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Rescues and Resource Allocation

blurred photograph of the ocean

For the past several days, the world has waited with bated breath to hear the fate of the occupants of the OceanGate submersible Titan. Launched on Sunday June 18th, the sub was intended to take Stockton Rush – CEO of OceanGate – and four passengers on a 10.5 hour voyage to the wreckage of the Titanic. Instead, communication was lost with Titan less than two hours into the voyage. When the sub failed to surface as scheduled, a massive search and rescue effort was initiated.

Among those searching were numerous ships and two C-130 Hercules aircraft from the U.S. Coast Guard as well as additional support from the 106th Rescue Wing of the New York National Guard. The Canadian Navy has dedicated the HMCS Glace Bay, while the Canadian Coast Guard has provided the John Cabot, with two additional ships – the Ann Harvey and the Terry Fox – en route. These were joined by Canadian P-3 Orion and P-8 Poseidon aircraft and the Motor Vessel Horizon Arctic. Two commercial vessels – the Skandi Vinland and the Atlantic Merlin – also joined the search, while France has sent L’Atalante.

This lengthy roster of responders seems understandable – especially given the 96-hour oxygen limit onboard the Titan. Some have, however, raised concerns about the resources allocated to find the occupants of the sub, especially in light of similar crises occurring elsewhere.

Just four days before the launch of Titan, a fishing boat carrying 500 refugees from Pakistan, Egypt, Syria and Israel/Palestine capsized off the coast of Greece. Rescuers managed to save 104 passengers – and recover an additional 79 bodies – but more than 300 passengers are still unaccounted for. Greek authorities have since been criticized for failing to render adequate aid to the migrants during the disaster. At the very least, the international response to this disaster (the mitigation of which would have used similar resources to those mobilized in the search for the Titan) was minimal, as was media coverage of the tragedy.

The comparison of these two cases raises an important question: how do we decide the appropriate level of resources to allocate in a rescue scenario?

The answer to this question is not an easy one, and requires care and sensitivity – especially in light of the details surrounding the Titan’s implosion. Of course, the obvious answer might seem to be that the inherent value of a human life justifies allocating whatever resources necessary to save that life. But here’s the thing: these kinds of resources aren’t infinite. For this reason, we are forced to make difficult decisions and do what we can to prioritise our resources as effectively as possible.

It’s this very idea that underpins triage – the practice used by emergency room doctors and combat medics during a time of crisis. Medical professionals do not have infinite time or medical resources, so are forced to use what they have to save as many lives as possible. The approach is strongly consequentialist in nature, and is eloquently described by utilitarian Peter Singer as “doing the most good you can do.”

While the heroic efforts of those that searched for the Titan should not be diminished, it’s an open question whether those resources are truly being implemented in a way that achieves the most good. At the very least, it provides a benchmark by which we might assess the appropriate level of response to other crises. Put simply: if the lives of five missing individuals truly warrant the search and rescue efforts being expended in the Atlantic, then consider what this means for the amount of resources that should have been (but were not) allocated to find the more than 300 people still missing in the Mediterranean.

And there’s something else we might need to consider too: namely, the responsibility that individuals have for putting themselves in a crisis in the first place. Last year, I wrote about how people’s risky choices might factor into the aid we give them after they lose their homes to extreme weather events. Luck Egalitarians note that while many of the bad things that happen to us are the result of random chance (like being struck by lightning), many other misfortunes occur as a direct result of deliberate gambles (like losing my life savings betting on a bad hand of poker). Luck Egalitarians refer to the latter as bad “option” luck, and believe that our obligations to help those suffering from this kind of bad luck are less than the obligations we have towards those suffering bad luck that results from random chance (referred to as bad “brute” luck).

How, then, might this concept apply to the passengers onboard the Titan? Such a journey is incredibly dangerous at the best of times. In this case, however, the risk was even greater given the battery of safety concerns with the jury-rigged nature of the vehicle. Despite this, each of the occupants decided to take on this risk for purely recreational purposes – even paying a quarter of a million dollars for the privilege of doing so. Does this mean that we should allocate no resources in an effort to save these individuals? That their fate – whatever it turns out to be – is merely each of them getting what they signed up for? Certainly not. But it does, again, make for an interesting comparison with those refugees who lost their lives in the Mediterranean. While they, too, chose to take on an extraordinary risk, many of them were compelled by circumstance; doing so to avoid poverty and conflict and – in many cases – a very real threat to their lives.

Ultimately, then, the appropriate level of resources to allocate in a crisis depends on a number of factors. Among these is a careful consideration of whether or not those resources are being mobilized in a way that ensures we are doing the most good we can do. We might also consider the extent to which individuals find themselves in a crisis as the result of their own deliberate and calculated gambles. With these factors in mind, it does become harder to understand how five individuals who chose to take a recreational journey fraught with risk have received more international support – and media attention – than the plight of 500 individuals who had little option but to embark on a dangerous voyage.

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Another Way: Moral Reasoning and Selective Focus

photograph of a forked path in pine forest

Imagine, with me, a scenario.

You and I are medical students working in an intensive care unit. Over the course of the last few weeks, we’ve been caring for Mrs. Rhodes: a kind woman who, despite her advanced years, has retained her sharp humor and optimism through an incredibly severe bout of pneumonia. In the last few days, however, her condition has rapidly deteriorated, and the decision was made to place Mrs. Rhodes on a form of heart-lung bypass known as ECMO: though her chances are slim, we hope that, by decreasing the burden on her heart and lungs, we will buy her time for the infection to pass and her lungs to heal.

