A Narrative Review of Military Reverse Triage

Military reverse triage has been described at several points in the literature. However, an extensive review of the concept and any gaps that may exist has not been conducted. This narrative review seeks to understand how reverse triage is used in the military literature and how it might be implemented in practice, as well as the documented historical applications of reverse triage.

Four databases were searched manually for English-language articles: PubMed, SCOPUS, JSTOR, and Worldwide Political Science Abstracts. In addition, a manual search of references, U.S. DoD, and NATO doctrine, as well as other published works that the investigator was familiar with that are not cataloged in databases (such as print volumes) was performed.

After duplicates were removed, 15 articles were located from the database search. An additional 14 records were located from the manual search, resulting in 29 records that were screened for eligibility. After reviewing the abstracts of the records, 11 were excluded as not specifically discussing military reverse triage, resulting in 18 records for this review. Recurrent themes in the records reviewed include (1) military necessity, (2) reverse triage from physician, patient, and unit perspective, (3) fiduciary duties, (4) international humanitarian law (IHL), (5) military doctrine, and (6) moral injury. Reverse triage has been described as rare but historically significant, with only 3 documented potential instances identified in this review. These include its use by the German Army in World War II to prioritize lightly wounded soldiers for rapid return to duty, the selective use of penicillin during World War II, and a reported instance during the Falklands conflict. Despite these examples, current literature offers limited practical guidance on implementing reverse triage, raising questions about decision-making authority, criteria for implementation, and ethical considerations such as prioritization based on military occupational specialty, rank, or demographic factors. These uncertainties highlight the need for further exploration of the operational and ethical dimensions of reverse triage.

Reverse triage has evolved with a focus on military necessity but remains absent in U.S. military doctrine and rare in practice. Limited historical documentation and scant discussion in doctrine leave uncertainty about whether and how the U.S. military would implement reverse triage in future large-scale combat operations. Addressing these gaps requires further empirical investigation into the perspectives of key stakeholders to guide ethical and operational decision-making.