Who to save: The Ethical Schools on Emergency Room Triage
Can you measure the value of a life?
As hospitals grapple with sparse resources, doctors and healthcare workers are faced with this grim dilemma and others. Who should receive full intensive care? The loving grandmother of many, or the first-year student at the local university? Whose life should be prioritized?
These questions illustrate the challenge of emergency room triage, or the process of allocating scarce medical resources. COVID-19 has reinvigorated debate on this issue, as patients exceed available ventilators in many hospitals. Such sensitive and critical questions require careful thought by both medical ethicists and medical professionals.
Why Ethics?
Ethics is the branch of philosophy concerned with right and wrong conduct. Studying it grants us guidelines for behavior, enabling us to answer difficult questions like the ones above. When lives are at stake, it is not enough to give a flippant answer. There has to be ethical grounding and reasoning for our decisions.
To give us a starting point, I have laid out the basic principles of the three major schools of ethical thought and tried to apply their theories to emergency room triage. The three schools are consequentialism, Kantian or deontological theory, and virtue ethics.
People typically try to answer triage questions with some form of consequentialism. Standard consequentialism contends that an action is morally right if and only if there is no other action that has better consequences. In other words, it selects actions that have consequences that lead to a certain desired outcome. In the case of emergency room triage, this could mean that doctors always make decisions that lead to an outcome like the greatest number of lives saved, or the most years of life saved.
The New York Times reviewed the triage plans of hospitals in states throughout the U.S. Almost all of them gave priority to healthy people who are most likely to recover. This is consequentialism in practice, where recovery rates are the maximized consequence. Yet, why should recovery rates be maximized? A consequentialist approach grapples with the issue of deciding what should be maximized, and who should be able to make this decision. Furthermore, consequentialist approaches contend with the likelihood for discrimination. For example, if we are maximizing recovery rates, those with extenuating medical conditions or disabilities could face discrimination.
One way to answer these questions is utilitarianism, a popular type of consequentialism that tries to maximize total well-being. Well-known utilitarian philosopher Peter Singer favors a utilitarian approach that considers factors like the life expectancy of patients, quality of life, and patient’s ability to help others. Even his approach does not escape concerns of discrimination. How should we measure quality of life? Furthermore, how do we determine someone’s ability to help others? Does an ER doctor or mother of several young children make more meaningful contributions to society? The answer is not obvious or clear.
Consequentialist approaches do offer us concrete metrics to make decisions, yet there is considerable room for debate on what the right metrics are. Furthermore, it inherently assigns some value to a human life in weighing one life against another. Is this right? There seems to be some arbitrariness with any group of humans making such serious decisions. Some may contend it is unethical to attempt to assign some kind of value to human life.
The Kantian or deontological approach addresses this concern. Kant’s guiding principle for behavior is the categorical imperative. A categorical imperative is a moral law that has two key elements: it is unconditional for all agents and its validity of does not depend on any further end. An example would be, keep your promises. Everyone should do it, and it is a good thing to do because it is an inherently good principle. Kant offers four ways of thinking about the categorical imperative: The Formula of Universal Law, Humanity, Autonomy, and the Kingdom of Ends. The Formula of Humanity is particularly important for our purposes. The Formula of Humanity contends that humanity is the objective end of a categorical imperative, or that our motivation for moral laws is our respect for each independent individual. In other words, we should treat other humans as inherently worthy of respect through our moral laws.
Let’s apply this to the consequentialist aim of maximizing number of lives saved. For Kant this violates the Formula of Humanity by using individuals for the end of maximizing number of lives saved, instead of treating each person as an independent being worthy of respect and care. Instead, Kant would seem to believe that medical providers have absolute moral duties to care for every patient. This principle of respect for persons can only be ensured if everyone has an equal opportunity to secure the scarce resource of adequate medical care. This is best accomplished by chance like a lottery or a first come, first serve system. Under Kant’s absolute moral duty, only a lottery system makes sense, as it exhibits no preference for one life over another.
In its most favorable interpretation, this approach can be seen as egalitarian. But it can certainly lead to questions of efficiency and waste. If we are granting everyone equal access, we may squander resources on hopeless cases, while sacrificing the lives of those who had great chances of survival, and the potential for meaningful lives upon recovery.
The final ethical school is virtue ethics. Aristotle is the foundational thinker in virtue ethics.
His criterion of right action is to act as the virtuous person would. How does the virtuous person act? By using his capacity for deliberation to act without excess of defect. The virtuous person is able to identify the relevant details of a situation and exhibit the correct emotions and actions for the given situation. Virtue ethics contends that the codifiability presented by the two other ethical schools is impossible. Moral sensitivity and judgement, shaped by experience, is necessary to properly apply rules or principles.
This emphasis on sensitivity to the details of a particular situation would seem to advocate for a case by case analysis if we apply it to triage. This eliminates the possibility for a codifiable principle to follow. Yet, a codifiable principle is exactly what we need in the case of medical emergencies. Doctors contending with urgent and severe situations have to be granted some kind of general guideline. While the case-by-case specificity required by virtue ethics may be appealing, it seems impractical for an emergency setting. It places an unfair burden on individual doctors and healthcare workers to make split second decisions while trying to carry out their actual medical responsibilities.
So, it seems that there is no perfect answer.
To summarize, consequentialism seems practical but leaves considerable room for debate and contends with the challenge of arbitrarily measuring lives. Deontological theory values each person equally yet could be inefficient and even wasteful. Virtue ethics pays careful attention to each individual case but seems highly impractical and even irresponsible in emergency room cases.
In practice, consequentialism is the favored approach. I can understand why. Triage requires some element of sacrifice, and consequentialism gives us a logical outcome to prioritize. Yet, there does seem to be something wrong about humans playing God, determining who lives and who dies, that makes me keen to consider a more deontological lottery-based approach.
These are incredibly tough questions that our healthcare professionals are contending with on the frontlines of the pandemic. There are incredible organizations like the Stanford Center for Biomedical Ethics and thinkers like Peter Singer trying to answer them and help our healthcare workers make the right decisions as they put themselves in danger every day. I certainly don’t have a concrete answer and it would be wrong for me to think that I can really understand the issue from the safety of my home. But as informed citizens I think it is crucial to understand and think about the real ethical challenges of the pandemic. If it was the life of a family member or dear friend or even yours at stake, how would you want to be treated?