Was den Menschen zum Menschen macht

Triage

8 Min. Lesezeit

🇩🇪 Deutsche Version: Triage

Note: The ethical judgments on this page refer exclusively to the action and the institutional form of decision — never to the person who is triaged or who triages. Every person possesses inalienable dignity, independent of urgency level, prognosis, or order of treatment. Cf. Note on ethical judgments.

Triage (Fr. trier, “to sort, to sift out”) is the procedure of classifying patients according to medical urgency and the prospect of success of treatment under conditions of scarce medical resources, independent of the order of arrival. Its origin lies in military medicine — the French surgeon Baron Dominique Jean Larrey, chief surgeon of Napoleon’s Imperial Guard, developed the first systematic sorting procedure on the battlefield in the late eighteenth / early nineteenth century. Triage was introduced into civilian emergency medicine in 1966 with Weinerman et al.

As a special form of medical care under resource scarcity, triage is an interpersonal relation and is therefore subject to the Personalist Norm: the patient is a person, not a case and not a bearer of utility. The core ontological question is therefore not whether sorting may take place at all — scarcity is a factual condition of finite corporeality — but rather according to which criterion sorting takes place, and whether this criterion preserves the dignity of every single person or weighs it against others.

The Fundamental Ontological Tension

The ethics of triage stands between two poles:

Utilitarian triage orients itself by the maxim “the greatest good for the greatest number.” It weighs persons against one another according to a utility index (expected life expectancy, social role, comorbidity, age, disability). From a personalist-ontological perspective it is a form of practical oblivion of the person and therefore an intrinsically evil act: the person is not affirmed for their own sake, but treated as the bearer of a statistical expected value. The functionalist concept of person, which binds personhood to the exercise of particular capacities, recurs here as an economic calculation. In its decision of 16 December 2021 (1 BvR 1541/20), the German Federal Constitutional Court (Bundesverfassungsgericht) expressly prohibited triage based on the characteristic of disability; the recommendations of the Academy for Ethics in Medicine and of the DIVI follow the same line.

Urgency-based triage decides exclusively according to current medical urgency and the concrete prospect of success in the acute case. Persons are not weighed against one another; scarcity is registered as an external condition, not as a valuation of the person. This form is compatible with the Personalist Norm, because every person continues to be addressed for their own sake in the concrete treatment situation.

The two forms are ontologically distinct: a triage decision cannot be simultaneously utilitarian and urgency-based, because their decision criteria are categorially distinct — the one compares persons against one another, the other judges each person in their own right.

The difference can be fixed by the guiding question:

  • Urgency-based triage asks per person: “How acute is this condition, and does treatment in the concrete acute case have a prospect of success?” — case-specific, the person is compared with themselves (stable ↔ life-threatening). Scarcity is an external condition, not a valuation of the person.
  • Utilitarian triage asks between persons: “For whom does the same expenditure of resources bring the greatest aggregate benefit?” — the criteria are life-years gained, age, disability, social role, comorbidity. Persons are weighed against one another; the person becomes the bearer of a utility index.

A concrete example: two patients, both in acute life-threatening condition, only one ventilator available.

  • Urgency-based decides according to the prospect of success of the concrete acute case or, where this is equal, by lot or by order of arrival — without factoring in life expectancy, age, or disability.
  • Utilitarian decides according to expected life-years gained or social benefit and thereby systematically discriminates against the old, the disabled, and the chronically ill.

Precisely this tipping point was marked by the Federal Constitutional Court in its decision of 16 December 2021 (1 BvR 1541/20): prospect of success in the acute treatment situation is permissible; disability or life expectancy as a criterion are not.

Ex ante and ex post

Particularly grave in personalist-ontological terms is ex-post triage: the discontinuation of a treatment already begun in favor of another person. Here the patient already under treatment is removed from a care relation that had addressed them as a person. The interpersonal affirmation that began with the commencement of treatment is revoked — not because the treatment had become hopeless, but because another is classified as “more valuable.” Ex-post triage is therefore especially restrictively regulated in German jurisprudence and in the AEM/DIVI recommendations as well.

Ex-ante triage faces the challenge of cleanly separating urgency from prognosis. Where prognostic criteria become utility criteria, it tips over into the utilitarian form. Both are ontologically distinct: a triage decision is either ex ante or ex post, never both at once.

