El triaje en pandemia: fundamentos éticos para la asignación de recursos de soporte vital avanzado en escenarios de escasez / Pandemic triage: ethical foundations for the allocation of advanced life support resources in scarcity scenario

Las pandemias y otras catástrofes de alto impacto sanitario azotan periódicamente a la humanidad, aumentando desproporcionadamente la demanda por atención en servicios de urgencia, unidades de cuidados intensivos y medios de soporte vital avanzado. Este desequilibrio obliga a una compleja toma de decisiones en que se deben asignar recursos proporcionalmente escasos en relación a una gran demanda. Así, los equipos clínicos asistenciales necesitan actuar bajo criterios consensuados, que orienten sus decisiones y alivien la pesada carga moral de seleccionar pacientes para terapias, en detrimento de otros. El triaje es una estrategia que permite establecer, bajo racionalidades propias a cada escenario, objetivos y criterios que faciliten la toma de decisiones complejas para el logro del mejor resultado. Estas estrategias deben considerar el marco de valores intangibles que apreciamos y que nos identifican cultural y socialmente, como son el respeto a la vida, la igualdad, la justicia y la libertad. Sin embargo, en escenarios excepcionales como el de la actual pandemia COVID-19, en que el sistema sanitario puede no dar abasto, deberán establecerse objetivos prioritarios, como salvar la mayor cantidad de vidas, del modo más humano, justo y eficiente posible. A la vez, deberán redefinirse jerarquías en los valores y principios clásicos de la práctica clínica cotidiana, adecuadas a la catástrofe sanitaria, bajo una ética propia de la salud pública, el mayor bien para la mayoría y el mejor cuidado de los que no pueden ser curados.

Pandemics and other global disasters regularly overwhelm humankind. These catastrophic events suddenly increase demand for health-care in emergency services, intensive care units, and for advanced life support devices. This imbalance requires complex decision-making in which scarce resources must be allocated in relation to high demand. Thus, health-care teams need to act under consensus criteria that guide their decisions and alleviate the heavy moral burden of selecting patients for therapies, excluding others. Triage is a strategy that allows to establish, under appropriate rationalities, objectives and criteria that facilitate complex decisions to achieve the best results. These strategies should consider the framework of intangible values that we appreciate and identify us culturally and socially, such as respect for life, equity, justice and freedom. However, in exceptional scenarios such as the current COVID-19 pandemic, where the health system may be overcome, priority goals should focus in order to save as many lives as possible and by mean the most humane, fair and efficient way possible. At the same time, hierarchies of classical values and principles of daily clinical practice should be redefined in an appropriate way to face this catastrophic scenario, under an ethics for public health, the greatest good for the most and the best care of those who cannot be cured.

Ethical considerations in neurology during the COVID-19 pandemic.

Coronavirus disease 2019 (COVID-19) pandemic has struck many countries and caused a great number of infected cases and death. Healthcare system across all countries is dealing with the increasing medical, social, and legal issues caused by the COVID-19 pandemic, and the standards of care are being altered. Admittedly, neurology units have been influenced greatly since the first days, as aggressive policies adopted by many hospitals caused eventual shut down of numerous neurologic wards. Considering these drastic alterations, traditional ethical principles have to be integrated with state-of-the-art ethical considerations. This review will consider different ethical aspects of care in neurologic patients during COVID-19 and how this challenging situation has affected standards of care in these patients.

Allocating medical resources fairly: the CSG bioethics guide / Asignación justa de recursos médicos: guía bioética del CSG

Abstract On April 12, 2020, a bioethics guide for allocating scarce hospital resources during the current Covid-19 pandemic was posted on the website of the Consejo de Salubridad General (CSG) of the Government of Mexico. The guide, entitled Guía bioética para asignación de recursos limitados de medicina crítica en situación de emergencia, was intended as a preliminary document, but the website posting did not describe it as a first step in the process. The publicity resulted in a wide array of comments and criticisms. That first version posted on the CSG website contained an age-based criterion for breaking a tie between two or more medically eligible patients who needed of a ventilator: younger patients would have preference over older ones. The final version of the guide eliminated that criterion and instead, relied on the leading public health principle, "save the most lives", without regard to personal characteristics other than the possibility of benefitting from the scarce medical resources.

