Accountability for reasonableness and criteria for admission, triage and discharge in intensive care units: an analysis of current ethical recommendations

Ramos, João Gabriel Rosa; Forte, Daniel Neves

doi:10.5935/0103-507X.20210004

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Revista Brasileira de Terapia Intensiva

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SPECIAL ARTICLE • Rev. bras. ter. intensiva 33 (1) • Jan-Mar 2021 • https://doi.org/10.5935/0103-507X.20210004 copy

Accountability for reasonableness and criteria for admission, triage and discharge in intensive care units: an analysis of current ethical recommendations

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Triage for intensive care unit admission is a frequent event and is associated to worse clinical outcomes. The process of triage is variable and may be influenced by biases and prejudices, which could lead to potentially unfair decisions. The Brazilian Federal Council of Medicine (Conselho Federal de Medicina) has recently released a guideline for intensive care unit admission and discharge. The aim of this paper is to evaluate the ethical dilemmas related to the implementation of this guideline, through the accountability for reasonabless approach, known as A4R, as elaborated by Norman Daniels. We conclude that the guideline contemplates A4R conditions, but we observe that there is a need for indication of A4R-concordant criteria to operationalize the guidelines.

Keywords:
Bioethics; Triage; Health care rationing; Noman Daniels; Intensive care units

Distributive justice guidelines	Definitions
Justice based on contractual freedom	"The fundamental ethical principle to be observed in the organization of health systems is respect for the freedom of the human being to make decisions and make choices that affect his or her life".⁽²³23 Fortes PA. Orientações bioéticas de justiça distributiva aplicada às ações e aos sistemas de saúde. Rev Bioética. 2008;16(1):25-39.⁾ This guideline can be extended to the maxim "to each person according to the laws of the free market"
Justice based on strict equality and individual needs	The fundamental ethical principle is egalitarianism, i.e., "accepting that all people are worthy", which invokes equal access to resources. This guideline can be extended to the maxim "to each person according to his/her needs"⁽²³23 Fortes PA. Orientações bioéticas de justiça distributiva aplicada às ações e aos sistemas de saúde. Rev Bioética. 2008;16(1):25-39.⁾
Justice based on merit and social contribution	Differentiation of citizens to ensure that the distribution of resources takes into account "the natural endowments, their dignity, level of training and position in the organizational hierarchy"⁽²³23 Fortes PA. Orientações bioéticas de justiça distributiva aplicada às ações e aos sistemas de saúde. Rev Bioética. 2008;16(1):25-39.⁾
Justice based on social utility and maximization of benefits	Decisions and standards aim to promote the good and should therefore be evaluated by their results. The utilitarian principle provides that one should seek "the greatest happiness of all whose interests are at stake" and leads to the maxim "the greatest well-being for the greatest possible number of people"⁽²³23 Fortes PA. Orientações bioéticas de justiça distributiva aplicada às ações e aos sistemas de saúde. Rev Bioética. 2008;16(1):25-39.⁾
Justice based on equity	Provides for two basic principles. The first states that each person should be allowed the maximum amount of basic freedom compatible with a similar amount for all other people. The second principle states that social inequalities, although they may exist, must satisfy two conditions: they are only allowed if the global amount benefits everyone (for example, inequality arising from actions that lead to an enrichment of the population is seen as fair, although unequal) and if there is equal access to opportunities⁽²³23 Fortes PA. Orientações bioéticas de justiça distributiva aplicada às ações e aos sistemas de saúde. Rev Bioética. 2008;16(1):25-39.^,²⁸28 Beauchamp TL, Childress JF. Principles of biomedical ethics. 7th ed. New York: Oxford University Press; 2013.^,³³33 Rawls J. Uma teoria da justiça. 3a. ed. São Paulo: Martins Fontes; 2008.⁾

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[1] Corresponding author: João Gabriel Rosa Ramos, Unidade de Terapia Intensiva, Hospital São Rafael, Avenida São Rafael, 2.152, Zip code: 41253-190 - Salvador (BA), Brazil. E-mail: jgrr25@gmail.com