Ethics of Triage

The great majority of triage decisions are based on the memory of a protocol in a time of great stress.  In real life it is never as simple as saying run over a dog to avoid hitting 4 people.

The base protocol is to save as many as you can by letting those most likely to die anyway die without any attempt to save them. In this way the lifesaving efforts are directed to those with the best chance of surviving longer term.

It was reported during March 2020 that in northern Italy as the health system was overwhelmed by Covid19 patients triage was for ventilators was based on age and that at one stage people over 60 were denied ventilators so they could be given to younger people who needed them and the allocation decision was being made by front line medical staff without benefit of a protocol as none had ever been needed before for this type of decision.

This can lead to long held feelings of guilt for the person making the decision and affect their willingness or ability to continue in their career.

To protect the mental health of the person making the decisions, a protocol is determined in advance and those making the final decision they are told that they are not making the decision to let someone die, they are merely following a policy determined by others that is fair and reasonable in difficult circumstances.

Some take all human consideration out of the decision by making selection of those who get lifesaving treatment by some form of lottery. Every patient in the hospital on a respirator and those waiting for a respirator are given a number. A means of "drawing lots" is used to see who wins or loses respirators. Respirators are given to those who win (or don't lose).

Another such way is simply first come first served. If you need one you go in the queue and if you are lucky someone with a respirator gets better or dies and you get there respirator. If you are unlucky you die before you get to the top of the queue and a respirator becomes available.

Both of these methods can result in saving the life of an old sick person with advanced dementia over the life or a newly qualified intensive care specialist, MBA, Ph. D. or budding Mother Theresa and this imposes a significant cost on society as a whole. There has to be a better way.

An economic rationalist would say what is the amount this person can contribute to production of valuable goods and services in the future versus how much they are expected to need support from the rest of society over their lives? Anyone in paid work would be saved in preference to someone not expected to do unsubsidised paid work  in future and even moreso if they are on any form of government benefit.

Age as a determinant can be an independently verifiable way to triage in a hospital setting and estimating age can be a "quick and dirty" way to triage, but with many errors at the margin. Those that look old are offered whatever palliative care is available if any and those that look much younger will get the ventilator and hopefully be saved (although a large proportion of patients who are put on an invasive ventilator (ie intubated) do not survive.

However some young people have diseases that limit their life expectancy severely, while some older people have long productive years of life in front of them.

Also, among older people there can be significant differences in life expectancy. Cancer and heart disease for example can mean a very low life expectancy for a younger person than an older healthier person has. Between two older people a smoker may have a lower life expectancy than a non-smoker  or a mature person with diabetes, hypertension, coronary artery disease and early stage dementia may have a lower life expectancy than an older person in good health.

So, if the goal is to maximise the overall benefit to society perhaps the expected disability adjusted life years is a better measure. But what about parapalegics? How is their disability taken into account? Does it matter if they caused it themselves eg by crashing a motorbike at high speed on the wrong side of the road? What about if skydiving? Or hit on a pedestrian crossing  in broad daylight by a car driven by a drunken drug addict that ran a red light in an unregistered vehicle?

Can people coming into hospital be given a point score on admission that takes all the circumstances listed above into account? How long would it take? how much would it cost to administer? Could you appeal? Could the dependants sue if the calculation was performed negligently and the person died for lack of a ventilator or an operation?

From the point of view of practical application the decision in accordance with the protocol has to be able to be made quickly and in accordance with the protocol by the front line worker. Society and the front line medical worker are both concerned that the perfect does not become the enemy of the good.

In a hospital setting, sometimes the decision can be made by the patient even if not conscious or having mental capacity through the application of a living will made previously by the patient. Examples are "Do Not Resuscitate" directions. There are also directions that the patient is not to be either put on or kept on life support for more than eg 5 days if they meet certain criteria. The criteria can be certain illnesses, prognoses or statuses. It could also be that certain other medical treatments are to be withheld based on certain criteria. A signed, witnessed living will and an enduring power of attorney copied to family members can make clear who is to make the decisions and in what circumstances they have discretion and in which circumstances the living will must be followed. This can relieve the front line medical staff of having to make any triage decision at all in most cases and also ease the making of difficult clinical decisions.

In many ways however the "best" triage decision is likely to be made by a senior medical practitioner who has thoughtfully considered all the above issues in advance and to relieve that burden age is a good but imperfect proxy for rapid estimation of societal benefit when overlaid over the clinical decision of who is most and least likely to survive in the medium term.