Resumen El 12 de abril de 2020, se publicó en el sitio web del Consejo de Salubridad General (CSG) del Gobierno de México una guía de bioética para asignar recursos hospitalarios escasos durante la actual pandemia de Covid-19. La guía titulada Guía bioética para asignación de recursos limitados de medicina crítica en situación de emergencia pretendía ser un documento preliminar, pero la publicación en el sitio web no lo describió como un primer paso en el proceso. La publicación resultó en una amplia gama de comentarios y críticas. La primera versión publicada en el sitio web del CSG contenía un criterio basado en la edad para romper el empate entre dos o más pacientes médicamente elegibles que necesitaran un ventilador: los pacientes más jóvenes tendrían preferencia sobre los de mayor edad. La versión final de la guía eliminó ese criterio y, en cambio, se basó en el principio principal de salud pública, "salvar la mayoría de las vidas", sin tener en cuenta las características personales que no sean la posibilidad de beneficiarse de los escasos recursos médicos.

Guía bioética de asignación de recursos de medicina crítica del Consejo de Salubridad General en México / Bioethics guide on scarce medical resource allocation in Mexico

Resumen El tema bioético sobre la asignación de recursos escasos no es nuevo, todos los países que han sido gravemente afectados por el SARS-CoV-2 han tenido que desarrollar y utilizar guías de triaje. Esto resulta más adecuado pues así la asignación de recursos limitados se hace de manera ética y justa, y no de manera discrecional y abierta a la corrupción. En México, en anticipación a la fase exponencial de la pandemia por SARS-CoV-2, el 30 de abril el Consejo de Salubridad General publicó la Guía bioética para asignación de recursos limitados de medicina crítica en situación de emergencia. Dicha guía tiene como base criterios de justicia social y parte de la tesis: todas las vidas tienen el mismo valor. Este texto tiene como objetivo proporcionar las razones bioéticas y biojurídicas que conforman esta guía de triaje en nuestro país. En resumen, proporciona una breve exploración de las razones éticas que justifican cierta manera específica de asignar recursos escasos en medicina crítica, así como del sustento procedimental apegado a los estándares en materia de derechos humanos.

Abstract The bioethical inquiry about allocating fairly scarce health resources is not new, all countries around the world that were seriously afflicted by SARS-CoV-2 have issued triage guidelines in order to address the dilemmas raised by the pandemic. There is no question about the need to create bioethical guidelines, since its creation provides a degree of certainty that fair and ethical decisions are taken. This also prevents that decisions are made in solitary and maybe motivated by corrupted actions. In Mexico, the creation of this guideline was a proactive and preventive measure to what was unavoidable, the exponential contagion phase of the pandemical scenario caused by Covid-19. On April 30, 2020 the General Sanitary Council published the Bioethical Guide to Allocate Scarce Resources on Critical Care Medicine in Emergency Situation. This guide has at its core that principle of utmost importance in social justice which main thesis is: "All lives have the same value". The aim of this contribution is to provide the ethical and legal principles established in the aforementioned bioethical guideline. In sum, a brief exploration of the ethical reasons that support a specific way to allocate scarce health resources is provided, as well as the foundations of the procedural part from a human rights-based approach.

[Ethical guides, criteria for admission in intensive care, palliative care. Multi-society recommendations for allocation of resources during the COVID-19 pandemic]. / Guías éticas para la atención durante la pandemia COVID-19. Recomendaciones multisocietarias para asignación de recursos.

Guidelines on resource allocation, ethics, triage processes with admission and discharge criteria from critical care and palliative care units during the pandemia are here presented. The interdisciplinary and multi-society panel that prepared these guidelines represented by bioethicists and specialists linked to the end of life: clinicians, geriatricians, emergentologists, intensivists, and experts in palliative care and cardiopulmonary resuscitation. The available information indicates that approximately 80% of people with COVID-19 will develop mild symptoms and will not require hospital care, while 15% will require intermediate or general room care, and the remaining 5% will require assistance in intensive care units. The need to think about justice and establish ethical criteria for allocation patients arise in conditions of exceeding available resources, such as outbreaks of diseases and pandemics, with transparency being the main criterion for allocation. These guides recommend general criteria for the allocation of resources relies on bioethical considerations, rooted in Human Rights and based on the value of the dignity of the human person and substantial principles such as solidarity, justice and equity. The guides are recommendations of general scope and their usefulness is to accompany and sustain the technical and scientific decisions made by the different specialists in the care of critically ill patients, but given the dynamic nature of the pandemic, a process of permanent revision and adaptation of recommendations must be ensured.

