Photo: CNS Before capitulating to the law of the jungle, it is worth thinking about triage and euthanasia writes Dr Catherine Kavanagh
Discussion is raging all over the internet (which is currently the only place where it can rage) about triage. Anecdotal claims are being made that automatic ‘Do Not Resuscitate’ (DNR) orders are being requested for disabled and elderly people living in managed care situations without any consultation with families or primary carers.
Perhaps these stories are true; perhaps they are not. However, one phenomenon that is certainly present is the reaction to such allegations when they surface. “Eugenics!” exclaim some people, “this is euthanasia. They want to kill off the elderly and the disabled!”
“Not euthanasia at all”, others claim “this is triage: when there aren’t enough resources to go around, we must resocrt to triage, to try and make the best and most ethical use possible of scarce resources”. Such statements are usually followed by some kind of theoretical example: “If a young man and an old person both present at an ICU needing a ventilator, we must give it to the young person, who has years of life in front of him!”
One feels oneself pushed towards either claiming that all patients at all times must be given all resources and all possible treatment, or else accepting the brutal logic of ‘strongest first’. Given that the former is likely impossible, since resources, even in the best managed situations, are finite, it seems that we must all become brutes, and it is alarming just how many people, who, when you object to compulsory DNRs, (if they exist), will now simply shrug it off as inevitable and refuse to think any more about it. However, before capitulating completely to the law of the jungle, it might be worth thinking about triage and euthanasia, and asking if we really need to do this.
The basic dictionary definition of triage is “the sorting of and allocation of treatment to patients and especially battle and disaster victims according to a system of priorities designed to maximise the number of survivors” (Merriam Webster) The original use is military, as the definition indicates, and in civilian situations which present similar problems to those of a battlefield, such as a car accident or some kind of outrage, we also talk about triage. There are different systems of prioritising patients on the basis of need, but all presume an immediate emergency, with a need for very quick decisions. The point to note here is that the goal is to maximise the number of survivors, and to ensure that those who need it most get treated first, and that those who can afford to wait, wait. There are those who will not be treated: those who are already dying, and are unlikely to benefit from treatment, will give place to those who are seriously injured, but will benefit from treatment.
We can see an important principle emerging here: benefitting from treatment. Triage, in any situation, is an action intended to give the best balance of treatment available in an emergency situation, to those who most need it and those who most likely will benefit from it. Need, balance and availability all factor in, but there is no patient whose needs are dismissed because they are no longer deemed useful to society or lack quality of life. Rather, if a patient does not receive treatment, it is because either:
a) He can no longer benefit from it, or
b) Given the availability of resources, including time to respond, someone else, who needs it just as badly, would benefit more.
One can imagine a situation where a few ambulances pull up at an emergency department all needing ICU treatment, but one patient will most likely never recover from the condition, another is likely to make a full recovery, whereas another may recover, but with ongoing problems: it seems reasonable to give the treatment to the person most likely to recover – but that is not to dismiss anyone else as useless, but simply to say that they would not benefit from the treatment.
This situation has been discussed for several decades in medical ethics, obviously not in relation to Covid-19, but in relation to pneumonia, colloquially known as the ‘old man’s friend’. Need a doctor prescribe antibiotics for every patient who comes down with pneumonia? The medical ethicist F. J. Fitzpatrick observes that the answer to that depends on the benefit to the patient: if there is no real benefit to the patient in treatment with antibiotics, then one is not obliged to give it. But if there is real benefit, then one is obliged to give treatment. It has nothing to do with age, but rather with the benefit to the patient. Again, if there are two patients requiring extensive medical treatment, which can really only be given to one of them, then it is the patient who will benefit most from the treatment who should get it. Once again, age is not a factor, but benefit to the patient. Moving on to Covid-19, one can see that the same criteria apply: all patients likely to benefit from treatment should receive it; in the case that there is not enough to go around, then those most likely to benefit most from it should be the ones who receive it.
It is difficult to see where compulsory DNR orders for the elderly and disabled would feature here, since triage is not a matter of anticipating emergencies before they happen, but of applying principles in an ongoing situation, and one cannot say for certain that any given old person or disabled person will necessarily be in a situation where there is another patient who will benefit more from treatment, which then becomes unavailable to them as a result.
However, there has been an increasing tendency in recent years to extend Fitzpatrick’s ‘benefit from treatment’ criterion to much broader quality of life issues. As he points out, ‘quality of life’ is a dangerously ambivalent term: “the phrase ‘quality of life’ can be used to intimate that some people’s lives are worthless, and therefore that we should act with a view to bringing about their death”.
Compulsory DNR orders for disabled and elderly people indicate an excessively narrow conception of ‘quality of life’: the thinking behind them can only be that these people do not have ‘quality of life’ anyhow, and that death from Covid-19 would be a good thing for them. That does look a lot more like euthanasia than triage, since triage aims to save life as much as possible, is not concerned so much with broader ‘quality of life’ issues as with immediate benefit given the resources available, and is not concerned with long-term disability or age. If the patient would benefit, and the resources are available, there is no reason not to treat a patient of 90 years of age, or a Down Syndrome patient, or whatever.
We can all imagine tragic situations where some people cannot be treated because they will not benefit from treatment, or because, given that there is not enough treatment to go around, they will have to yield to someone else who will benefit more, and we can all sympathise with medical personnel who have to make such judgements, which is what is meant by triage. However, it is going too far to assume that some people’s quality of life does not merit access to treatment, even if it is available, and therefore to exclude them from getting treatment before they ever become ill – whatever the situation might be with regard to availability or benefit to the patient or the patient’s wishes. That is to deliberately condemn some people to death, without making any attempt to deal with whatever situation might present itself in real time, and far from being triage, does look very much like involuntary euthanasia.
Dr Catherine Kavanagh is senior lecturer and acting head of the Department of Philosophy at Mary Immaculate College, Limerick.