The problem, though, is that Mrs. Rhodes is not the only patient with this pneumonia: since Mrs. Rhodes’ admission to our unit, the causal infection has spread throughout the nursing home where she was being cared for. Over the past few weeks, therefore, our service has become overrun with ill seniors: many who just require supportive care, and some, like Mrs. Rhodes, who require invasive life support. And as of this morning, Mrs. Rhodes has continued to deteriorate, and all five of our ECMO machines are now occupied.

Later that night, as we hope that none of our patients will deteriorate further, we receive a call from a resident obstetrician. A young pregnant woman has just been seen in the emergency room. She’s eclamptic, and is showing early signs of cardiopulmonary failure: without some form of life support, both her and her fetus are at risk. The obstetrician asks if any ECMO machines are available.

We, then, are faced with a dilemma: do we allow this young woman and her fetus to die, or do we reallocate one of our ECMO machines, and allow one of our elderly patients to die in the process? We look down our patient panel, and see Mrs. Rhodes’ vital signs and laboratory results: it’s clear that her chances of recovery are dim to pitch dark. But is that grounds to sentence her to almost certain death? The ethical quicksand begins to surround us. Does it matter that we can save the lives of the mother and her fetus if we reallocate the machine? Does it matter that Mrs. Rhodes is older? Or is it ageist for us to even think so? Is Mrs. Rhodes entitled to the machine, given that she’s currently attached to it? Does it matter if Mrs. Rhodes is a leader in our community? If the mother is an alcoholic? If Mrs. Rhodes smokes?

Who gets a chance to live, and who doesn’t?

.  .  .

Ethical dilemmas are frequently framed by limitations; in fact, it is often the limitations themselves which give a dilemma moral weight. We are finite beings with finite options, capabilities, and resources, and this simple fact undergirds many of the dilemmas which we might encounter. In the case of Mrs. Rhodes, for example, our dilemma arises from a limited number of lifesaving ECMO machines: and appreciating this limitation, we turn our moral attention to the question of how to fairly and equitably allocate our limited resources.

Real-life ethical dilemmas, however, do not exist in a vacuum: they are inexorably dependent on the context in which they occur, on the socioeconomic, political, and philosophical systems which surround us.

These systems are causally connected to what happens, and often determine who it happens to; and dilemmas, in all of their alluring simplicity, can lead us to believe that these limitations are simply facts, and not the result of the unnamed systems which brought the dilemma about.

We may debate, for example, the merits of reallocating the ECMO machine or not; we may spill a significant amount of ink over what the moral thing to do is in such a case. Such a focus on the dilemma at hand, however, obscures the role of the systems which brought the dilemma about: we forget that the choice to buy five ECMO machines, and not six, was a choice. People gathered in a (likely exquisitely furnished) conference room, and decided that the procurement of five ECMO machines provided the greatest benefit at the least cost. When we debate and decide if Mrs. Rhodes or the young mother should get the ECMO machine, then, we are truly debating who must die to maintain the financial status quo — a reality which the dilemma, as presented above, wholly obscures. With this perspective, we see that a valid ethical analysis of the case of Mrs. Rhodes is that the time for moral action was in that conference room, and that a hospital which cannot care for a nursing home of sick seniors is negligently underprepared.

One could very well argue that when we get to the point where we are deciding who dies a preventable death for the maintenance of an unjust status quo, we can no longer claim that what we’re doing is truly moral in any meaningful sense. But when we only ask the question posed by a dilemma — in this case, who should get the ECMO machine — we fail to ask these broader questions, and we fail to see the full scope of the problem before us.

The same goes for similar dilemmas which we might encounter. Rare diseases go unresearched and untreated due to economic calculus, but what if non-economic values could guide how research priorities are set? We might ask questions about how to best allocate our individual resources to various charities, but what if individual philanthropy itself, in its modern form, frequently propagates injustice? We can ask questions about the dilemmas which are posed to us, but we must also ask questions of the systems which impose the limitations that inform these dilemmas.

Some dilemmas arise from limitations that are inherent to our nature: we cannot be in two places at once, and we cannot live forever. But, with disturbing frequency, the limitations which inform real-life ethical dilemmas are artificial: they are the contingent result of the decisions which we, as individuals and as societies, make, and though their role might be obscured, these decisions are relevant to how we choose to ethically resolve the dilemmas we face. Understanding ethical decision-making requires attention to these choices and the systems and beliefs which arise from them — attention to the things which, in the dilemmas we face, may lead us another way.

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The Heartless Matter of Organ Transplantation and COVID Vaccination

photograph of surgery

Boston’s Brigham and Women’s Hospital has removed one of its patients from its transplant list because he refuses to get the COVID-19 vaccination. 31-year-old DJ Ferguson, who suffers from a hereditary heart issue that causes his lungs to fill with blood and fluid, had previously been prioritized for a life-saving heart transplant. However, according to his family, he has been removed from the transplant list due to his vaccine hesitancy. DJ’s father, David Ferguson, said, “[i]t’s kind of against his basic principles; he doesn’t believe in it. It’s a policy they are enforcing and so because he won’t get the shot, they took him off the list [for] a heart transplant.” DJ’s family are currently considering moving him to another facility but are unsure whether he would survive the trip.

The fair distribution of scarce resources has been an issue throughout the pandemic. For example, in its early days, there was considerable discussion about distributing life-saving ventilators when the number of people needing them outstripped hospital reserves. States such as Alabama, Kansas, and Tennessee all produced guidance recommending, suggesting, or explicitly stating that a patient’s disability status could be considered a reason to withhold — or even withdraw — ventilation. In other words, they deprioritized the disabled in favor of the non-disabled. This problem has, to a degree, eased with the development of effective vaccines and the production of more ventilators.

