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Triage: An Ethical Dilemma

By Master Sgt. Eric W. Pelkey

Class 74, Sergeants Major Course

June 28, 2024

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Female Soldiers in uniform standing in a line for a photo

SSoldier lies broken and bleeding among his fallen brothers and sisters after the initial onslaught of a large-scale combat operation (LSCO). The battle, the first of its kind in decades, rages in the distance as the Soldier looks to the sky in desperation.

Suddenly, a vehicle appears, and its passengers exit and begin lifting the wounded off the battlefield. Recognizing one of these arrivals, the Soldier cries for help. In response, the newcomer assesses the Soldier’s condition. Unfortunately, he bears bad news.

“I can’t take you now,” he says. “We’ll come back when we can.”

The distressed Soldier quietly thinks of home as he fades to black.

Unbeknownst to the Soldier, his acquaintance practiced proper medical triage when deciding whom to remove from the battlefield.

The Army defines triage as “the process of sorting casualties based on need for treatment, evacuation, and available resources” (Department of the Army, 2020, p.10-3). Doctrine emphasizes prioritizing those most capable of returning to duty and likely to survive based on available resources (Department of the Army, 2020).

Triage was not practiced or executed as frequently during the nation’s Global War on Terrorism (GWOT). At the time of GWOT’s counterinsurgency operations (COIN), triage practices focused more on prioritization of evacuation than treatment. In other words, the United States’ ability to project substantial combat power during COIN operations largely afforded our military the opportunity to evacuate most Soldiers injured on the battlefield promptly, despite the level of care required.

That precedent contrasts with past conflicts. As evidence, hostile death totals during the GWOT are among the lowest combat-related deaths in history, with approximately 5,461 occurring in over 20 years of continuous operations. Nonhostile totals are significantly less, at approximately 1,596 (Department of Defense [DoD], 2024).

As the nation moves closer to LSCO, the need for triage becomes more critical, given the likelihood of prolonged casualty care (PCC). Once relegated primarily to physicians, the threat of far-forward, austere environments places all potential care providers in a position of responsibility for triage. Nonmedical personnel performing buddy aid or evacuation duties may fall into this category.

Unfortunately, triage generates potential ethical dilemmas due to the subjective nature of prioritizing care. That is especially true if the casualty is a friend, peer, or subordinate of the caregiver. In short, Soldiers will face daily ethical dilemmas regarding the fair and impartial treatment of battlefield casualties during LSCO.


The decision-making process becomes more challenging during military operations due to associated risks. Fortunately, combat operations during the GWOT afforded combat lifesavers, combat medics, battalion aid stations, and leaders a reprieve from difficult triage decisions. That respite is mainly due to the large availability of evacuation services and a limited scope of practice available at or below role-one care (battalion aid station and below). Therefore, triage responsibility primarily landed at the feet of physicians above role-one care.

In 2009, for instance, the Secretary of Defense (SECDEF) issued a mandate requiring medical evacuation of all critically injured (CAT-A) coalition members within 60 minutes upon an approved evacuation request. This order increased deployed aeromedical evacuation and surgical units across the United States Central Command’s (USCENTCOM) operational environment.

The USCENTCOM Commander additionally set a 15-minute launch requirement for aeromedical evacuation assets upon receipt of an approved CAT-A evacuation request (Garrett, 2013). U.S. military doctrine reflects the change instituted by the SECDEF and USCENTCOM Commander. Unfortunately, the standards and principles currently used in evacuation meet resistance as the nation focuses on conflict with a new pacing threat.

The Problem, Dilemmas, and Impact

As the military prepares for LSCO, realizing limited evacuation opportunities brings the concept of PCC to the forefront of the medical community. The key tenet of PCC finds casualties remaining in “austere, remote, or expeditionary settings” for longer periods than previously experienced during the GWOT (Joint Trauma System, 2021, p. 5). Simply, casualties will not evacuate within the time frames established in military doctrine.

