Resource Scarcity in Austere Environments: An Ethical Examination of Triage and Medical Rules of Eligibility

Contents
Editors and Contributors
About the Editors
Contributors
Acronyms and Abbreviations
Chapter 1: Introduction and Synopsis
	1.1 Introduction
	1.2 Disaster & Crisis Focused Interventions: A Spectrum of Activities United by Scarcity
	1.3 Humanitarian & Military Actors: Differing Goals & Intention
	1.4 Origin and Definition of Triage
		1.4.1 Triage Categories
	1.5 Outline & Synopsis
		1.5.1 Section I
			1.5.1.1 ‘Gate-Keeping Access to Deployed Military Health Services’ – Perspectives of Military Medical Leaders—Bricknell and Kowitz
			1.5.1.2 Reconsidering Triage: Medical, Ethical and Historical Perspectives on Planning for Mass Casualty Events in Military and Civilian Settings—Horn, James, Draper, and Mayhew
			1.5.1.3 Medical Rules of Eligibility: A Comparative Analysis—Clifford, Eagan, and Eagan
			1.5.1.4 Ethical and Legal Basis for the Standards of Triage Used in the Russian Military Medical Service—Kholikov
		1.5.2 Section II
			1.5.2.1 The Phenomenon of Allocation. Military Pathways in the Light of Biomedical Ethical Principles—Fischer
			1.5.2.2 Battlefield Triage and Resource Allocation During a Pandemic: What Can We Learn from the Past and How Must We Adapt for the Future?—Krick, Hogue, Studer, Reese, and Weiss
			1.5.2.3 Medical Triage by Moral Responsibility—Woodside
			1.5.2.4 Medical Rules of Eligibility – Can Preferential Medical Treatment Provisions Be Ethically Justified?—Messelken
			1.5.2.5 Fairness in Military Care: Might a Hybrid Concept of Equity Be the Answer? —Gilbert, Stevens, and Hurst
			1.5.2.6 Cicero and the Problem of Triage. Why There Is No Moral Algorithm in Distributing Scarce Resources—Koch
			1.5.2.7 Facing Death: An Ethical Exploration of Thanatophobia in Combat Casualty Care—Jeschke, Martinez, Choi, Dorsch, and Huffman
	References
Chapter 2: ‘Gate-Keeping Access to Deployed Military Health Services’ – Perspectives of Military Medical Leaders
	2.1 Introduction
	2.2 Scenario – Case Example
	2.3 Legal, Ethical and Clinical Principles
	2.4 Policies for Entitlement to Care
	2.5 Military Medical Planning
	2.6 Medical Rules of Eligibility
	2.7 Triage
	2.8 Review of the Scenario Questions
	2.9 Training of Medical Personnel
	2.10 Conclusions
	References
Chapter 3: Reconsidering Triage: Medical, Ethical and Historical Perspectives on Planning for Mass Casualty Events in Military and Civilian Settings
	3.1 Introduction
		3.1.1 Why MASCAL Management Needs to Be Rethought
	3.2 Case Study 1 – The NHS
		3.2.1 Evidence from the UK National Health Service That Normal Standards Cannot Be Maintained in Times of Extreme Pressure
		3.2.2 NHS Adaptations to Extreme Pressure (Analogous to a MASCAL Incident)
			3.2.2.1 From ‘Triage for Priority’ to Flow
			3.2.2.2 Strategies to Maximise Flow: Diversion/Remote Monitoring
	3.3 Case Study 2 – Historical Considerations: Mass Casualty Management on the Western Front of the Great War (1915–1918)
		3.3.1 Lowest Capable Provider
		3.3.2 Context Specific Excellence: The ‘Best Care Feasible’ Vs ‘Gold Standard Care’
		3.3.3 Focussing on Quality End of Life Care
	3.4 Some Ethical Considerations
	3.5 Summary
	References
Chapter 4: Medical Rules of Eligibility: A Comparative Analysis
	4.1 Introduction
	4.2 An Overview of NATO Doctrine
		4.2.1 An Overview of NATO Medical Doctrine
		4.2.2 Developing NATO Medical Rules of Eligibility
	4.3 A Review of Canadian Armed Forces (CAF) Medical Doctrine
		4.3.1 Health Services Planning
		4.3.2 Developing CAF Medical Rules of Eligibility
	4.4 A Review of the United States Department of Defense (DoD) Doctrine
		4.4.1 Joint Services Doctrine
		4.4.2 A Review of U.S. Army Medical Doctrine
		4.4.3 U.S. Doctrine – Conclusion
	4.5 Key Similarities Between NATO, CAF, and US DoD Medical Doctrine
		4.5.1 Key Differences Between NATO, CAF, and U.S. DoD Medical Doctrine
	4.6 Conclusion
	References
Chapter 5: Ethical and Legal Basis for the Standards of Triage Used in the Russian Military Medical Service
	5.1 Conclusion
	References
