The Ethics of Triage

As the global crisis of the Coronavirus pandemic deepens we are facing a barrage of ethical problems related to the provision of health care.

Equitable access to medical treatment is an issue that will manifest on different levels. It will manifest globally: in areas where health systems are deficient or sections of the population have limited access, the effects stand to be much worse if large-scale infection takes hold.

Populations in countries with underlying issues of poverty or other large public health issues already putting stress on health systems will suffer higher mortality rates and may find it more difficult than wealthier nations to source supplies such as protective gear and medicines.

The statistics stand something like this: Of persons infected, about 20 out of 100 will need hospital care. Of those, about 5, or 5 percent of people overall, (roughly a quarter of those who are hospitalized) will need intensive care including the use of a respirator for assisted breathing.  Mortality rates from COVID-19 are differing between places, but on average it is as high as 3-6 per cent.

If the pandemic gets away from us and infections spiral, even developed countries with good health care, services will be stretched, likely way beyond capacity. As intensive care beds are filled, some people will miss out on medical resources. The question of who is going to miss out, or who is going to be prioritized, will leave doctors and medical staff facing very tough decisions about how best to distribute scarce resources.

When hospitalizations increase to the point where demand for intensive care outstrips capacity, the process of triage is used to make decisions about which patients to prioritize. I’ll come back to this concept of triage in a moment, but first, it could not be more urgent for people in places facing down imminent rises in infection rates and community infections to understand that the more preventative measures are heeded the more we reduce the need for doctors to make tough decisions in terms of access to care. Social distancing measures are vital because even those not as vulnerable to the worst outcomes of infection have a role to play in helping to curb its spread. Though around 80 percent of cases are mild, the danger lies in the threat of overwhelmed healthcare systems if really high percentages become infected –and this is why experts are telling us that we need stringent measures to contain the spread.

Triage is the treatment policy adopted in wartime where the numbers of casualties far outstripped medical resources in terms of access to doctors, medicines, and care facilities.

Wounded patients were divided into three categories: the first, those likely to survive without medical assistance; the second, those who may survive with assistance and probably not without; and the third, those who would probably not survive even with medical assistance. Of these categories, only those falling into the second would receive medical treatment.

How does such a principle look in the time of global Coronavirus pandemic? Hospitals may be forced to adopt such a policy with the use of intensive care staff and equipment, and as health systems reach breaking point, choices about who will get access to life-saving treatment will be a real ethical and practical issue.

How will those decisions be made? If someone needs intensive care their chances of survival without assistance are greatly reduced already. Patients deemed to have a higher chance of survival based on other factors, such as general health or age, are likely to be prioritized over those with existing health problems or the elderly.

It is possible that the elderly or terminally ill, for example, might be placed in the equivalent third category, so that the resources spent in trying to save them might be deemed better spent on someone whose chances of survival are good with care but poor without.

A raft of other factors could be in the mix. It is likely age would be a factor, and if numbers of infections rose sharply, there is the possibility of age cut-offs getting lower, so that first under 70 might be prioritized, next under 60, next under 50 and so on. Would profession be a consideration – should healthcare workers, for example, be prioritized? How about parents or people with young children, or other dependents?

These kinds of choices are not unfamiliar in bioethics (they have to be made, for instance, by doctors considering allocation of the fewer organs available for transplant than patients in need of them), but the salient difference here is the sheer numbers of cases where such decisions are faced.

By virtue of doctors and medical staff having to confront these tough triage decisions on a large scale, a kind of consequentialist ethics is forced upon them. Triage is inherently utilitarian, because it allocates resources according not to need but best outcome. A patient in poorer health has fundamentally higher care needs, which translates to demand on medicine, equipment, and staff; but if those resources can be split between two less critical patients with a reasonable chance of saving both, that is the best (probable) outcome. This decision is not based on individual patients’ needs, but on a better outcome overall, according to consequences.

Whatever factors come to play a role in individual decisions made by doctors and healthcare professionals, once the healthcare system has reached this stage there will necessarily have to be a process of ethical weighing-up of costs and benefits, which thrusts a utilitarian framework onto decision-making.

One may, in theory, reject utilitarian reasoning and argue that we have a duty to everyone, and that everyone has a right to equal treatment, access to care, or other necessities such as protective equipment. But rights are powerless when the capacity to uphold or honor them does not exist. In a scenario where infections spiral out of control and health systems collapse, the notion of a universal right to life-saving treatment will be meaningless.

This is an ethical issue in terms of how it affects individual outcomes throughout the pandemic, and it is also an ethical issue by virtue of the awful position it puts doctors, nurses, and medical staff in. Imagine having to choose between two young patients, one with a chronic condition so somewhat less likely to recover. Imagine having to choose between a healthcare worker and a layperson, or between the mother of an infant or an older child. The point is that it can become a situation where doctors are forced to make ‘ethically impossible’ choices.

Peter Singer, a utilitarian philosopher, claims ethics is not an ‘ideal’ system–that it is not something which works only in theory–but, he says, “the whole point of ethical judgements is to guide practice.” In other words, ethics is not about ideals, but practical outcomes.

He is right, in the context of triage in the age of COVID-19, only insofar as these particular practical ethical issues arise as a result of better ethical options, like preparedness and mitigation, having been foregone. In other words, if ethics is not an ideal but a practical reality, utilitarian ethics is a reality here not because it was, as it turns out, right all along, but because other ethical failures have put us in the position of being left with no other choice.

I said at the beginning that the more preventative measures are heeded, the more we reduce the need to make tough decisions in terms of access to care. Triage is not therefore an ethical position, but rather the unhappy position of having to use a kind of moral calculus, which it is better to have avoided in the first place. We therefore need to mobilize our capacity, at the individual level and as a society, using the measures epidemiologists are urging, to mitigate the need for triage. We can think of it as our duty to our families, to our communities, to our nations, and to humanity. Failure at this level would be an ethical failure.

We should, however, take the opportunity to consider what other ethical failures threaten to lead us to disaster in this crisis. Given the general shortage of specialist care facilities, and even of basic protective gear for front-line staff in many parts of the world, the issue of preparedness is also burning.

Why are there not enough critical care facilities in so many countries when a deadly global pandemic has been warned of for many decades? Many nations spend large percentages of their GDP on defense against threats of invasion or international conflict, yet are completely, tragically unprepared for this, predictable, event.

The situation of front-line medical staff having to make heart-rending decisions about who will receive life saving medical treatment and who will miss out is a morally onerous burden that could, had governments better protected their citizens by being ready for such an event, have been largely prevented.