic planning (Kotalik 2006). This has been the situation in the current COVID-19 pandemic, when many patients present with severe pneumonia that can be rapidly lethal if not supported by mechanical ventilation and expert care in an intensive care unit (ICU). If the local capacity for such care is exhausted, the first response to this situation must be to move people to other facilities in the region, province, or state where the resources are available or to bring these resources to where sick people are. If all possibilities of transportation were exhausted, it will be necessary to resort to a process of assigning patients to resources (e.g., ventilators, ICU beds) that in this article we call “clinical triage.” Declaration of need for triage should always be a temporary response, activated as a last resort in crisis and deactivated as soon as possible.

The triage process recognizes that all human lives are of equal worth, and this would not be served if an opportunity to save the life of one person would be lost because of a nonurgent or likely futile treatment of another person. The triage process recognizes that in the situation of extreme scarcity, the different care needs of patients must be understood in conjunction with the common good, taking into account estimated opportunities for lifesaving and recovery. Triage decisions are always difficult, and no physician should be placed in a position of assigning patients to suboptimal care without guidance of a protocol or policy and support of a care team (Pacholczyk 2020).

The protocol for triaging patients who meet inclusion criteria for aggressive lifesaving therapy will typically consist of three steps: (1) application of exclusion criteria, (2) assessment of mortality risk, and (3) periodic clinical assessments to reassess the best care.

Applying exclusion criteria in step 1 will identify and exclude patients with the highest probability of mortality regardless of applying lifesaving therapy. In step 2, patients with a moderate degree of mortality but most likely to survive with the particular therapy will be prioritized for treatment. In step 3, clinical assessment is repeated every forty-eight hours to determine whether or not to continue the intervention (New York State Department of Health 2015). We need to keep in mind that published triage protocols, and those being developed for COVID-19, are untested and may possibly have unexpected, unintended consequences, for example, removing so many patients by exclusion criteria that ICU beds remain empty. Therefore, the impact of these protocols must be monitored in real time so that adjustments can rapidly be made.

Standard of care tools for objective clinical assessment (e.g. Sequential Organ Failure Assessment, Glasgow Coma Scale) may be used to make criteria objective and fair for all. Offering only “evidence-informed options” is central to ensuring that objective medical criteria regarding benefit and risk are used in recommending access to resources for patients.

In situations when triage scores two patients with exactly the same level of priority but only one patient can be accommodated, the tie can be broken either by enacting less-ideal criteria such as first come, first served basis or by random choice. Tiebreakers that imply a judgment about the value of different lives, such as age, gender, or disability, should be avoided.

Patients who meet exclusion criteria and will not have access to lifesaving therapies, for example, ventilation, must be offered the most appropriate alternative forms of medical care as clinically indicated. Alternative forms of care may include life-prolonging or life-sustaining interventions outside an ICU (e.g., oxygen, antibiotics, blood transfusions, fluids) or comfort measures only. Fluid and nutrition should always be provided unless there are medical contraindications. All patients benefit from a palliative approach to care in order to optimize symptom management and quality of life regardless of the focus of care. No patient should be left without care.

All patients presenting with a life-threatening illness that may require lifesaving interventions, and especially those who are either not eligible or choose to forgo such interventions, should be offered spiritual and psychological support corresponding to their religious tradition and worldview (Hilliard 2020). Ministers, priests, counselors, and other personal support staff should be given adequate personal protective equipment so that they may interact with patients at the bedside, and Catholic patients and staff can receive anointment of the sick and other sacraments (Hilliard 2020).

Values and Principles Guiding Triage in Scarcity of Resources

The general goals of clinical triage in scarcity are to minimize death and serious illness. To accomplish this goal, patients for whom intensive care and ventilator therapy would most likely be lifesaving are prioritized. Survival is defined by examining a patient’s short-term likelihood of surviving the acute medical episode with the use of specific medical interventions and not by focusing on a patient’s long-term prognosis related to an underlying chronic medical condition or disability.

Patients with the highest likelihood of survival without medical intervention, along with patients with the smallest likelihood of survival with medical intervention, should have the lowest level of access to lifesaving supports such as ventilator therapy. Thus, patients who are most likely to survive without the ventilator, together with patients who will most likely survive with ventilator therapy, increase the overall number of survivors. This type of approach maximizes the overall benefits and minimizes harms while providing equality of opportunity and justice by treating equals equally and similar cases similarly. However, there are significant limits that have to be placed on decision-making based on this approach, and in a triage protocol, these can be expressed as safeguards.