However, unlike ventilators, we cannot simply manufacture more bodily organs, such as hearts (at least, not yet). The supply of hearts is dictated by how many people donate them. Unlike other donatable organs, like kidneys or livers, donating a heart isn’t something one can do as a kind act during their lifetime. If you’re donating your heart, you’re already dead. As such, hearts are incredibly precious resources. They possess value born from the life that the donor no longer lives and the organ’s potential for its recipient – heart transplantation both takes and awards life.

Because someone must die for a transplantable heart to be made available, there is rightfully an ethical imperative to ensure that the ‘right’ person receives the organ. Giving such a vital and scarce resource to someone who would treat it improperly squanders its potential and disrespects the person who donated the organ. Turk, from the sitcom “Scrubs,” summarizes this well when he refuses to perform surgery on another character’s longtime patient when he finds out that the person has continued to drink, saying:

Dr. Cox, I know it’s really hard on you medical guys, because you spend most of your time with your patients and you get emotionally attached. But as a surgeon, the person I’m closest to is the guy who’s giving us the liver, because it’s a gift, and I think it’s important that it goes to the person that’s proven they’re up to the responsibility.

While the phrase ‘responsibility’ clouds the water here somewhat, the general message remains the same: some people are more deserving of organs than others. While we may wish to save everyone, this isn’t possible given the global shortage of organs. Roughly 17 people die each day because of a lack of organs in the U.S. alone. So for each person who receives an organ, there are numerous others deemed less worthy who must miss out.

In “Scrubs,” it comes down to a matter of responsibility and the ability of potential recipients to demonstrate they will treat the organ with the regard it demands. In a sense, they have to earn that organ. In DJ Ferguson’s case, the point of contention is slightly different. As Arthur Caplan, Head of Medical Ethics at NYU Grossman School of Medicine, states, “Organs are scarce, we are not going to distribute them to someone who has a poor chance of living when others who are vaccinated have a better chance post-surgery of surviving.” So, the concern here isn’t whether Ferguson’s shown he is responsible enough (although you could make a case that his actions demonstrate he isn’t). Instead, it is simply a matter of maximizing outcomes and minimizing risks. Being vaccinated against COVID-19 means you’re less likely to die from the disease, and a reduction in this risk improves the chances of getting the best ‘value-for-money’.

Pinning so much on the vaccination status of a potential organ receipt might strike some as odd. After all, there are countless ways to act that might jeopardize an organ’s recipient but which would seem unreasonable to use as exclusion criteria (denying a transplant to someone who enjoys extreme sports, for example). However, it is essential to remember that individuals are at substantial risk from infections post-transplantation as their immune systems are compromised. This is because the body’s immune system sees donated organs as a foreign entity that must be destroyed, causing organ rejection. To help prevent this, organ recipients take drugs to suppress their immune systems. While allowing successful organ implantation, it means that the recipient is at greater risk from infections. Even something as innocuous as a cold can be fatal, and the same goes for COVID-19. With this increased risk comes an accompanying increase in the threat posed to the positive outcome of transplantation. Therefore, a vaccinated person is a much less risky investment than a non-vaccinated person. Given our interest in maximizing the benefits someone will receive from a donated organ, it seems reasonable (even prudent) to make vaccination a requirement for anyone to receive an organ.

David Ferguson has said his son “is fighting pretty damn courageously, and he has integrity and principles he really believes in, and that makes me respect him all the more… It’s his body. It’s his choice.” David may be right. His son may indeed be acting bravely by exercising his right to bodily autonomy in a dire situation, which might make him deserving of respect. But this does little to change the fact that, when deciding who should receive a heart transplant, DJ is a risky investment. If we’re concerned with making sure that the consequences of a transplant are as positive as possible — “positive” meaning conferring the most amount of life — a person’s choice to be unvaccinated must be taken into consideration.

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Hotline Ping: Chatbots as Medical Counselors?

photograph of stethoscope wrapped around phone

In early 2021, the Trevor Project — a mental health crisis hotline for LGBTQIA+ youths — made headlines with its decision to utilize an AI chatbot as a method for training counselors to deal with real crises from real people. They named the chatbot “Riley.” The utility of such a tool is obvious: if successful, new recruits could be trained at all times of day or night, trained en masse, and trained to deal with a diverse array of problems and emergencies. Additionally, training workers on a chatbot greatly minimizes the risk of something going wrong if someone experiencing a severe mental health emergency got connected with a brand-new counselor. If a new trainee makes a mistake in counseling Riley, there is no actual human at risk. Trevor Project counselors can learn by making mistakes with an algorithm rather than a vulnerable teenager.

Unsurprisingly, this technology soon expanded beyond the scope of training counselors. In October of 2021, the project reported that chatbots were also used to screen youths (who contact the hotline via text) to determine their level of risk. Those predicted to be most at-risk, according to the algorithm, are put in a “priority queue” to reach counselors more quickly. Additionally, the Trevor Project is not the only medical/counseling organization utilizing high-tech chatbots with human-like conversational abilities. Australian clinics that specialize in genetic counseling have recently begun using a chatbot named “Edna” to talk with patients and help them make decisions about whether or not to get certain genetic screenings. The U.K.-based Recovery Research Center is currently implementing a chatbot to help doctors stay up-to-date on the conditions of patients who struggle with chronic pain.

