‍Editor's Note: The address was recorded at The Center for Bioethics & Human Dignity’s 2015 summer conference, “Science, Research, and the Limits of Bioethics.”

Ethicists must now consider the difficult issues of a groundbreaking third type of triage in civilian Mass Casualty Events (MCEs), in addition to intake and reverse triage. Catastrophic events such as Hurricane Katrina make it clear that some patients who require life support following an MCE may not receive it, merely for lack of available resources. These patients are likely to die. The resource gap may nevertheless contract if we apply existing trends in healthcare to MCE planning. At the same time, despite the development of civilian triage algorithms since the 1980s, limited research supports their use. Thus, a first ethical question must be: assuming that triaging some patients out of life support will be necessary, and given available policies that might reduce the need to do so, what are the ethics of triaging patients out according to existing algorithms which lack sufficient scientific support? This question can be applied to both intake and reverse triage scenarios, already accepted in the literature. A new, third type of triage must emerge from recent U.S. Government recommendations for palliative treatment for those excluded from necessary life support. Because the same already-limited resources are often required for both life-supported and palliated patients—but in very different amounts—“Life Support/Palliative Triage” would require decisions on resource allocation between the two groups. The resulting dilemma has yet to be even raised let alone considered: what resource allocation decisions are ethical for a healthcare system to make in this scenario? The alternatives are fraught with implications for our very civilization. Clearly the ethical questions arising from MCE triage concern ethicists in disaster and emergency care as well as critical and even palliative care. Well-known bioethical values such as justice and the principle of double effect can guide societal discussion of these dilemmas.