Disaster Ethics & the Trouble with Triage
"Pandemics are uniquely destabilizing." Matthew Lee Anderson, founder of the journal Mere Orthodoxy, gave a presentation on the imago Dei and the value of a life at The Center for Bioethics & Human Dignity's virtual conference on June 26, 2020. The West, he said, derives its idea of human rights from the concept that men and women are made in the image of God, and therefore have intrinsic value and worth. From this, we can determine ethical norms on how a patient should be treated in a medical setting. Those norms, however, get turned on their heads in a triage situation.
During a disaster—whether a natural disaster, armed conflict, or pandemic—the medical infrastructure can become overwhelmed due to the sudden surge of patients requiring medical care. When this happens, decisions must be made as to who receives limited supplies or who will be treated when there are limited numbers of medical personnel. At times, rather than receiving the normal standard of care, a patient is merely stabilized. Treatment may have to wait until supplies or personnel become available. In the direst circumstances, some patients may be given comfort care because their death is imminent.
Normally, the physician's priority is to care for the particular patient. In a surge situation, the priority changes to saving the most lives. As Dr. Cheyn Onarecker, who serves on the triage team at St. Anthony's Hospital in Oklahoma City, said in his presentation at the conference, this shift in priorities cuts to the very core of doctors' values and can lead to mental harm.
In a pandemic, which is less localized and less temporally bound than a natural disaster, hospitals will go from having adequate resources one week to repurposing other wards and triaging supplies another week. Dr. Aaron Kheriaty, in his article on the impossible ethics of triage situations in The New Atlantis, points out:
This one unsettling fact always remains to haunt us: If hospitals exceed their surge capacity, patients who otherwise would have lived will die. Lives will be lost simply because we lacked the resources to offer everyone the basics of modern medicine.1
The difference of one week may be the difference between surviving COVID-19 and dying from it. To a patient and his family, this can feel like a cruel injustice.
Outside of the hospital, governing bodies have to balance the harms done by not imposing some kind of quarantine or stay-at-home measures on the populace and the harms done by stifling the economy, which can be particularly devastating to the poor. U.S. leaders felt this tension in June, when cases increased. As the British magazine The Economist put it, the U.S. had too many cases to open safely and not enough cases to justify fully remaining in lockdown.2
Either option comes with harms, which is the nature of disaster ethics. The same is true in the hospital setting, and even in our personal lives. Choosing to isolate ourselves from loved ones in long-term care facilities may be the right option to protect them from getting COVID-19, but isolation and loneliness come with their own set of mental and physical problems. Even when all appropriate actions are taken to mitigate harms, a pandemic creates a context where options come with a moral cost.
Deliberating Between Wrong & Wrong
A friend of mine, who teaches ethics at a local university, said ethics is not really about deliberating between right and wrong, because if something is clearly right, that is what one must do. Rather, he says, ethics is about deliberating between wrong and wrong. Even in our pluralistic society, where objective right and wrong are no longer a given, my friend had a point: the most difficult ethical discussions are about how we mitigate wrongs.
This comes into clear view when we encounter a disaster scenario. What is the right course of action, considering that harm will be done no matter what one chooses to do?
As an example, let's assume that three patients are admitted to the ICU with severe COVID-19 symptoms. All three are struggling to breathe and require ventilation. There are only two ventilators available. How do you decide who gets a ventilator? Certainly there are protocols, such as ensuring that the third patient is given oxygen and other types of standard care, but that patient may very well die because there are not enough ventilators. Any criteria you use would entail discrimination of some kind, whether based on age, disability, behavior (e.g., smoker versus non-smoker), or some other factor.
Some argue that medical personnel should get preferential treatment when medical supplies are limited. After all, saving one doctor may allow him to get back into the fray and save other patients. But as Dr. Kheriaty asks, what about police officers or janitors or food service workers? Or the lead scientist working on a COVID-19 vaccine? Are their jobs any less vital than the medical worker's? Then there are the long-term ramifications of those decisions:
In any case, if we consider some to be indispensable in this hour, does this not imply that others—the artists and poets, the homeless and unemployed—are dispensable? How will such practices shape our attitudes and impact social solidarity once the virus is gone and the dust has settled?3
Even in the face of impossible ethical choices, it doesn't mean we give up altogether. In times of limited resources, there are some ethical norms we can turn to. First, limited medical resources should go to those who have the most immediately severe cases but who are also the most likely to survive if given treatment.
Second, standards should be in place for those in at-risk groups. For example, an older person with diabetes may benefit from taking a particular drug while in the ICU, whereas a younger person with no underlying conditions may find that same drug less beneficial. The older person, therefore, should receive the drug first.