On initial reading, the idea of using AI to help people through a mental or physical crisis might make the average person feel uncomfortable. While we may, under dire circumstances, feel okay about divulging our deepest fears and traumas to an empathetic and understanding human, the idea of typing out all of this information to be processed by an algorithm smacks of a chilly technological dystopia where humans are scanned and passed along like mere bins of data. Of course, a more measured take shows the noble intentions behind the use of the chatbots. Chatbots can help train more counselors, provide more people with the assistance they need, and identify those people who need to reach human counselors as quickly as possible.

On the other hand, big data algorithms have become notorious for the biases and false predictive tendencies hidden beneath a layer of false objectivity. Algorithms themselves are no more useful than the data we put into it. Chatbots in Australian mental health crisis hotlines were trained by analyzing “more than 100 suicide notes” to gain information about words and phrases that signal hopelessness or despair. But 100 is a fairly small amount. On average, there are more than 130 suicides every day in the United States alone. Further, only 25-30% of people who commit suicide leave a note at all. Those who do leave a note may be having a very different kind of mental health crisis than those who leave no note, meaning that these chatbots would be trained to only recognize clues present in (at best) about a quarter of successful suicides. Further, we might worry that stigma surrounding mental health care in certain communities could disadvantage teens that already have a hard time accessing these resources. The chatbot may not have enough information to recognize a severe mental health crisis in someone who does not know the relevant words to describe their experience, or who is being reserved out of a sense of shame.

Of course, there is no guarantee that a human correspondent would be any better at avoiding bias, short-sightedness, and limited information than an algorithm would be. There is, perhaps, good reason to think that a human would be much worse, on average. Human minds can process far less information, at a far slower pace, than algorithms, and our reasoning is often imperfect and driven by emotions. It is easy to imagine the argument being made that, yes, chatbots aren’t perfect, but they are much more reliable than a human correspondent would be.

Still, it seems doubtful that young people would, in the midst of a mental health crisis, take comfort in the idea of typing their problems to an algorithm rather than communicating them to a human being. The facts are that most consumers strongly prefer talking with humans over chatbots, even when the chatbots are more efficient. There is something cold about the idea of making teens — some in life-or-death situations — make it through a chatbot screening before being connected with someone. Even if the process is extremely short, it can still be jarring. How many of us avoid calling certain numbers just to avoid having to interact with a machine?

Yet, perhaps a sufficiently life-like chatbot would neutralize these concerns, and make those who call or text in to the hotline feel just as comfortable as if they were communicating with a person. Research has long shown that humans are able to form emotional connections with AI extremely quickly, even if the AI is fairly rudimentary. And more seem to be getting comfortable with the idea of talking about their mental health struggles with a robot. Is this an inevitable result of technology becoming more and more a ubiquitous part of our lives? Is it a consequence of the difficulty of connecting with real humans in our era of solitude and fast-paced living? Or, maybe, are the robots simply becoming more life-like? Whatever the case may be, we should be diligent that these chatbots rely on algorithms that help overcome deep human biases, rather than further ingrain them.

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Should Clinicians Have Soapboxes?

blurred photograph of busy hospital hallway

Despite the tendency to talk about the pandemic in the past tense, COVID-19 hasn’t gone. Infection rates in multiple countries are swelling, prompting some – like Kenya, Austria, the Netherlands, and Belgium – to employ increasingly stringent measures. Unsurprisingly, alongside increasing infection rates comes an increase in hospital admissions. Yet, there’s one trait that most of those requiring COVID-19 treatment share – they’re unvaccinated.

This trend isn’t surprising given that one of the points of vaccination is to reduce the seriousness of the infection, thus reducing the need for serious medical interventions. Simply put, vaccinated people aren’t ending up in hospitals as often because they’re vaccinated. The people who haven’t been vaccinated, for whatever reason, are more likely to have severe complications if infected, thus needing clinical care. So far, so simple.

This tendency for hospital beds to be occupied by the unvaccinated invites questions regarding the burden on healthcare systems. After all, emergency care services are better placed to respond to emergencies – like bus crashes, heart attacks, or complicated births – when their wards, ambulances, and hallways aren’t preoccupied with patients. If those patients are there because of their choice not to be vaccinated, it’s only natural to wonder whether they are equally deserving of that resource-use.

But is it appropriate for those working in the medical profession to voice such concerns? If you’re in the hospital seriously ill, does it help to know that your nurse, doctor, consultant, or porter may resent your being there?

This question’s been brought to the forefront of the COVID-19 discussion because of a recent Guardian article entitled ICU is full of the unvaccinated – my patience with them is wearing thin. In it, an anonymous NHS respiratory consultant writes, “I am now beaten back, exhausted, worn down by the continuous stream of people that we battle to treat when they have consciously passed up the opportunity to save themselves. It does make me angry.” Similar sentiments come from the Treating the unvaccinated article in The New Yorker, where critical care physician Scott Aberegg recounts:

There’s a big internal conflict… On the one hand, there’s this sense of ‘Play stupid games, win stupid prizes.’ There’s a natural inclination to think not that they got what they deserved, because no one deserves this, but that they have some culpability because of the choices they made… When you have that intuition, you have to try to push it aside. You have to say, [t]hat’s a moral judgment which is outside my role as a doctor. And because it’s a pejorative moral judgment, I need to do everything I can to fight against it. But I’d be lying if I said it didn’t remain somewhere in the recesses of my mind. This sense of, Boy, it doesn’t have to be this way.

It’s not unsurprising that clinicians feel this way. They’ve seen the very worst this pandemic has to offer. The prospect that any of it was avoidable will undoubtedly stir up feelings of anger, betrayal, or even injustice; clinicians are, after all, only human. While expecting clinicians not to have such opinions seems like an impossible demand, should they be voicing them on platforms with such a broad reach?