There is particular concern regarding the safeguards needed for people with disabilities. As recently expressed by representatives of over 200 disability-related organizations in Ontario, it would be improper if persons with disabilities were deprived of the possibility of intensive care based on their disability alone, because they need support for daily living or because they need some disability-related accommodation (Arch Disability Law Centre 2020). Canadian (University of Toronto Joint Centre for Bioethics 2005; Christian et al. 2006) and American (Emanuel et al. 2020; Gostin, Friedman, and Wetter 2020; Di Camillo 2020; Daley 2020; Petrini 2010) ethicists, among others, have identified values that need to be considered in developing clinical triage criteria. These key values include the following:

Respect for the dignity of all persons: Care must be provided to all in need. Discrimination or prejudicial treatment against patients based on age, health status, race, and gender should not be tolerated in triage protocols. This is very different from acknowledging that some health conditions make certain intensive therapies not appropriate as they are unlikely to help and more likely to cause harm. A value judgment by a healthcare professional based on the assumed patient’s quality of life should not be a factor in decisions to provide types of care. Personalist perspective promotes the collective good by safeguarding and giving value to the well-being of every individual (Schiedl 2020).

Respect for the autonomy of caregivers that also honors the duties of care and stewardship is a mirror image of the principle of respect for the autonomy of those who receive care (patients). Because patients are generally considered to be in a dependent position and medical professionals in an authoritative position, the physicians’ rights to autonomy have not received much attention recently, but the fact is that both patients and physicians are moral agents and deserve equal respect. Any action that involves both parties requires mutual consent. Consequently, patients cannot claim that their autonomy allows them to demand a particular intervention such as intensive care or ventilation, if this would conflict with the professional duties of physicians or with the physicians’ rights to freedom of conscience.

It is in this context that we can appreciate the crucial role that trust between doctor and patient forms the basis for a fruitful dialogue on how to balance appropriate and futile interventions. As our Church teaches, “…for such a decision to be made, account will have to be taken of the reasonable wishes of the patient and the patient’s family, as also of the advice of the doctors who are specially competent in the matter” (Vatican 1980).

Equity is a concept of fairness that treats persons equally, taking into account relevant differences. Ethically sound responses to a public health emergency must not exacerbate disparities in access to care. An example of the equity principle in practice would be to apply the first come, first served rule for prioritization of people with the same or similar likelihood of benefit when competing for the same resource.

Moral Distress in Emergency Triage

The concept of “moral distress” emerged from nurses’ experiences of being ordered to act contrary to their understanding of patient best interest. It now is understood to arise “when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” (Jameton 1984, 6). It is directly related to restraints on freedom of an informed conscience as well as conscientious objection to what is judged immoral or unethical.

The result of moral distress which has compromised integrity has been called “moral residue” (Webster and Baylis 2000). Sources of moral distress in clinical triage in scarcity lie primarily in the requirement for behavior that contradicts doctors’ primary duty to care for the sick, to save lives where possible, and in applying innovative practices and treatments without rigorous research which can result in harm and delay in effective treatment. It also arises from concerns regarding abandonment of those who are dying and their families when there are limits on pastoral and palliative care because of isolation. Since palliative care, according to Pope Francis, “…bears witness that the human person is always precious, even if marked by age and sickness,” every effort must be made to ensure this care to all seriously ill and dying patients, especially if they are excluded from intensive and respiratory care (Gallagher, Passmore, and Baldwin 2020).

Clinical triage in scarcity also causes anguish from the awareness of the significant probability of death or long-term harm to patients. This anguish can also extend to patients who are not able to access treatments or are frightened to go to hospital with symptoms from nonpandemic illnesses, such as acute coronary syndrome or early stroke or patients who have delayed access to investigations or treatment for other conditions such as cancer. Physical and emotional fatigue, and ethical conflicts between duties to the sick, risks to self and risks to family requiring isolation from them, escalate distress. There can be a temptation to abandon prayer and other spiritual supports at a time when they are needed most.

For Catholics, moral distress may be compounded by difficult decisions regarding the use of palliative sedation (International Association of Catholic Bioethicists 2012). It can be morally acceptable under certain conditions but, unfortunately, is often confused with euthanasia. It is important to have a good understanding of the difference between palliative sedation and euthanasia. Palliative sedation is a specialized medical intervention used to address refractory, irreversible symptoms in the last hours or short days of life that have not responded to any other treatments. Sedation is provided and maintained at the lightest possible level to control symptoms and is continued until natural death occurs from the underlying medical condition. When used appropriately, palliative sedation does not hasten death and is distinct from euthanasia (Herx 2021). There can also be spiritual distress in awareness of patients who may choose or be provided euthanasia because of fears and feelings of abandonment or fear that they may lack access to adequate care during a time of scarcity and be left to suffer.