Se presentan las guías sobre ética de asignación de recursos, procesos de triaje con criterios de ingreso y egreso de unidades de cuidados críticos y atención paliativa durante la pandemia. El panel interdisciplinario y multisocietario que las preparó estuvo representado por bioeticistas y por especialistas vinculados al fin de la vida: clínicos, geriatras, emergentólogos, intensivistas, expertos en cuidados paliativos y en reanimación cardiopulmonar. La información disponible indica que aproximadamente 80% de las personas con COVID-19 desarrollarán síntomas leves y no requerirán asistencia hospitalaria, mientras que 15% precisará cuidados intermedios o en salas generales, y el 5% restante requerirá de asistencia en unidades de cuidados intensivos. La necesidad de pensar en justicia y establecer criterios éticos de asignación surgen en condiciones de superación de los recursos disponibles, como en brotes de enfermedades y pandemias, siendo la transparencia el principal criterio para la asignación. Estas guías recomiendan criterios generales de asignación de recursos en base a consideraciones bioéticas, enraizadas en los Derechos Humanos y sustentadas en el valor de la dignidad de la persona humana y principios sustanciales como la solidaridad, la justicia y la equidad. Las guías son recomendaciones de alcance general y su utilidad consiste en acompañar y sostener las decisiones técnicas y científicas que tomen los distintos especialistas en la atención del paciente crítico, pero dado el carácter dinámico de la pandemia, debe asegurarse un proceso de revisión y readaptación permanente de las recomendaciones.

Guías éticas para la atención durante la pandemia COVID-19: Recomendaciones multisocietarias para asignación de recursos / Ethical guides, criteria for admission in intensive care, palliative care. Multi-society recommendations for allocation of resources during the COVID-19 pandemic

Se presentan las guías sobre ética de asignación de recursos, procesos de triaje con criterios de ingreso y egreso de unidades de cuidados críticos y atención paliativa durante la pandemia. El panel interdisciplinario y multisocietario que las preparó estuvo representado por bioeticistas y por especialistas vinculados al fin de la vida: clínicos, geriatras, emergentólogos, intensivistas, expertos en cuidados paliativos y en reanimación cardiopulmonar. La información disponible indica que aproximadamente 80% de las personas con COVID-19 desarrollarán síntomas leves y no requerirán asistencia hospitalaria, mientras que 15% precisará cuidados intermedios o en salas generales, y el 5% restante requerirá de asistencia en unidades de cuidados intensivos. La necesidad de pensar en justicia y establecer criterios éticos de asignación surgen en condiciones de superación de los recursos disponibles, como en brotes de enfermedades y pandemias, siendo la transparencia el principal criterio para la asignación. Estas guías recomiendan criterios generales de asignación de recursos en base a consideraciones bioéticas, enraizadas en los Derechos Humanos y sustentadas en el valor de la dignidad de la persona humana y principios sustanciales como la solidaridad, la justicia y la equidad. Las guías son recomendaciones de alcance general y su utilidad consiste en acompañar y sostener las decisiones técnicas y científicas que tomen los distintos especialistas en la atención del paciente crítico, pero dado el carácter dinámico de la pandemia, debe asegurarse un proceso de revisión y readaptación permanente de las recomendaciones.

Guidelines on resource allocation, ethics, triage processes with admission and discharge criteria from critical care and palliative care units during the pandemia are here presented. The interdisciplinary and multi-society panel that prepared these guidelines represented by bioethicists and specialists linked to the end of life: clinicians, geriatricians, emergentologists, intensivists, and experts in palliative care and cardiopulmonary resuscitation. The available information indicates that approximately 80% of people with COVID-19 will develop mild symptoms and will not require hospital care, while 15% will require intermediate or general room care, and the remaining 5% will require assistance in intensive care units. The need to think about justice and establish ethical criteria for allocation patients arise in conditions of exceeding available resources, such as outbreaks of diseases and pandemics, with transparency being the main criterion for allocation. These guides recommend general criteria for the allocation of resources relies on bioethical considerations, rooted in Human Rights and based on the value of the dignity of the human person and substantial principles such as solidarity, justice and equity. The guides are recommendations of general scope and their usefulness is to accompany and sustain the technical and scientific decisions made by the different specialists in the care of critically ill patients, but given the dynamic nature of the pandemic, a process of permanent revision and adaptation of recommendations must be ensured.

