Good doctors make the care of their patients their first concern…They treat each patient as an individual. They do their best to make sure all patients receive good care and treatment that will support them to live as well as possible, whatever their illness or disability.

GMC, Good Medical Practice

Healthcare professionals are trained to be compassionate, humane, and unbiased. These and other traits, accompanied by the core ethical principles of beneficence, non-maleficence, autonomy, and justice, arm doctors with the moral sangfroid that enables them to make difficult decisions in their day-to-day practice.

Triage, by definition, classifies patients into groups to be prioritised or subordinated. Doctors are forced to deny or withdraw potentially life-saving treatment, usually against the patient’s and the family’s wishes. Thus, one can see how the implementation of triage guidelines appears to violate the very core of healthcare’s guiding principle — putting the needs of the patient first. The core principles of beneficence, non-maleficence, and autonomy are made redundant, and, depending on the criteria that are used to classify patients, the principle of justice may be violated too. Prioritising patients due to race or religion would be indisputably unfair; however, other criteria, like age, are more controversial. A set of guidelines may consider age-based stratification just, which may be contrary to the beliefs of a large number of doctors, who are then expected to implement these guidelines.

Doctors can’t execute guidelines like a computer executes an algorithm — doctors are humans, whose professional interactions depend on their compassion, humanity, and fairness. This exposes them to moral injury, or the injury to one’s conscience that results when one violates one’s deeply held moral beliefs. Moral injury can produce profound emotional guilt, shame, and anger, which can last for years following the event. It can seem inappropriate to implement guidelines that have the potential to inflict such psychological and moral suffering. Doctors are used to making difficult decisions — why should they be deprived of this responsibility in times of crisis?

Nevertheless, when patient demand far exceeds available resources, the decisions are of a completely different nature than those encountered in day to day practice. One can try to do the best for every patient, but, in doing so, may actually not do enough to ensure the survival of any of them. Unable to provide potentially life-saving treatment to every patient in need, the question becomes how to best allocate these limited resources. Hard choices become inevitable… And moral injury does too. Are triage guidelines at the root of this moral injury, or are they actually shielding doctors from the brunt of their decisions?

A set of well-outlined, evidence-based guidelines protect doctors from choices that they don’t have the professional competence to make. As discussed above, the interpretation of what exactly constitutes “optimal resource allocation” will vary; however, most ethicists agree that, if unable to save all lives, the goal should shift to trying to save the most lives. How does this translate into practice? How do doctors know what combination of factors make a COVID-19 patient more or less likely to benefit from ventilator assisted therapy? Few people in the world have sufficient expertise to be able to ascertain how to best allocate scarce resources in a given situation — drafting guidelines allows doctors around the world to incorporate this professional expertise into their practice. Doctors are thus supported in the decision-making process, and any resulting moral injury would be mitigated by the security of knowing that their actions were in line with the best evidence available.

Good guidelines — some key considerations

Triage guidelines are vital; nevertheless, the moral relief afforded by following guidelines relies on the premise that these broadly align with doctors’ moral compasses. The guidelines drafted need to be just, non-discriminative, and respectful of the intrinsic dignity of every patient. Even then, no guidelines will align with all healthcare workers’ beliefs, and these concepts can be interpreted in very different ways — one only has to look at the various triage guidelines that have been published in the past weeks.

Guidelines also need to incorporate other key practical aspects. First and foremost, they need to specify the point at which they should be implemented, and should have different levels corresponding to the level of demand for the limited resources. Selection criteria should escalate as demand increases — pre-emptive use of narrow selection criteria can result in unnecessary denial of treatment. Good guidelines need to also make the patient selection criteria explicit and communicable, in order for these to be of real practical use to doctors. Simultaneously, these need to be published and made available to those affected, their families, and to the general population. This is vital in order to maintain public good faith in healthcare services.

As the COVID19 pandemic arms itself to be a global tragedy, public appreciation for healthcare workers is at an all-time high. A range of services have been deployed to lighten the burden on their physical and mental health; however, one must not overlook the moral cost of this crisis. The publication of good-quality guidelines is arguably the best way to offer support; thus, health services must not overlook their importance, and should strive to ensure that their guidelines meet the high standard required to offer practical support in decision-making.

By Blanca Sanz-Magallón.