U.S. Army Staff Sgt. Iris Barajas, a tank commander assigned to the 4th Infantry Division

Current LSCO casualty estimates, against the nation’s No. 1 pacing threat, place the Army at risk of having insufficiently trained Soldiers making triage decisions resulting in a Commander’s inability to project combat power. Soldiers operating outside of the medical community receive little triage training. While containing some objective triage criteria, current doctrine leaves room for subjective decision-making that could cause tension, stress, and emotional degradation as casualty numbers grow.

The act of triage, whether performed by a medical professional or not, places Soldiers at risk of encountering the ethical dilemma of individual vs. community and truth vs. loyalty, as characterized by Dr. Jack D. Kem of the Army’s Command and General Staff College (2006).

Individual vs. Community

The dilemma of individual vs. community occurs during triage when care providers ignore their moral code to do no harm, potentially resulting in casualty death, to prioritize care for those most likely to return to duty. It is a case of one vs. the many, historically occurring in mass casualty incidents or when medical resources (material or personnel) are scarce (Howe, 2003).

In a PCC environment, prioritization could mean postponing treatment of critically ill or injured casualties, depending on resources. The chosen delay could affect those who could survive if treated or evacuated as described in current doctrine.

In these scenarios, the definition of noncompatible with life may change from gross injury to an injury treatable under doctrinal evacuation conditions – but, due to resource limitation, classified as a lower priority (Joint Trauma System, 2021).

For example, during the GWOT, the military had tremendous success treating those suffering from limb amputations. In a LSCO environment, a Soldier with an amputation may rank after someone in order of precedent who is ill with dehydration if intravenous (IV) fluid resources are scarce.

The amputee will likely not return to duty, whereas the dehydrated Soldier likely will, so the situation calls for prioritizing the resource for the dehydrated Soldier. Though an extreme example, such situations could occur.

Truth vs. Loyalty

Returning a Soldier to duty leads to another common ethical dilemma facing care providers. Truth vs. loyalty is a mixed agency issue where an individual has dual loyalties. For a Soldier, these loyalties are between individuals (casualties) and the Army (or unit).

The dilemma occurs when medically treating Soldiers to return to duty, knowing they stand a chance of sustaining critical injury or dying – even if returning is against the Soldier’s best medical interests.

Essentially, the care provider creates the capacity for the Soldier to return to duty, without necessarily recommending it happen (Howe, 2003). Like individual vs. community, care providers violate their do no harm principle by placing the needs of the Army or mission first.

Sapper Leader Course instructor Staff Sgt. Ariana Sanchez instructs students during a boat rigging event at Fort Leonard Wood, Missouri

The link of causality created inherently violates the values leaders and professional care providers adopt as they grow within the military. Specifically, the ones prioritizing people first.

Given the large estimate of casualties expected in future LSCO scenarios and the likelihood of exercising PCC regularly, the chance of returning a Soldier to duty despite what is in their best interest is high.

Impact of Congestion

Soldiers try to do what is morally and legally right. However, ethical dilemmas create issues.

The first impact of the discussed dilemmas deals with the congestion of the medical evacuation system and forward surgical capabilities. Improper triage leads to inaccurate order of precedence for evacuation purposes.

Once evacuation occurs, a casualty takes a bed or uses resources intended for someone more likely to return to duty. When the return to duty casualty finally arrives for treatment, no space nor resources remain to accommodate the Soldier. The Soldier’s condition worsens, preventing the ability to return to duty.

Such a scenario is why proper triage and regular re-triage are paramount in a PCC environment: They aid in projecting combat power. One needs to avoid improperly prioritizing casualties once evacuation becomes an option to prevent increased morbidity or mortality of casualties.

Improper prioritization is especially damaging during mass casualty incidents. Evacuation and roles of care cannot keep up with demand, resulting in casualties left unattended or attended by minimally trained Soldiers.

The situation is akin to an automobile crash during rush hour traffic. Traffic slows down or stops until a tow truck moves the wrecked vehicles. However, traffic prevents the tow truck from arriving promptly.

Impact of Moral Injury

The second impact involves moral injury. The stress of continually making life-or-death decisions, like other traumatic events, may weigh heavily on a Soldier’s mental health.

Moral injury can decrease morale, foster resentment, induce depression, produce anxiety, or lead to a host of other issues among Soldiers.