Ethical surgical triage of patients with head and neck cancer during the COVID-19 pandemic.

BACKGROUND: Coronavirus has serially overtaken our metropolitan hospitals. At peak, patients with acute respiratory distress syndrome may outnumber mechanical ventilators. In our Miami Hospital System, COVID-19 cases have multiplied for 4 weeks and elective surgery has been suspended. METHODS: An Otolaryngologic Triage Committee was created to appropriately allocate resources to patients. Hospital ethicists provided support. Our tumor conference screened patients for nonsurgical options. Patients were tested twice for coronavirus before performing urgent contaminated operations. N95 masks and protective equipment were conserved when possible. Patients with low-grade cancers were advised to delay surgery, and other difficult decisions were made. RESULTS: Hundreds of surgeries were canceled. Sixty-five cases screened over 3 weeks are tabulated. Physicians and patients expressed discomfort regarding perceived deviations from standards, but risk of COVID-19 exposure tempered these discussions. CONCLUSIONS: We describe the use of actively managed surgical triage to fairly balance our patient's health with public health concerns.

Triage tool for the rationing of blood for massively bleeding patients during a severe national blood shortage: guidance from the National Blood Transfusion Committee.

The emerging COVID-19 pandemic has overwhelmed healthcare resources worldwide, and for transfusion services this could potentially result in rapid imbalance between supply and demand due to a severe shortage of blood donors. This may result in insufficient blood components to meet every patient's needs resulting in difficult decisions about which patients with major bleeding do and do not receive active transfusion support. This document, which was prepared on behalf of the National Blood Transfusion Committee in England, provides a framework and triage tool to guide the allocation of blood for patients with massive haemorrhage during severe blood shortage. Its goal is to provide blood transfusions in an ethical, fair, and transparent way to ensure that the greatest number of life years are saved. It is based on an evidence- and ethics-based Canadian framework, and would become operational where demand for blood greatly exceeds supply, and where all measures to manage supply and demand have been exhausted. The guidance complements existing national shortage plans for red cells and platelets.

Principled decisions and virtuous care: an ethical assessment of the SIAARTI Guidelines for allocating intensive care resources.

This article sets forth ethical principles for responding to extraordinary circumstances in which the demand for medical care threatens to overwhelm available resources, as in the COVID-19 pandemic. In light of these principles, the author then assesses the ethics of the SIAARTI guidelines for rationing ICU beds and ventilators under such circumstances.

Medically Necessary, Time-Sensitive Procedures: Scoring System to Ethically and Efficiently Manage Resource Scarcity and Provider Risk During the COVID-19 Pandemic.

Hospitals have severely curtailed the performance of nonurgent surgical procedures in anticipation of the need to redeploy healthcare resources to meet the projected massive medical needs of patients with coronavirus disease 2019 (COVID-19). Surgical treatment of non-COVID-19 related disease during this period, however, still remains necessary. The decision to proceed with medically necessary, time-sensitive (MeNTS) procedures in the setting of the COVID-19 pandemic requires incorporation of factors (resource limitations, COVID-19 transmission risk to providers and patients) heretofore not overtly considered by surgeons in the already complicated processes of clinical judgment and shared decision-making. We describe a scoring system that systematically integrates these factors to facilitate decision-making and triage for MeNTS procedures, and appropriately weighs individual patient risks with the ethical necessity of optimizing public health concerns. This approach is applicable across a broad range of hospital settings (academic and community, urban and rural) in the midst of the pandemic and may be able to inform case triage as operating room capacity resumes once the acute phase of the pandemic subsides.

Ethical dilemmas in COVID-19 times: how to decide who lives and who dies?

