Resource Allocation in a Response to Bioterrorism

Standard accounts of a formal principle of justice require that similar cases be treated similarly. In an extreme event healthcare institutions may not have the capacity to absorb large numbers of patients that suddenly present themselves. An important problem is whether differential treatment is always morally wrong, or whether it can be justified in some instances.

The classic approach to sorting battlefield injuries is triage, a nineteenth-century French policy based on the strictly utilitarian principle of the greatest good for the greatest number. Depending on the particular model, triage utilizes three or five categories that range from urgent to nonurgent to care not needed. Although triage has become a familiar term in the civilian medical world, especially in busy emergency rooms, in its original military context the idea included a criterion of social merit, that the argument for care in any particular case turned on the potential for the individual to return to duty.

Under ordinary circumstances clinical triage differs from battlefield triage. In the former case the most seriously ill are not simply set aside. Rather, resources are made available through such ad hoc means as the temporary diversion of ambulances to other emergency rooms (Kipnis). Under extreme conditions these routine bypass procedures may not be feasible. A social worth criterion could be transferred to civilians if the circumstances were sufficiently dire that, for example, the very survival of the community was threatened. According to theologian Paul Ramsey, the comparative social worth of individuals can justifiably be measured in these highly defined circumstances.

First priority must be given to victims who can quickly be restored to functioning. They are needed to bury the dead to prevent epidemic. They can serve as amateur medics or nurses with a little instruction—as the triage officer directs the community's remaining medical resources to a middle group of the seriously but not-so-seriously injured majority. Among these, one could argue, a physician should first be treated (Ramsey).

A social worth criterion applied to extreme conditions appears to be incompatible with respect for each individual person, for the inevitably unsuccessful act of treating some is sacrificed in exchange for the potential survival of a valuable individual whose survival would in turn benefit the larger number. However, an argument can be made that the unequal treatment is justifiable precisely because one respects all of the others whose survival is made more likely because of the treatment of this one. Respect for all the others that might survive is respect for each of them as individuals, hence egalitarianism is preserved (Childress, 2003).

But not all who are possessed of critical skills may be required for the benefit of the community. Rather, only a few may be needed, therefore it would be unfair to guarantee all of these individuals a place at the head of the queue. Instead, to ensure that at least some of them survive without providing inappropriate advantages to all of them, essential workers may be entered into a weighted lottery in such a way that their selection is more likely, on average, than that of others (Childress, 2003).

As has been observed, the successful management of a bioterrorism event requires a high degree of public trust. Therefore, criteria for triage and resource allocation should be formulated as part of a public consensus process. Transparency in the development and application of resource allocation principles under extreme conditions should include their defense and readjustment in light of public reaction. Precedent can be found in the case of the allocation of organs (Childress, 1997). The articulation and adjustment of allocation principles must take place well in advance of the event itself.

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