Triage Systems Worldwide

There is no globally binding triage system; different countries and levels of care have developed their own sets of rules.

Clinical triage systems (emergency department):

  • Manchester Triage System (MTS) — developed in 1994 by the Manchester Triage Group; 52 presentational flowcharts, five color-coded levels (red, orange, yellow, green, blue). Dominant in the United Kingdom and large parts of Europe.
  • Emergency Severity Index (ESI) — the US standard; a five-level algorithm based on acuity and expected resource requirement.
  • Australasian Triage Scale (ATS), Canadian Triage and Acuity Scale (CTAS), Andorran Triage Model (ATM).

Triage systems for mass casualty incidents (MCI) (prehospital, disaster medicine):

  • START (Simple Triage and Rapid Treatment) — four categories: Immediate, Delayed, Minimal, Expectant.
  • SALT (Sort, Assess, Lifesaving Interventions, Treatment/Transport) — a further development of START; lower under-triage rate and more precise status assessment.
  • Others: SHORT, META, Careflight.

Clinical and MCI systems are modeled as mutually exclusive in the ontology, because they are conceived for fundamentally different contexts of care.

All systems named here — MTS, ESI, ATS, CTAS, ATM as well as START and SALT — are urgency-based triage systems. They sort according to acute medical urgency and prospect of success in the concrete acute case, not according to person-extrinsic utility characteristics such as age, disability, social role, or expected remaining life-years. No established triage system is utilitarian in its rules; the danger of a utilitarian tipping lies not in the system but in its application — namely, when prognostic criteria are reinterpreted in the individual case as utility criteria across persons. Precisely this boundary was drawn by the Federal Constitutional Court in 1 BvR 1541/20.

The Category “Expectant”

Ontologically especially sensitive is the category Expectant of the MCI systems: patients with a low probability of survival under the given resources, who receive palliative accompaniment instead of curative treatment. In personalist-ontological terms, the personhood and the dignity of the affected person remain fully preserved in this category: what is restricted is solely the second actuality (deutera energeia, the actual exercise of function under resource scarcity), not the first actuality (prote energeia, personhood itself). The First Dimension — personhood as the ground of being — remains untouched. Palliative accompaniment is in this case not an expression of devaluation, but the concrete form of the affirmation of the person in a limit situation.

Ontological Classification

Superordinate concept: medical care (special case under resource scarcity)

Subforms by ethics:

Subforms by temporal position:

  • Ex-ante triage and ex-post triage are ontologically distinct.

Subform by context:

  • Disaster-medicine triage (mass casualty incident, MCI) — typically uses START or SALT.

Triage systems:

  • Clinical: Manchester Triage System, Emergency Severity Index, Australasian Triage Scale, Canadian Triage and Acuity Scale, Andorran Triage Model.
  • MCI: START, SALT.
  • Clinical and MCI systems exclude each other.

Triage categories: Immediate (red), Delayed (yellow), Minimal (green), Expectant (blue/black).

Ontological relations:

Chapter assignment: Chapter 5: Oblivion of the Person (utilitarian variant); Chapter 4: Personhood (medical care as interpersonal relation).

Sources: Generated by querying the Personhood ontology.

Further sources:

  • Federal Constitutional Court (BVerfG), decision of 16 December 2021 — 1 BvR 1541/20 (triage ruling on the protection of persons with disabilities)
  • Academy for Ethics in Medicine (AEM) / DIVI: Ethical statements on the distribution of scarce resources in intensive care medicine
  • Larrey, D. J.: Mémoires de chirurgie militaire et campagnes (1812—1817) (German edition not applicable; French original)
  • Weinerman, E. R. et al. (1966): Yale studies in ambulatory medical care. V. Determinants of use of hospital emergency services. American Journal of Public Health 56(7), 1037—1056.
  • Manchester Triage Group (2014): Emergency Triage, 3rd ed., Wiley-Blackwell.
  • Gilboy, N. et al. (2012): Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care, Version 4. AHRQ Publication No. 12-0014.
  • Lerner, E. B. et al. (2011): Mass casualty triage: an evaluation of the science and refinement of a national guideline (SALT). Disaster Medicine and Public Health Preparedness.
  • Aquinas: Summa Theologiae, II-II, q. 64, a. 5.
  • Singer, P.: Practical Ethics (1979/1993). Cambridge University Press.

See also

Graphansicht

Backlinks