Medical Triage Scores and Systems in Military Settings: Advantages, Limitations, and Ethical Concerns.

Abstract

Introduction: Military triage is a cornerstone of combat casualty care and aims to optimize the use of limited medical resources in hostile environments. Over time, military triage systems have evolved according to the nature of conflicts, operational constraints, and technological advances. This review aimed to analyze the military triage systems described in the literature, including their characteristics, advantages, limitations, and associated ethical concerns.

Materials and methods: A scoping review was conducted according to relevant PRISMA-ScR guidelines using PubMed and Google Scholar databases. Articles published in English up to July 7, 2025, were screened using predefined keywords related to military triage. Two independent reviewers selected studies addressing military triage systems, operational doctrines, or historical perspectives. Data extraction included study characteristics, conflict settings, triage methodologies, implementation modalities, and ethical considerations.

Results: Twenty-eight articles published between 1984 and 2025 were included. Most studies originated from the United States and the United Kingdom and primarily addressed asymmetric warfare. The NATO triage system remained the most widely used model, although several modified systems were identified, including the Modified Military Sieve, Modified Physiological Triage Tool, Fast Triage in Burns, and Sacco Triage Method. Recent developments focused on physiological scoring systems, wearable biosensors, computerized algorithms, and artificial intelligence-assisted triage. Ethical concerns frequently involved expectant casualty management, distributive justice, reverse triage, resource scarcity, and conflicts between military objectives and medical ethics.

Conclusions: Military triage systems continue to evolve from simple clinical algorithms toward technology-assisted decision-making tools. Despite advances in physiological monitoring and artificial intelligence, triage remains highly dependent on human judgment and operational context. Ethical dilemmas remain central to military triage and require continued consideration in future doctrine and system development.