SUMMARY The respiratory disease caused by the coronavirus SARS-CoV-2 (COVID-19) is a pandemic that produces a large number of simultaneous patients with severe symptoms and in need of special hospital care, overloading the infrastructure of health services. All of these demands generate the need to ration equipment and interventions. Faced with this imbalance, how, when, and who decides, there is the impact of the stressful systems of professionals who are at the front line of care and, in the background, issues inherent to human subjectivity. Along this path, the idea of using artificial intelligence algorithms to replace health professionals in the decision-making process also arises. In this context, there is the ethical question of how to manage the demands produced by the pandemic. The objective of this work is to reflect, from the point of view of medical ethics, on the basic principles of the choices made by the health teams, during the COVID-19 pandemic, whose resources are scarce and decisions cause anguish and restlessness. The ethical values for the rationing of health resources in an epidemic must converge to some proposals based on fundamental values such as maximizing the benefits produced by scarce resources, treating people equally, promoting and recommending instrumental values, giving priority to critical situations. Naturally, different judgments will occur in different circumstances, but transparency is essential to ensure public trust. In this way, it is possible to develop prioritization guidelines using well-defined values and ethical recommendations to achieve fair resource allocation.

RESUMO A doença respiratória provocada pelo coronavírus 2019 (COVID-19) é uma pandemia que produz uma grande quantidade simultânea de doentes com sintomas graves que necessitam de cuidados hospitalares especiais, sobrecarregando a infraestrutura dos serviços de saúde. Todas essas demandas geram a necessidade de racionar equipamentos e intervenções. Diante desse desequilíbrio, como, quando e quem decide, há o impacto dos sistemas estressores dos profissionais que se encontram na linha de frente do atendimento e, em segundo plano, questões inerentes à subjetividade humana. Nesse percurso, surge ainda a ideia do uso de algoritmos da inteligência artificial para substituir o profissional de saúde nessa tomada de decisão. Nesse contexto, fica o questionamento ético de como gerenciar as demandas produzidas pela pandemia. O objetivo deste trabalho é refletir, do ponto de vista da ética médica, sobre princípios basilares das escolhas executadas pelas equipes de saúde, no enfrentamento da pandemia da COVID-19, cujos recursos são escassos e as decisões ocasionam angústia e inquietação. Os valores éticos para o racionamento de recursos de saúde em uma epidemia devem convergir para algumas propostas embasadas em valores fundamentais, como maximizar os benefícios produzidos por recursos escassos, tratar as pessoas de forma igualitária, promover e recomendar os valores instrumentais, dar prioridade para situações críticas. Naturalmente ocorrerão julgamentos diferentes em circunstâncias distintas, mas é fundamental que haja transparência para garantir a confiança pública. Desse modo, é possível elaborar diretrizes de priorização utilizando valores e recomendações éticas bem delineados para atingir procedimentos justos de alocação de recursos.

Moral dilemmas faced by hospitals in time of war: the Rambam Medical Center during the second Lebanon war.

Rambam Medical Center, the only tertiary care center and largest hospital in northern Israel, was subjected to continuous rocket attacks in 2006. This extreme situation posed serious and unprecedented ethical dilemmas to the hospital management. An ambiguous situation arose that required routine patient care in a tertiary modern hospital together with implementation of emergency measures while under direct fire. The physicians responsible for hospital management at that time share some of the moral dilemmas faced, the policy they chose to follow, and offer a retrospective critical reflection in this paper. The hospital's first priority was defined as delivery of emergency surgical and medical services to the wounded from the battlefields and home front, while concomitantly providing the civilian population with all elective medical and surgical services. The need for acute medical service was even more apparent as the situation of conflict led to closure of many ambulatory clinics, while urgent or planned medical care such as open heart surgery and chemotherapy continued. The hospital management took actions to minimize risks to patients, staff, and visitors during the ongoing attacks. Wards were relocated to unused underground spaces and corridors. However due to the shortage of shielded spaces, not all wards and patients could be relocated to safer areas. Modern warfare will most likely continue to involve civilian populations and institutes, blurring the division between peaceful high-tech medicine and the rough battlefront. Hospitals in high war-risk areas must be prepared to function and deliver treatment while under fire or facing similar threats.

Triage of mass casualties in war conditions: realities and lessons learned.

PURPOSE: The authors made a retrospective analysis of three triage situations of war wounded in Chad and Rwanda in which mass casualties overwhelmed available medical facilities. METHODS: The triage classification is based on the waiting period for surgery. The categories are: extreme, first, second and third emergencies, expectant, walking wounded. RESULTS: In Chad, 23 wounded adults were received in 24 hours, and 19 were operated up on within 48 hours. In Rwanda 1, 94 wounded were received in two hours, of whom 68 were operated upon, 23 on the first day. In Rwanda 2, 59 wounded were received in 12 hours, treatment of extreme and first emergencies required 48 hours, while second and third emergencies were treated during the three following days. CONCLUSIONS: These episodes were very different when considering the setting, the number of casualties, the type of wounds, the logistical and medical difficulties. The authors report the difficulties faced and the lessons learned. "Il faut toujours commencer par le plus douloureusement blessé sans avoir égard aux rangs et aux distinctions." You must always begin with those who are most seriously wounded without regard to rank or other distinction. Baron Larrey (1766-1842), surgeon to Napoléon's Imperial Guard.

