Distributive justice in disaster triage: Utilitarianism competes with egalitarianism, autonomy, and the physician-patient relationship

Disasters that produce an overwhelming number of casualties demand that healthcare resources be rationed. Given the gravity of these decisions, it is imperative that they be guided by acceptable principles of distributive justice. Utilitarianism governs current disaster triage protocols because the efficient use of resources prevents the greatest amount of disability and mortality in the population. However, this conflicts with maximin egalitarianism, which demands that the most severely injured patients be prioritized even if it is not an efficient use of resources. Utilitarian triage also conflicts with the egalitarian principle of equal chances, which states that all people should be given an opportunity to be given treatment since all persons value their lives equally. Utilitarianism protects the needs of the entire population, and so demands that an individual patient’s right to autonomy and a fiduciary relationship with their physician must be sacrificed. Like other policies in a democratic society, the legitimacy of disaster triage protocols comes from support by the majority. For this reason, choosing the values that guide disaster triage requires open and transparent communal disaster planning that reflects the values of all members of society. Rather than prioritizing one principle over another, it is likely that the most just approach to allocating resources in disaster triage may be to apply a mixture of distributive justice principles