On the one hand, the answer is yes. Entering the medical professions in no way invalidates one’s right to free speech, be that in person or print. Much like how any other member of the public can pen an article in an internationally respected newspaper if invited, clinicians have the right to share their views. If that view concerns their increasing inability to accept the preventable loss of life, then, at least in terms of that clinician’s rights, there is very little to stop them ethically. To try would be to revoke a privilege which many of us would likely consider to be fundamental and, without a robust justification, unassailable.

However, those experiencing the pandemic’s horrors may have more than just a right to share their opinions; they might have a duty. Those working on the frontlines in the battle against the pandemic know better than most the state of the healthcare services, the experience of watching people die from the illness, and the frustration from having to cope with much of it is seemingly preventable. Given that they have this unique knowledge, both from a medical and personable standpoint, it would seem that clinicians have a responsibility to be as honest with the general public as possible. If that means sharing their woes and frustrations about the reluctance of people to take even the most basic steps to save themselves, then so be it. After all, if they don’t tell us this information, it seems unlikely that anyone else is.

But, such a principled stance may detrimentally affect trust in the healthcare system, and subsequently, that system’s effectiveness.

As The Prindle Post has recently explored, shame is a complex phenomenon. Its use in trying to shape people’s behaviors is far from simple. This complexity has been seen in several previous public health concerns where shame has had the opposite effect intended. As both The Wall Street Journal and NPR have recently reported, shame makes for a terrible public health tool as it deters engagement with clinicians. If you believe that you’re going to be shamed by your doctor, you’re probably less likely to go. For smokers and alcoholics, this chiefly detrimentally affects only a single person’s health. During a global pandemic,however,  it means there’s one more potentially infectious person not receiving medical care. Scaled-up, this can easily result in countless people refusing to visit hospitals when they need to – increasing infection rates and preventing medical assistance from getting to those that need it.

All this is not to say that doctors, nurses, surgeons, and countless others involved in the care of the vulnerable should be automatons, devoid of emotion and opinion about the unvaccinated. Again, they’re human, and they’re going to have thoughts about what they see during the course of their professional careers. But whether those opinions should be broadcast for the entire world to read and see is an entirely different question.

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COVID Vaccines and Primary Care

photograph of elderly man masked in waiting room

Dr. Jason Valentine, a general practitioner in Alabama, has decided to no longer treat unvaccinated patients. Starting October 1st, that is. At the beginning of August, Valentine’s clinic made the announcement, clarifying that his personal rule applied to both current patients and new patients. So long as you are unvaccinated, Dr. Valentine will not be seeing you. When asked why he was choosing not to treat unvaccinated patients, Valentine said “COVID is a miserable way to die and I can’t watch them die like that.” In Alabama, the state with the highest number of new COVID cases per day, such a sentiment is understandable. But is it ethical?

As most people know, doctors are bound by a creed called the Hippocratic Oath. The name of this oath comes from the historical figure of Hippocrates, a fifth century Greek physician, to whom the oath is traditionally attributed (although he was likely not the original author). The Hippocratic oath is the earliest-known source of many central idea of medical ethics that we still hold to today: e.g., the patient’s right to privacy, the obligation of the physician to not discriminate between the poor and the rich, and, most famously, the pledge to do no harm.

Doctors today continue to take a version of the Hippocratic Oath, though the oath has undergone major alterations in the past 2500 years. Still, the pledge to “do no [intentional] harm” remains. Major debates have been carried out historically over what exactly falls under the pledge to “do no harm” — that is, under what conditions are doctors guilty of breaking their oaths? More specifically, is Dr. Valentine breaking the Hippocratic Oath by refusing to see unvaccinated patients?

One argument for thinking that Valentine is breaking his oath is that refusing to see unvaccinated patients constitutes an illegitimate act of medical discrimination. Medical doctors have, historically, been stoically determined to ignore unpalatable particulars about the individuals they were treating. For example, during the Civil War, doctors in both the Union and the Confederate armies treated soldiers injured on the battlefield, regardless of their allegiance (excluding, sadly, Black soldiers on either side). During the second World War, British surgeons operated on Nazi prisoners of war, in many cases saving their lives. Under the Geneva convention, doctors are bound to treat soldiers from their army and enemy soldiers impartially — enemy soldiers are not to receive worse treatment or a lower medical priority because of their military allegiance. Surely, then, if the Geneva convention would forbid a doctor to refuse to see patients who were Nazis, it would prevent doctors from refusing to treat patients who had not received a vaccination for a dangerous and highly-contagious disease?

But there is legal precedent that complicates this verdict, as well. Specifically, doctors are allowed to, and do frequently, refuse to see children who have not received their recommended childhood vaccines and do not have a medical reason barring them from receiving vaccines. Reasons for these policies often include considerations of the extreme vulnerability of other patients that the voluntarily-unvaccinated may encounter in the office, including young children who are immunocompromised and babies who have not yet received all of their vaccines. Another consideration is that many childhood vaccines prevent infection from nearly eradicated diseases like the measles. When children are not vaccinated against these illnesses, breakthrough cases stand a higher chance of spreading, thereby resurrecting an almost defeated enemy.

