The principle of justice dictates that criteria for triage of civilian patients must be based on their medical condition and not on their social connections. Ethically acceptable criteria for withholding or withdrawing care from patients could include the likelihood of benefit from medical care, the urgency of need for care, and the availability of the resources needed to care for a particular patient. Unacceptable criteria might include social worth, patient contribution to their illness/injury, or the patient’s ability to pay for care. No patient group should receive special consideration in a disaster situation, other than that dictated by their physiology – including children.

Such principles of justice may be difficult to strictly follow, however, since judgments of social worth are nearly inevitable sometimes. For example, if some of the survivors of a tsunami are healthcare workers with minor injuries, they might be given priority for treatment because of their value in then being able to help others. Physicians might be given the first doses of protective vaccine in a pandemic, so that they will not become infected and will be able to care for those who are. Such decisions amount to prioritization based on social worth, but may be justified in this very restricted context if the individual’s abilities are indispensable to the larger goal of this disaster’s containment. The decisions should be strictly limited to only those skills that are essential to the successful management of the disaster, and not to general social assessments.³

A historical example of the subversion of patient-centered ethical values by consequentialist arguments can be found in the “Nazification” of the medical profession in pre-WWII Germany.⁴ In a decades-long process, German physicians were gradually convinced to adopt consequentialist principles in medical decision-making in order to serve the interests of the “state” as the highest “good” and to bring the “greatest happiness” to the greatest number of people. The process began with the replacement of academic physicians at universities with patriotic doctors who were not qualified as teachers or researchers and were less likely to question the shift in ethical decision-making. Physicians were promoted to positions of power on the basis of their political beliefs, and became increasingly involved in judgments regarding the “social worth” of certain groups of patients. They were then recruited to research “humane” methods of killing persons whose social worth was questioned. Consequentialist-type reasoning was offered to convince physicians that they were doing what was best for the “greatest number” of Germans. Ultimately, refusal by physicians to participate in these activities was branded as “unpatriotic,” and therefore harmful to society.

Consequentialism may be a legitimate ethical framework in which to make decisions regarding how resources should be allocated when mass casualties overwhelm the traditional delivery of medical care, but is not the ethical framework applied to usual medical care.

One consideration is the re-allocation of hospital beds from current inpatients to future ones, in a process sometimes called “reverse triage.” In reverse triage, patients who are capable of being cared for in lower acuity beds or at home are discharged to make room for incoming casualties.