Third, according to Dr. Onarecker, criteria such as age, chronic disease, or disability should not be used to exclude patients from access to critical services. Some bioethicists say that in certain triage situations, it is permissible to use selection criterion, such as prioritizing medical professionals, because they knowingly put themselves in harm's way and they can later help save other patients. One could make this case for medical professionals who had not been equipped with proper protective equipment but still cared for patients. But discriminating on the basis of age, disease, or disability can veer into stigmatization rather than selecting the most "appropriate" patient to put on a ventilator.
Fourth, Dr. Onarecker recommends not having the triage decisions be made by the attending physician because the physician's duty is to treat the patient. Someone else, such as a triage officer or triage team member, should make the decisions as to who gets treatment. From the patient's perspective, this helps maintain patient-doctor trust.
Living with the Unfairness of a Pandemic
Ethical deliberation and enumeration of norms is one thing. Living with what is ethically sound is another.
Some doctors and nurses have reported on the fear they feel when they go into work. Some isolate themselves from their families because they do not want to spread the virus to their loved ones. Other medical professionals must contend with the fact that their neighbors protest against wearing masks or obeying lockdown orders, while they wish they had more protective equipment and could safely see their families. Some have had to tell patients' families that their loved ones will not be put on ventilators because there are none left. Many doctors end up with PTSD or moral injury.
From the patient's perspective, it can seem unfair. I had a small taste of what it is like to potentially be re-prioritized because of limited medical resources. I live in Dallas, and Texas saw some of its worst numbers for the pandemic at the end of June. On the Thursday before the CBHD conference, Governor Abbott signed an executive order mandating that all elective surgeries in Dallas, Harris (Houston), Travis (Austin), and Bexar (San Antonio) counties be halted until further notice to provide additional space for the increase in COVID-19 patients. In this case, "elective" meant "not immediately, medically necessary to correct a serious medical condition or to preserve the life of a patient who without immediate performance of the surgery or procedure would be at risk for serious adverse medical consequences or death, as determined by the patient's physician."4 Surrounding counties would be ordered to follow suit if more hospital space was needed.
This order came thirteen days before I was scheduled to have surgery to remove the remainder of the cancer doctors had discovered in my abdomen in March. My situation was not life-threatening, although it was medically necessary, placing me in that blurry space between "elective" and "immediately necessary." I did not know if my surgery was going to be de-prioritized and rescheduled to a later time.
As of this writing (June 29), I am still scheduled for surgery, but that could change in the next week, depending on the needs of both COVID and non-COVID patients. My situation is mild compared to that in places like New York. I cannot imagine how many patients and their families felt when they were placed in a potentially fatal triage situation because there was too little room or too few ventilators. Undoubtedly it must have felt incredibly unfair.
At the end of the day, the triage situation isn't fair. In a fallen world, there are times when we cannot fully live out the principles we know are right because one principle—such as caring for one patient—conflicts with another principle—such as saving as many lives as possible. For all of us in our respective situations, this conflict of principles hurts.
I think this pain fuels the anger we see on the news, at our jobs, in our churches, and even among family members. One pastor I know said that anger is a secondary emotion that comes out of fear, hurt, or frustration. A pandemic caused by an unknown virus breeds these emotions, but in the midst of this destabilizing situation, there are truths that remain stable. One of these is that every human being, whether he or she is elderly, or has underlying conditions, or cannot be placed on a ventilator, has inherent dignity found in the imago Dei.
1. Aaron Kheriaty, "The Impossible Ethics of Pandemic Triage," The New Atlantis (Apr. 3, 2020): thenewatlantis.com/publications/the-impossible-ethics-of-pandemic-triage.
2. "Decoding the confusing messages of the coronavirus epidemic in America," The Economist (June 27, 2020): economist.com/united-states/2020/06/27/decoding-the-confusing-messages-of-the-coronavirus-epidemic-in-america.
3. Kheriaty, ibid., note 1.
4. Governor's office press release (June 25, 2020): https://gov.texas.gov/news/post/governor-abbott-issues-executive-expanding-hospital-capacity-order-suspends-elective-surgeries-in-four-texas-counties.
has an M.S. in chemistry from the University of Texas at Dallas, and an M.A. in bioethics from Trinity International University. She resides in Dallas and currently works as a freelance science writer and educator.This article originally appeared in Salvo, Issue #54, Fall 2020 Copyright © 2020 Salvo | www.salvomag.com https://salvomag.com/article/salvo54/unfair-care