For example, during the recent COVID-19 pandemic, nurses found themselves in the uncommon position of prioritizing treatment due to the overwhelming number of patients entering the medical system nationwide. Emerging studies show that nurses are experiencing symptoms like post-traumatic stress because of the ethical conflict they endured (Hossain & Clatty, 2021).

If health care professionals endure such long-standing stress, imagine the average Soldier positioned to make decisions concerning someone of personal relations. Unit members often become tight-knit. Loss or the fear of loss can be demoralizing on different levels. The impact on mental health alone makes triage too important to ignore.

The Root Cause

The root cause of triage-induced ethical dilemmas is training and doctrine gaps in the subject matter, including a lack of training focused on moral injury. Every medical professional has likely had triage training, but no doctrine teaches the nonmedical Soldier to triage in a LSCO environment.

The current Tactical Combat Casualty Care (TCCC) manual and PCC Manual simply state to conduct triage (Joint Trauma System, 2021). Additionally, the current Soldier Manual of Common Tasks for all skill levels does not discuss triage as a task.

U.S. Army 1st Sgt. Janina Simmons, assigned as a First Sergeant for Headquarters and Headquarters Battery, 108th Air Defense Artillery Brigade, 32nd Army Air and Missile Defense Command, speaks at AUSA Warfighter Conference in Fayetteville, North Carolina

For transparency, the Army’s medical community has several individual tasks focusing on triage from a medical professional standpoint. However, as stated previously, any Soldier may conduct triage activities in LSCO.

Furthermore, medical and evacuation doctrine describes triage categories but leaves room for subjectivity. This ambiguity leads some to experience the burden of an ethical dilemma that leads to moral injury.

Essentially, the Army forces Soldiers to exercise judgment without experience to decide on the best course of action. Physical triage training is insufficient for Soldiers to acquire the sets and repetitions needed to make a sound, logical decision on a LSCO battlefield.

A Solution to Triage

Two primary solutions, tied directly to the root causes, come to mind when considering triage problems.

First, prioritization of training across all skill levels should help level expectations and understanding of proper triage. Make triage a trainable and testable task among all Soldiers.

Furthermore, including a moral injury topic in triage or ethics training warrants consideration, given the far-reaching impact of improper triage on mental health.

Retired Lt. Col. Pete Kilner (2017), a former U.S. Military Academy professor, discusses a leader’s responsibility to implement practices to reduce the likelihood of moral injury. These actions include training on ethical reasoning, wherein leaders explain the why behind decisions (Kilner, 2017). However, the availability and currency of doctrinal guidance play a role in the ability of effective leader engagement. The ability to norm a situation is challenging without supporting guidance.

This difficulty leads to the second solution, doctrinal updates. Modern triage categories worked well in a COIN environment. Now that LSCO is again a focus point within the military complex, it is time to reevaluate the categorical definitions in doctrine.

One recommendation, published in Military Review, involves defining triage through operational priorities. The premise is to tie triage categories to operational demands, adjusting return to duty criteria based on mission criticality.

The idea relies on Commanders defining conditions where triage practices adjust, favoring return to duty, to maintain specific levels of combat power (Beldowicz et al., 2022). Having predetermined Command guidance should aid in creating an environment of understanding, ultimately void of the potential ethical dilemmas discussed.

Triage Through the Three Ethical Lenses

Principles-Based Ethics

To ensure the proposed solutions’ viability and ethical integrity, Kem recommends viewing them through a principles-based lens. Doing so reveals if conflicting rules or regulations contradict the solutions (2006).

Currently, no regulations or laws prevent or conflict with the execution of triage training at unit or institutional levels. Medical training models (TCCC and PCC) include the task of triage, which highlights its importance as a necessary step in medical treatment (Joint Trauma System, 2021). In worst-case scenarios, lack of triage or improper triage could constitute the crime of medical abandonment.

Furthermore, Article 12 through Article 14 of the Geneva Conventions call for fair and impartial treatment of friendly and enemy battlefield casualties. Soldiers lacking proper triage training may inadvertently violate these laws when battle stressors place them in a heightened emotional state. Although the risk of violating laws or international treaties because of poor triage is low, it exists, especially if nonmedical Soldiers lack sufficient training.