For these reasons, one may be inclined to praise the doctor’s choice. Surely, if people are barred from seeing their general practitioner, this might motivate the unvaccinated to receive the vaccination, and undo some of the damage done by rampant misinformation regarding vaccine safety and efficacy. However, consider a (hypothetical) doctor who refused to treat patients who drank too much alcohol, or refused to exercise. In these cases, doctors would surely be seen as refusing to do their primary job: assuring the health of their patients to the best of their (possibly limited) abilities. Some philosophers, like Cass Sunstein, refer to actions and laws like these as “paternalism”: acts of mild coercion for the sake of protecting the coerced, are sometimes seen as acceptable — seatbelt laws and cigarette taxes are commonly-accepted paternalistic laws aimed at mildly coercing safer behavior. But when the coercion becomes harmful, or potentially harmful, these measures are generally seen as morally impermissible. For example, holding someone at gunpoint until they throw away all of their cigarettes may be incredibly effective, and maybe even good for the smoker in the long-run, but is surely morally wrong if anything is. The difference between paternalistic measures and harmful coercion is usually understood as a difference in potential harm and a difference in the degree of autonomy the coerced maintains. When laws increase the tax in cigarettes, smokers may be mildly financially harmed, but this generally will not amount to anything financially destructive. Generally, they retain the choice between either taking on a small additional financial burden or giving up smoking. In the gun-to-the-head case, the smoker no longer (meaningfully) retains a free choice. She must give up smoking or face her own death. Anything less than compliance, in this case, results in the most extreme kind of harm.

Clearly there will be many instances of coercive measures that fall somewhere between these two extremes. This raises a tough question for Dr. Valentine: does refusing to treat voluntarily unvaccinated patients constitute a case of permissible paternalism, or impermissible harmful coercion? One reason for thinking that such a decision may not result in real harm is the abundance of options of doctors that most people have access to. Surely needing to switch primary care doctors is merely an inconvenience, and not a significant harm. However, there are factors complicating this. Many people have insurance plans that severely limit what doctors they can see. Additionally, if Valentine is allowed to refuse unvaccinated patients, there is nothing stopping all of the doctors in his area from taking on the same rule. Someone may be effectively denied all medical care, then, if all local doctors decide to take up a similar rule. An inability to access a primary care doctor seems like a more severe harm than the instances of mild coercion in the cases of paternalistic cigarette tax laws.

There is no easy ethical analysis to give to Dr. Valentine’s decision. While we can surely sympathize with the protocol, and hope it leads to increased vaccination rates, we do not want large swaths of the general public living without a primary care doctor. Like many other aspects of COVID-19, ethicists here have their work cut out for them mapping brand new territory.

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Who Should Get the Vaccine First?

photograph of doctor holding syringe and medicine for vaccination

As at least one COVID-19 vaccine is scheduled to enter clinical trials in the United States in September, and Russia announced that it will be putting its own vaccine into production immediately, it seems like an auspicious moment to reflect on some ethical issues surrounding the new vaccines. Now, if we could produce and administer hundreds of millions of doses of vaccine instantaneously, there would presumably be no ethical question about how it ought to be distributed. The problem arises because it will take a while to ramp up production and to set up the capacity to administer it, so the vaccine will remain a relatively scarce resource for some time. Thus, I believe that there is a genuine ethical question here: namely, which moral principles ought to govern who gets the vaccine when there is not enough to go around and the capacity to administer it remains inchoate? In this column, I will weigh the pros and cons of a few principles that might be used.

One fairly straightforward principle is that everyone is equally deserving of treatment: everyone’s life matters equally, regardless of their race, gender, or socioeconomic status. The most straightforward way of fulfilling the principle is to choose vaccine recipients at random, or by lot. The trouble with this method is that, although it arguably best adheres to the principle of equality, it also fails to maximize the good. We know that not everyone is equally vulnerable to the virus; choosing vaccine recipients by lot would mean that many vulnerable people would die needlessly at the back of the line.

One way of defining “the good” in medical contexts is in terms of quality-adjusted life years, or “QALYs.” One QALY equates to one year of perfect health; QALY scores range from 1 to 0. If our aim in distributing the vaccine is to maximize QALYs, then we would prioritize recipients for whom a vaccine would make the greatest difference in terms of QALYs. Since the vaccine would make the greatest difference to members of vulnerable groups, we would tend to put these groups at the front of the line. We could also combine the principle of maximizing QALYs with the equality principle by selecting individual members of each group by lot while shifting all members of vulnerable groups to the front of the line.

While the principle of maximizing QALYs would in this way help the most vulnerable, it might be open to the objection that it neglects those who perform particularly important social functions. These perhaps include government officials and workers in essential industries who cannot shelter in place. One justification for prioritizing these individuals would be that since they contribute more to the functioning of society, they are entitled to a greater level of protection from threats to their productivity, even if giving them the vaccine first would fail to maximize QALYs. Another idea is that prioritizing such individuals maximizes overall well-being, rather than QALYs: more people benefit if society functions well than if members of vulnerable groups live longer. In a sense, then, we can view the dispute between the principle of maximizing QALYs and the principle of rewarding social productivity as a dispute between two ways of defining “the good.”

Finally, we might consider using the vaccine to reward those who have made significant contributions to social welfare in their lives, both on the grounds of intrinsic desert and to provide incentives for individuals to make similar contributions in the future. For example, we might decide that, between two individuals A and B for whom the vaccine would make an equal difference in terms of QALYs, if A is a war veteran, retired firefighter, teacher, and so on, then A ought to receive the vaccine first. One troubling feature of using this criterion is that owing to past discriminatory policies, this principle might heavily favor men over women. On the other hand, men may already be favored over women by the principle of maximizing QALYs, since they appear to be more vulnerable to COVID-19.

A final suggestion is just to let the market decide who will get the vaccine. But it’s hard to see how that idea is compatible with any of the normative principles discussed in this column. This method of distribution will not maximize QALYs or reward those who make or have made significant contributions to social welfare, and it seems at odds with the notion that all lives matter equally — in effect, it expresses the idea that the lives of the wealthy matter more.

