Disaster Medicine and Public Health Preparedness

Case Report

Resource Allocation After a Nuclear Detonation Incident: Unaltered Standards of Ethical Decision Making

J. Jaime Caro c1, Evan G. DeRenzo, C. Norman Coleman, David M. Weinstock and Ann R. Knebel


This article provides practical ethical guidance for clinicians making decisions after a nuclear detonation, in advance of the full establishment of a coordinated response. We argue that the utilitarian maxim of the greatest good for the greatest number, interpreted only as “the most lives saved,” needs refinement. We take the philosophical position that utilitarian efficiency should be tempered by the principle of fairness in making decisions about providing lifesaving interventions and palliation. The most practical way to achieve these goals is to mirror the ethical precepts of routine clinical practice, in which 3 factors govern resource allocation: order of presentation, patient's medical need, and effectiveness of an intervention. Although these basic ethical standards do not change, priority is given in a crisis to those at highest need in whom interventions are expected to be effective. If available resources will not be effective in meeting the need, then it is unfair to expend them and they should be allocated to another patient with high need and greater expectation for survival if treated. As shortage becomes critical, thresholds for intervention become more stringent. Although the focus of providers will be on the victims of the event, the needs of patients already receiving care before the detonation also must be considered. Those not allocated intervention must still be provided as much appropriate comfort, assistance, relief of symptoms, and explanations as possible, given the available resources. Reassessment of patients' clinical status and priority for intervention also should be conducted with regularity.

(Disaster Med Public Health Preparedness. 2011;5:S46-S53)

(Received September 19 2010)

(Accepted January 12 2011)

Key Words:

  • resource allocation;
  • nuclear weapons;
  • radiation injuries;
  • ethics, medical;
  • decision making;
  • prognosis;
  • triage;
  • algorithms;
  • ethics;
  • resource allocation;
  • nuclear detonation;
  • priority setting;
  • need;
  • efficiency


c1 Correspondence: Address correspondence and reprint requests to Dr J. Jaime Caro, United Biosource Corp, 430 Bedford St, Suite 300, Lexington, MA 02420 (e-mail: jaime.caro@mcgill.ca).

Author Affiliations: Dr Caro is with the Department of Epidemiology, Biostatistics and Occupational Health, and Division of General Internal Medicine, McGill University, and with United Biosource Corporation; Dr DeRenzo is with the Center for Ethics, Washington Hospital Center; Drs Coleman and Knebel are with the Office of the Assistant Secretary for Preparedness and Response, US Department of Health and Human Services; and Dr Weinstock is with the Dana-Farber Cancer Institute, Harvard Medical School.

The US Department of Health and Human Services (DHHS) provided funding to support this publication and convene the authors. The contents of the articles represent the personal views of the individual authors and do not necessarily express the opinion or policy of DHHS or its components. No statement in the articles should be construed as an official position of DHHS or its components.