By Davide Battisti and Silvia Camporesi.
It is likely that, like us, you will have had an experience in Emergency Departments (EDs), or that you can recall an experience of accompanying a relative or friend there.
Let’s consider the scenario where the reason for you, your relative, or friend going to the ED was the presence of symptoms that required immediate evaluation and intervention, although they weren’t immediately life-threatening. You would have arrived at the ED in your own car or accompanied by a friend’s car; an ambulance wouldn’t have transported you there.
If that was the case, it is likely that your experience and ours in EDs would have something in common: after an initial screening by a specialized operator (referred to as a triage nurse), you would have been assigned a number or a colour and asked to wait your turn in a waiting room. It might have taken hours before you were seen by the ED doctor.
Most of us have a general understanding of the purpose of triage: to prioritize patients based on the urgency of their need to be seen, with the aim of saving the maximum number of lives given the available resources. The term “triage” originated in the 18th century from the French word “trier,” meaning to select or choose based on quality. Deciding who to serve first based on some quality of the condition is considered a matter of “substantial fairness.”
However, we don’t usually think of triage as a means to save lives, as it was originally intended in wartime scenarios. Instead, under ordinary circumstances, we have the expectation that all lives can be saved in EDs, with the caveat that some patients will be seen before others because of some quality of their condition, for example because the development is time-dependent and requires a more urgent intervention. This is generally seen as fair, hence we do not “complain” if a patient who has arrived after us is seen before us, because we know that EDs do not work on a first come first served basis.
Yet, the pandemic has revealed the tragic reality of triage: in extraordinary situations, triage interventions may not be able to save all lives, which could have been saved under ordinary conditions. Doctors and nurses at the peak of the SARS-CoV-2 outbreak in 2020 experienced moral distress and demanded to be provided triage criteria to guide and justify the allocation of limited life-saving resources.
However, even in ordinary, non-disaster contexts, the principles underlying triage intervention demand careful consideration. First, triage remains a daily reality in various healthcare systems, particularly in the Global South, where resources are limited.
Second, triage criteria and procedures are seldom transparent, accessible, or justified to the public. Further, they are also rarely consistent across different countries, and even within the same country, different hospitals will often adopt a different triage system. That means that an ED patient in Bristol and an ED patient in Leeds, with the same condition, might be assigned different colours, corresponding to different priorities. Some of this variability is inherent in the system: different operators will rank patients differently within a certain expected margin. However, some of these procedural inconsistencies are avoidable. To this end, the criteria used to rank patients should be made publicly accessible, and transparent. Therefore, an in-depth conceptual and empirical exploration of ED triage in ordinary circumstances is needed to promote fair and legitimate ED triage in everyday life.
Our paper addresses this need by proposing five requirements that should be respected to ensure fair triage from the point of view of procedural fairness, building on the seminal work of “accountability for reasonableness” proposed by Daniels and Sabin, and applying it to the context of EDs. We also outline conceptual and empirical research questions to determine whether ED triage meets the five requirements of procedural fairness, particularly in specific national or state contexts. This is a vastly under-researched area in bioethics, at the convergence of emergency medicine, theories of justice, and democratic theory. We hope that, like us, you will find it important and fascinating and will decide to contribute to its development.
Authors: Davide Battisti, Silvia Camporesi
Department of Law, University of Bergamo, Italy (Battisti)
Department of Political Science, University of Vienna, Austria (Camporesi)
Competing interests: None declared.
Social media accounts of post authors:
Davide Battisti: @davidebattisti93 (X); @davidebattisti (IG)
Silvia Camporesi: @silviacamporesibioetica (IG)