Here is my proposal, for what it’s worth. If the disease were deadlier and there was not effective basic protection against transmission, then we would have to worry much more about the ability of government and essential industries to function without the vaccine. Luckily, COVID-19 does not pose such a threat. This means that operationalizing the principle of maximizing QALYs probably also would maximize overall social well-being, despite prioritizing vulnerable groups over essential workers and non-vulnerable groups. As I suggested above, we ought to select individual members of groups by lot, so as to affirm their basic equality. And in cases where we would make a roughly equal difference in terms of QALYs, we ought to favor the would-be recipient who has made a significant contribution to social welfare in their lives.

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Life-Life Tradeoffs in the Midst of a Pandemic

photograph of patients' feet standing in line waiting to get tested for COVID

Deciding who gets to live and who gets to die is an emotionally strenuous task, especially for those who are responsible for saving lives. Doctors in pandemic-stricken countries have been making decisions of great ethical significance, faced with the scarcity of ventilators, protective equipment, space in intensive medical care, and medical personnel. Ethical guidelines have been issued, in most of the suffering countries, to facilitate decision-making and the provision of effective treatment, with the most prominent principle being “to increase overall benefits” and “maximize life expectancy.” But are these guidelines as uncontroversial as they initially appear to be?

You walk by a pond and you see a child drowning. You can easily save the child without incurring significant moral sacrifices. Are you obligated to save the child at no great cost to yourself? Utilitarians argue that we would be blameworthy if we failed to prevent suffering at no great cost to ourselves. Now, suppose, that you decide to act upon the utilitarian moral premise and rescue the child. As you prepare to undertake this life-rescuing task, you realize the presence of two drowning children on the other side of the pond. You can save them both – still at no cost to yourself – but you cannot save all three. What is the right thing to do? Two lives count more than one, thus you ought to save the maximum number of people possible. It seems evident that doctors who are faced with similar decisions ought to maximize the number of lives to be saved. What could be wrong with such an ethical prescription?

Does the ‘lonely’ child have reasonable grounds to complain? The answer is yes. If the child happened to be on the other side of the pond, she would have a considerably greater chance of survival. Also, if, as a matter of unfortunate coincidence, the universe conspired and brought closer to her two extra children in need of rescue, she would have an even greater chance of survival – given that three lives count more than two. But, that seems to be entirely unfair. Whether one has a right to be rescued should not be determined by morally arbitrary factors such as one’s location and the number of victims in one’s physical proximity. Rather, one deserves to be rescued simply on the grounds of being a person with inherent moral status. Things beyond your control, and which you are not responsible for, should not affect the status of your moral entitlements. As a result, every child in the pond should have an equal chance of rescue. If we cannot save all of them, we should flip a coin to decide the one(s) that can be affordably saved. By the same logic, if doctors owe their patients equal respect and consideration, they should assign each one of them, regardless of morally arbitrary factors (such as age, gender, race, social status), an equal chance to receive sufficient medical care.

What about life expectancy? A doctor is faced with a choice of prolonging a patient’s life by 20 years and prolonging another patient’s life by 2 months. For many, maximizing life expectancy seems to be the primary moral factor to take into account. But, what if there is a conflict between maximizing lives and maximizing life? Suppose that we can either save a patient with a life expectancy of 20 years or save 20 patients with a life expectancy of 3 months each. Maximizing life expectancy entails saving the former, since 20 years of life count more than 5 years of life, while maximizing lives entails saving the latter. It could be argued that the role of medicine is not merely to prolong life but to enhance its quality; this would explain why we may be inclined to save the person with the longest life expectancy. A life span of 3 months is not an adequate amount of time to make plans and engage in valuable projects, and is also accompanied by a constant fear of death. Does that entail that we should maximize the quality of life as well? Faced with a choice between providing a ventilator to a patient who is expected to recover and lead a healthy and fulfilling life and providing a ventilator to a patient who has an intellectual disability, what should the doctor do? If the role of medicine is merely to maximize life quality, the doctor ought to give the ventilator to the first patient. However, as US disability groups have argued, such a decision would constitute a “deadly form of discrimination,” given that it deprives the disabled of their right to equal respect and consideration.

All in all, reigning over life and death is not as enviable as we might have thought.

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The Ethics of Triage

photograph of empty cots in a medical tent

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.

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Emergency Rationing in Italy

blurred photograph of crowded hospital waiting room

When facing rationing health care resources, how can we ethically make decisions regarding directing care? In answering, we may attend to a famous thought experiment that brings out the tensions of making choices facing lose-lose options: The Trolley Problem. Originally articulated by Philippa Foot in 1967 in order to draw out tensions in utilitarian moral frameworks, this thought experiment has highlighted distinctions in common moral intuitions in domains from bioethics to military ethics. The classic trolley case was posed in a series of cases that press on whether considering the consequences of a presented choice is the correct deliberative path:

“Suppose that a judge or magistrate is faced with rioters demanding that a culprit be found for a certain crime and threatening otherwise to take their own bloody revenge on a particular section of the community. The real culprit being unknown, the judge sees himself as able to prevent the bloodshed only by framing some innocent person and having him executed. Beside this example is placed another in which a pilot whose airplane is about to crash is deciding whether to steer from a more to a less inhabited area. To make the parallel as close as possible it may rather be supposed that he is the driver of a runaway tram which he can only steer from one narrow track on to another; five men are working on one track and one man on the other; anyone on the track he enters is bound to be killed. In the case of the riots the mob have five hostages, so that in both examples the exchange is supposed to be one man’s life for the lives of five.”