Chapter 6: The Phenomenon of Allocation: Military Pathways in the Light of Biomedical Ethical Principles
	6.1 Introduction
	6.2 Terminological Aspects
	6.3 Allocation, Allocational Problems and Tragic Choices
	6.4 Implicit vs. Explicit Allocation
	6.5 Triage
	6.6 Allocational Problems in the Context of War
	6.7 Allocation and Bioethical Principles
	6.8 The Physician-Patient-Relationship
	6.9 Conclusion
	References
Chapter 7: Applying Battlefield Triage Ethics and Resource Allocation to a Contemporary Public Health Crisis: Lessons Learned from the Past and Adapting Them for the Future
	7.1 Introduction
	7.2 Ethical Foundations
	7.3 Ethical Priorities on the Battlefield
	7.4 Public Health Ethics and Triage
	7.5 Lessons from the Battlefield
	7.6 Conclusion
	References
Chapter 8: Medical Triage by Moral Responsibility in Crisis and War
	8.1 Introduction
	8.2 Some Assumptions
	8.3 Impartiality
		8.3.1 Endorsements of Impartiality
		8.3.2 Against Impartiality
	8.4 TMR, Liability, and the Just Distribution of Harm
		8.4.1 Moral Liability to Defensive Killing
		8.4.2 LRSs and Liability to Allowed Harm
	8.5 Some Objections and Replies
	8.6 TMR, COVID-19, and Vaccination
		8.6.1 The Moral Right to Refuse Vaccination
		8.6.2 Vaccination Priority
	8.7 TMR and the Medical Ethics of War
	8.8 Conclusion
	References
Chapter 9: Medical Rules of Eligibility – Can Preferential Medical Treatment Provisions Be Ethically Justified?
	9.1 Introduction
		9.1.1 A Cursory Look at IHL – Legal Framework during Armed Conflict
	9.2 Medical Rules of Eligibility – Macro-Triage in the Military
		9.2.1 Military Trauma Care
		9.2.2 Example of Applying MROE
	9.3 Can Medical Rules of Eligibility Be Morally Justified?
		9.3.1 Pro – Why Preferential Medical Treatment for Own Soldiers Is Legitimate
			9.3.1.1 “Military Necessity” or Military Triage Reasoning
			9.3.1.2 Fiduciary Obligation to Win Wars
			9.3.1.3 Associative Duties
			9.3.1.4 Missing Reciprocity: The Other Side Does Not Provide HC or Does Not Respect HCP
			9.3.1.5 Unjust Combatants Have No Claim to HC
			9.3.1.6 MROE Are a Precondition for Military Interventions that, Overall, Still Bring a Better Outcome for the Local Population
			9.3.1.7 Local Responsibility, Do Not Interfere with Local System
			9.3.1.8 Avoid Moral Injury Among HCP
		9.3.2 Contra – Why Preferential Medical Treatment Is Ethically Problematic
			9.3.2.1 MROE Are Against the Principles of Humanity and Non-discrimination
			9.3.2.2 MROE Lead to an Ineffective Use of Resources – Too Much Reserve Capacity
			9.3.2.3 Responsibility at Least with Regard to Caring for Some Patients
			9.3.2.4 Health Care as a Remainder of Peace
	9.4 Conclusions
	References
Chapter 10: Fairness in Military Care: Might a Hybrid Concept of Equity Be the Answer?
	10.1 Introduction
	10.2 Equity in Bedside Resource Allocation
	10.3 Traditional Concepts Employed in the Debate
		10.3.1 Egalitarianism
		10.3.2 Prioritarianism
		10.3.3 Desertism
		10.3.4 Sufficientism
	10.4 On Which Philosophical Ground Physicians Base Their Decision?
	10.5 Exploring Hybrid Equity: Are Hybrid Concepts Robust Enough?
	10.6 Conclusion
	References
Chapter 11: Cicero and the Problem of Triage: Why There Is No Moral Algorithm in Distributing Scarce Resources
	11.1 Introduction
	11.2 Moral Inequality
		11.2.1 A Simple/Simplified Case
		11.2.2 Revisionist Just War Theory
		11.2.3 Moral Blackmail
		11.2.4 Consequentialism
		11.2.5 Against Punishment
	11.3 Cicero’s Concept of Different “Personae”
		11.3.1 Perspective Agency
		11.3.2 Four Roles
		11.3.3 Institutional Protections and Its Limitations
		11.3.4 Excursus: Ex-Ante- and Ex-Post-Triage
		11.3.5 The Complexity of Roles with Military Medical Personnel
	11.4 Conclusion
	References
Chapter 12: Facing Death: An Ethical Exploration of Thanatophobia in Combat Casualty Care
	12.1 Background
		12.1.1 Conceptual Diagram of Death Aversion in Modern Military and Medical Cultures
		12.1.2 Current Cultural Paradigm of Casualty Management
		12.1.3 Terror Management Theory and Medical Decision Making
		12.1.4 Emergent Themes – Challenges Relative to Death Aversion
		12.1.5 Possible Ways Forward
	References