Sgt. 1st Class Joanna Carter, U.S. Army Human Resources Command, performs facing movements during a phase II appearance board

Consequences-Based Ethics

Anyone planning major change should consider the consequences. Consequences-based ethics is another way to view a desired solution. Determining possible results or outcomes of a given course of action aids in maximizing positive, desirable emotions (Kem, 2006).

The consequence of not updating doctrine or implementing training guidance is deploying Soldiers who lack the confidence and emotional intelligence to make rational life-or-death decisions. Commanders’ unwillingness to allocate time for triage training could limit their flexibility on the battlefield, due to the congestion of evacuation channels – complicating and slowing the movement of personnel.

Furthermore, proper training improves prompt decision-making abilities and adaptability while simultaneously desensitizing Soldiers to the potential stressors of warfare. As a result, Soldiers are less likely to succumb to moral injury because of a difficult triage decision.

A short-term morale boost due to a gap in the unit’s training calendar does not replace the benefit of teaching Soldiers how to make lifesaving decisions and preserve combat power. The greater benefit is to fill gaps with proper doctrinal-based triage training.

Virtues-Based Ethics

The risk of increased morbidity or mortality because of poor decision-making can lead to moral injury. The third ethical lens ties directly to moral injury by examining the personal virtues associated with a solution.

Virtues-based ethics deals primarily with socially acceptable behaviors. In a sense, people of virtue maintain compliance with societal expectations (Kem, 2006). When people fail to, they risk moral injury.

When examining solutions through a virtues-based lens, one should feel compelled to act, given the gaps discovered in training and doctrine. Not addressing these problems can lead to disastrous consequences, as discussed above: increased morbidity and mortality on the battlefield.

Remaining passive when action would affect change and reduce the risk of combat death qualifies as an affront to societal virtues. Furthermore, updating doctrinal descriptions for training activities increases the societal understanding of correct triage. Changing culture is difficult but, in this instance, feasible.

Final Recommendation

Viewing the proposed solutions through the three ethical lenses reveals the feasibility of their implementation. The biggest hurdle is allocating time and resources to training events.

Investment in training time is a small price to pay for an increased understanding of triage priorities that lead to the best outcomes. For this reason, Army leadership should immediately implement the discussed solutions. Units and Soldiers need time to digest and understand the change before deploying to support LSCO. Early implementation is critical to best results.


Each Soldier deployed in support of a future LSCO operation may face scenarios forcing them to triage battlefield casualties to maximize combat power. These are tough, emotion-filled decisions lacking a guaranteed solution.

However, we can lessen the risk of an ethical dilemma by instituting training guidance and making doctrinal changes supporting LSCO scenarios. Allowing units to norm the triage decision-making process aids in creating a culture of understanding.

The time to implement change is now. Failure to do so places Soldiers at risk of facing ethical dilemmas regarding the fair and impartial treatment of battlefield casualties during LSCO.


Beldowicz, B., Modlin, R., Bellamy, M., & Hiller, H. (2022). Situational triage: Redefining medical decision-making for large-scale combat operations. Military review.

Department of the Army. (2020). Army health system (FM 4-02).

Department of Defense. (2024). Defense Casualty Analysis System. Defense Manpower Data Center.

Garrett, M. (2013). USCENTCOM review of medical evacuation (MEDEVAC) procedures in Afghanistan [Memorandum].

Hossain, F., & Clatty, A. (2021). Self-care strategies in response to nurses’ moral injury during COVID-19 pandemic. Nursing ethics, 28(1), 23–32.

Howe, E. (2003). Military medical ethics, vol 1, ch12. The Borden Institute.

Joint Trauma System. (2021). Prolonged Casualty Care Guidelines.

Joint Trauma System. (2021). Tactical Combat Casualty Care (TCCC) Guidelines.

Kem, J. (2006). Ethical Decision Making: Using the “Ethical Triangle.” Command General Staff College Foundation.

Kilner, P. (2017). How Leaders Can Combat Moral Injury in Their Troops. Association of the United States Army.

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