This last case has been taken up as The Trolley Problem: a runaway tram must be directed either towards a track with five working men on it or a track with one man on it. Each case is presented in terms where the decision is between an action that results in the deaths of five or the death of one.

Morally relevant features in the deliberation favor different schools of thought in ethics: the consideration in favor of minimizing lives lost highlights the importance of the consequences of the choice, diverting the tram at all may speak to implicating an agent in the deaths (however many result), or, on the other hand, we may think that facing the choice implicates the agent whether she acts or not, or that making a choice between the paths qualifies vicious or problematic because it suggests that lives can be reduced to figures and statistics instead of adopting an appropriate respect for the incommensurate value of human lives.

The confounding tension of these (and likely other) morally relevant features in the trolley problem makes it an ethical puzzle that has stuck with philosophers and non-philosophers for decades. Though it was originally presented to draw out the tensions between favoring the morally relevant consequences of an act and any other features, the difficulty in squaring our explanation for the morally permissible response to cases like the trolley problem has led to various interpretations of moral intuitions and ethical principles in their own right.

For instance, Foot uses the case to discuss the Doctrine of Double Effect, which dates back to Thomas Aquinas in the history of “Western” philosophy. It draws a distinction between what you aim to do and the side effects of your action. If your aim is morally permissible, but it has morally bad effects, the Doctrine of Double Effect delineates when such actions are permissible. If you foresee negative side effects of your choice, but they are not part of your aim, then your choice is morally permissible. If the morally bad effects of your action are part of your aim, or are a necessary part of achieving your aim, then we attribute the effects to your action and it is not morally permissible.

Thus, if you redirect the tram to collide with one person rather than five, this would qualify as a morally permissible action because your aim is not to kill the one person, rather it is to save the five people (or to minimize deaths), and the death of the one person is a foreseen side effect. If the one person did not die, all the better, from the perspective of your aims and choice.

Between consequentialist reasoning (minimize deaths!) and principles like the Doctrine of Double Effect (bad effects are permissible as long as your aim is good and outweighs the bad!), there are multiple ethical frameworks that can make sense of permissible harm, even deaths, that result from one’s actions.

The healthcare choices facing the medical community in Italy are reaching a selection framework similar to the trolley problem. In the case of triage, or prioritizing some patient care over others, the side effects are clearly unfortunate; some people will not be receiving care that they need. Typically, decisions regarding triage prioritize care roughly in terms of first-come, first-served mitigated by severity. But when resources become extreme in terms of scarcity, or conditions become extreme in terms of survival, the stakes change. On battlefields and in the conditions we are seeing in Italy, the situations of need are such that physicians are facing incredibly difficult rationing decisions. By giving resources to one patient, they can anticipate others experiencing significant harm, deteriorating health, or even death.

The reality of the effects of COVID-19 in Italy is that resources have become incredibly scarce remarkably quickly. Resources include staff time and intention, materials like masks and respirators, and space like beds and rooms. There are limited amounts of each, and decisions regarding how to allot them are particularly fraught when lives are at stake.

In an opinion article for the New York Times, medical experts articulated the difficulty facing physicians:

“The goal should be saving as many people as possible, and treating those who are likely to get the greatest benefit from care. This will mean that treatment cannot be allocated on a first-come-first-served basis, as it normally is. Traditionally, patients on ventilators are not displaced for other patients, and later arriving patients can be turned away in a shortage.

But in the coronavirus pandemic, business as usual would make patients with a good prognosis if treated suffer for want of treatment, while patients who arrive earlier but have a grave, or even hopeless, prognosis would receive treatment. Under that standard of care, more lives would be lost.”

The advice here adopts a standard of care that aims to maximize lives saved, similar to the majority of respondents to the Trolley Problem. In crises like the one affecting areas currently hit hardest by this pandemic, the calculation that saves the most lives means an alteration in how we ration care, in how we triage.

A major concern is maintaining the health of those professionals who are treating the ill. Thus, the role of the patient will play a large role in allocating health care. The perennial press for the Trolley Problem is what the physicians are currently facing: “What if the one person on the tracks opposite the five is the leader of a country?” “What if the one person is in charge of their family?” “What if the one person is a doctor?”… Unfortunately, this last question is particularly pertinent. As health care professionals treating the ill are currently in high demand, it is crucial to keep them healthy. Keeping one health care worker able to serve the ill population has ripple effects for the health of the community.

Deciding which principles to adopt in order to protect the health of our communities in the face of this pandemic are going to be difficult. The decision to withhold care is heart-wrenching, and should put pressure on our global community to increase the resources available to those in need to reduce the necessary triage and rationing. Indeed, that is almost always a response when the Trolley Problem is posed – surely, there’s a way out of making this decision. We have a moral obligation to help one another, and as Italy is part of the EU, perhaps the EU is specially positioned to provide aid and resources (and is, perhaps, failing in this duty).

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Questions on the Ethics of Triage, Posed by a Sub-Saharan Ant

an image of an anthill

This article has a set of discussion questions tailored for classroom use. Click here to download them. To see a full list of articles with discussion questions and other resources, visit our “Educational Resources” page.

In a new study published in Proceedings of the Royal Society B, behavioral ecologist Erik Frank at the University of Lausanne in Switzerland and his colleagues discuss their findings that a species of sub-Saharan ants bring their wounded hive-mates back to the colony after a termite hunt. This practice of not leaving wounded ants behind is noteworthy on its own, but Frank and fellow behavioral ecologists note that the Matabele ants (Megaponera analis) engage in triage judgments to determine which injured ants are worth or possible to save–not all living wounded are brought back to the nest for treatment.

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