Project 1:

Systemising the Ethical Basis of Triage

The COVID-19 pandemic has been overwhelming public health-care systems around the world. With demand exceeding the availability of medical resources in several regions, hospitals have been forced to invoke triage. To ensure that this difficult task proceeds in a fair and organised manner, governments scrambled experts to draft triage guidelines under enormous time pressure.


Although there are similarities between the documents, they vary considerably in how much weight their respective authors place on the different criteria that they propose. Since most of the recommendations do not come with ethical justifications, analysing them requires that one traces back these criteria to their underlying theories of distributive justice. In the literature, COVID-19 triage has been portrayed as a value conflict solely between utilitarian and egalitarian elements. While these two accounts are indeed the main antipodes, the aim of this project was to show that in fact all four classic theories of distributive justice are involved: utilitarianism, egalitarianism, libertarianism, and communitarianism.


Detecting these in the documents and classifying the suggested criteria accordingly enables one to understand the balancing between the different approaches to distributive justice – which is crucial for both managing the current pandemic and in preparation for the next global health crisis.


Associated Publication:

Meier, L. J. (2022): Systemising Triage: COVID-19 Guidelines and Their Underlying Theories of Distributive Justice. Medicine, Health Care and Philosophy 25 (4): 703-714. DOI: 10.1007/s11019-022-10101-3.

Project 2:

Simulating the Prioritisation of Scarce ICU Resources

Kathrin Knochel, Katharina Adaktylos-Surber, Eva-Maria Schmolke, Lukas J. Meier,

Katja Kuehlmeyer, Kurt Ulm, Alena Buyx, Gerhard Schneider, Markus Heim

Germany has so far escaped a situation in which COVID-19-related triage would become necessary. To prepare for such a scenario, we conducted a simulation of the (re-)allocation of ICU resources during the pandemic as it would be performed by front-line intensivists at our university hospital. The prospective single-center cohort study with both a quantitative analysis of ICU patients and a qualitative content analysis of two focus groups with intensivists comprised five ICUs of internal medicine and anesthesiology and followed a convergent parallel mixed methods design.


After training the attending senior ICU physicians (n = 13) in rationing, an impending ICU congestion was simulated. All ICU patients were rated according to their likelihood to survive their acute illness. From each ICU, the two patients with the most unfavorable prognoses (n = 10) were evaluated by five prioritisation teams for triage.


Patients nominated for the prioritisation visit (n = 10) had higher Sequential-Organ-Failure-Assessment scores and already a longer stay at the hospital and on the ICU compared with the other patients. The order within this worst prognosis group was not congruent between the five teams. However, an in-hospital mortality of 80% confirmed the reasonable match with the lowest predicted probability of survival. Qualitative data that we collected in parallel highlighted the tremendous burden of triage and the need for a team-based consensus-oriented decision-making approach to ensure best possible care and to support professionals. Transparent communication within the teams, the hospital, and to the public was seen as essential for prioritisation implementation.


To mitigate potential biases and to reduce the emotional burden of triage, a consensus-oriented, interdisciplinary, and collaborative approach should be implemented. Prognostic comparative assessment by intensivists is feasible. The combination of long-term ICU stay and consistently high Sequential-Organ-Failure-Assessment scores resulted in a greater risk for triage in patients. Reliably differentiating between patients with very low chances to survive remains challenging and requires further conceptual and empirical research.


Associated Publication:

Knochel, K.; Adaktylos-Surber, K.; Schmolke, E.-M.; Meier, L. J.; Kuehlmeyer, K.; Ulm, K.; Buyx, A.; Schneider, G.; Heim, M. (2022): Preparing for the Worst-Case Scenario in a Pandemic: Intensivists Simulate Prioritization and Triage of Scarce ICU Resources. Critical Care Medicine 50 (12): 1714-1724. DOI: 10.1097/ccm.0000000000005684.

Project 3:

Translating Theories of Justice into Clinically Applicable Triage Protocols

Kathrin Knochel, Eva-Maria Schmolke, Lukas J. Meier, Alena Buyx

During the COVID-19 pandemic, national triage guidelines were developed to address the anticipated shortage of life-saving resources. Rationing and triage imply that, in addition to individual patient interests, population health must also be considered. In this project, we analyse how triage protocols can translate abstract theories of distributive justice into concrete material and procedural criteria for rationing intensive-care resources.


To this end, we reconstruct the development and implementation of a rationing protocol at a German university hospital, describe the ethical challenges of triage, clarify the aspirational norms, and summarise specific norms of fair resource allocation for developing and implementing an institutional policy and practice model. We also reflect on how critical topics are seen by clinicians and specify which interventions helped to manage the perceived burdens of triage dilemmas. 


The practical need to allocate life-sustaining treatments demands guidance even in the absence of conceptional and legal consensus. Applied norms should reflect broader public and scientific opinion. Such frameworks of norms are the basis of institutional triage protocols, but they often fail to take into account practical challenges of the clinical context: the fears of healthcare professionals, the inadequacy of support systems, and the lack of training in rationing – all of which may impede the implementation of triage protocols. Therefore, involving relevant stakeholders early on and promoting interdisciplinarity is crucial for developing practice models that are to be applicable and widely accepted.


The project seeks to inform the debate about triage concepts and policies to ensure the best possible treatment and fair allocation of resources as well as to help protect patients and health-care professionals in worst-case scenarios.


Associated Publication:

Knochel, K.; Schmolke, E.-M.; Meier, L. J.; Buyx, A. (2023): Translating Theories of Justice into a Practice Model for Triage of Scarce Intensive-Care Resources during a Pandemic. Bioethics. DOI: 10.1111/bioe.13198.