Triage in surgery: from theory to practice, the Medecins Sans Frontières experience.

Establishing triage is necessary in mass casualty events. If the concept of triage itself is easy, its application in the field encounters many difficulties at times unforseen. MSF offers a list of the main obstacles encountered when establishing an efficient triage system.

[Euthanasia and other decisions at the end of life (Proposal for a more transparent terminology and some thoughts on the legal framework of medical treatment)]. / Az életvégi orvosi döntésekrol, közöttük az eutanáziáról. (Javaslat egy áttekinthetobb terminológiára és gondolatok az orvoslás jogi szabályozásáról).

Indication of euthanasia is only one of several medical decisions at the end of life. Precise definition of this topic related to the clinical events happening around the sick-bed is not complete in the legal and medical literature. The present review attempts to classify the different end of life events with the aim of clarifying which of these do not belong to the concept of passive euthanasia. Euthanasia is not a legal category. The everyday expressions of active and passive euthanasia are simplifications, which cover actions of different purposes. Use of these in medical and legal literature can be confusing and misleading. We differentiate decisions at the end of life on basis of their purpose. Based on the definition and category of the Hungarian Doctors' Chamber, euthanasia is the act or the lack of action in order to mercifully shorten or end the life of a suffering fellow-man to help him. Concepts of active, passive and forced euthanasia are defined. The terms of indirect and intermediate euthanasia are not used in order to avoid misunderstanding. Help and participation of non-professionals in the implementation cannot be completely excluded from the concept of euthanasia, and we believe euthanasia is not merely related to doctors. We outline those medical decisions at the end of life which do not belong to the category of passive euthanasia, namely: withdrawal of ineffective and life sustaining treatments, letting go of the patient, contra-indication of therapy escalation, use of palliative therapy, pain-relieving treatment, compromise medicine, consideration of reanimation and choosing cost-effective therapy. We touch upon the subject of the living will, why it cannot be applied, and its relation to active and passive euthanasia. With reference to the legal regulation of life saving and life sustaining treatment, we deal with the expected spirit of medical legislation.

Should palliative care be a necessity or a luxury during an overwhelming health catastrophe?

In the event of a widespread health catastrophe in which either or both human and material resources were in critically short supply, rationing must take place, especially if the scarcity will last for some time. There are several tested allocation methods that are routinely used during emergencies. These include triage procedures employed by emergency departments and the military on the battlefield. The goal is to save the lives of as many as possible. When it is not possible to save all, or even most, who come for care, what should be done, if anything, with those whose fate is death? The central tenet and goal of medicine is the relief of suffering. If we take this seriously as an axiom of practice, then healthcare providers and the institutions in which they work are duty-bound to provide comfort and relief to all, especially the dying. There are several ways this can be done. One is to prepare by training sufficient individuals to provide what might be called emergency palliative care. These people do not all have to be doctors but could (and should) include people from a range of backgrounds including nursing, allied health, pastoral care, and social work. For them to be able to do their jobs effectively, some basic supplies should be stockpiled so the pain and suffering associated with untreated illness and injury can be relieved. However, what happens when there is a shortage of, say, opiates, so that relief of air hunger and pain cannot be eased? Then critical decisions must be made. Alternative sources of symptom relief not considered under ordinary circumstances might be used. However, it is possible to imagine a situation when all resources are in critically short supply. Those remaining resources, logically and morally, should be allocated to persons who can survive. In this scenario, what can be offered to the suffering dying? This might depend on the attitude of personnel caring for patients. In desperate circumstances, it is possible the proscription against active euthanasia could be justifiably overridden by concern for ongoing, relentless, and unmitigated suffering. Any justification that could be made for such action would be undermined by arbitrary or capricious administration. Thus, preparation for a catastrophic healthcare emergency should take into account all conceivable outcomes.