Triage for the Next Pandemic: Selecting on the Basis of "Social Worth"

Here is the issue in a “nutshell” as written by Margaret R. McLean in a report prepared by Center Director of Biotechnology and Health Care Ethics for the Santa Clara County (California) Public Health Department on Ethical Preparedness for Pandemic Influenza and as excerpted by the Markkula Center for Applied Ethics at Santa Clara University, July 2007.

“...one of the most vexing questions about the just rationing of health care resources is which ethical principle ought to guide decision making—save the most lives (e.g., in fires and floods); save the sickest (e.g., in organ transplant protocols); save the most-likely to recover (e.g., in triage during war); save people who can preserve society (e.g., the Centers for Disease Control (CDC) recommendation during a pandemic).

Deciding who can best preserve society means making “social worth” distinctions, which, because they run counter to the instinct for fairness, would ordinarily be considered inappropriate criteria. In the emergency situation of pandemic flu, however, making distinctions on the basis of social worth may be necessary. The hard truth of the matter is that failure to make these sorts of distinctions (giving priority, for example, to doctors, EMS workers, law enforcement personnel, vaccine scientists, firefighters, bus drivers, and sanitation workers) could translate into a high level of injustice accompanied by social chaos, exacerbating an already complicated situation. Hence, prioritizing certain essential personnel, while unfair during non-pandemic conditions, may be the best way to minimize, and ideally avoid, further social breakdown during a flu pandemic.”

Triage (deciding because of limitation of resources, who should be energetically treated with the hope for recovery or who should be left untreated) involves medical utility (who is the most sick but also the more likely to recover with treatment) and social utility (what the treatment of a particular individual will contribute to the welfare of the community.) Medical utility is based on science and clinical evidence and the guidelines are not too controversial. Social utility is a different matter and could give rise to much discussion. Read the excellent article reviewing the matter of triage in an influenza viral pandemic prepared by the University of Pittsburgh Medical Center Pandemic Influenza Task Force.

As you will see in this article, social utility is also considered the main ethical consideration but modified by the specific medical utility of each candidate. And finally, if there are a number of eligible patient candidates for energetic treatment but not all can be accommodated because of lack of resources, then those treated and those left untreated should be selected not on the basis of unfair “first come, first served” but on the basis of a lottery.

I don’t see where the ethics of triage in an influenza pandemic and specifically the triage utilizing the criterion of “social worth” in the decisions have been presented to the public educating them that this may be what the public will experience in the next pandemic but also giving them an opportunity to express their opinions about such methods. I hope my blog thread will stimulate some discussion here. ..Maurice.

Graphic: "Balance of Social Worth in an Emergency" created, in part, by me using ArtRage and Picasa 3 tools.