We are in triage every second of every day

We are always in triage. I fervently hope that one day we will be able to save everyone. In the meantime, it is irresponsible to pretend that we aren’t making life and death decisions with the allocation of our resources. Pretending there is no choice only makes our decisions worse.

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https://www.wnyc.org/widgets/ondemand_player/radiolab/#file=%2Faudio%2Fxspf%2F655987%2F

Spoilers ahead— listen to the episode beforehand if you don’t want to hear rough summaries first.

I quite liked the above episode of RadioLab. The topic is triage, the practice of assigning priority to different patients in emergency medicine. By extension, to triage means to ration scarce resources. The episode treats triage as a rare phenomenon– in fact, it suggests that medical triage protocols were not taken very seriously in the US until after Hurricane Katrina– but triage is not a rare phenomenon at all. We are engaging in triage with every decision we make.

The stories in “Playing God” are gripping, particularly the story of a New Orleans hospital thrown into hell in a matter of days after losing power during Hurricane Katrina. Sheri Fink from the New York Times discusses the events she reported in her book, Five Days at Memorial. The close-up details are difficult to stomach. After evacuating the intensive care unit, the hospital staff are forced to rank the remaining patients for evacuation, because moving the patients is backbreaking labor without the elevators and helicopters and boats are only coming sporadically to take them away. Sewage is backing up into the hospital and the extreme heat is causing some patients and pets to have seizures. Meanwhile, on the news, the staff hears exaggerated reports of looting and lawlessness in the city. Believing they have no choice, some of the staff begin to think euthanizing the sickest patients (and those hardest to transport for evacuation) may be the merciful thing to do. It is alleged that some patients were euthanized, though no one involved was ever charged. Tragically, the possible killings took place on the same day that the rescue vehicles returned.

The crux of this story is that giving in to the logic of triage put the hospital staff on a slippery slope to “playing God.” The episode goes on to discuss ways of formalizing triage so people don’t have to rely on their own judgment at such a fraught time. (Utilitarian triage is discussed, and you can almost hear the speakers holding their noses.) Very often, concerns for the caregiver’s conscience take center stage, though no one acknowledges how selfish this is. Triage is portrayed very unsympathetically throughout, as if the people being forced to make the choice must be at fault somehow for having gotten in the situation.

But it was the last story that made me want to write this. Sheri Fink, the guest reporter, describes a woman she met in a American-run disaster-relief hospital in Haiti. Nathalie was a charming middle-aged woman whose life was spared because she went to the hospital for difficulty breathing. When the earthquake struck, her entire family was at their home, which collapsed and killed them all. Nathalie was putting on a brave face, just glad to be alive, and she radiated gratitude for the care she had received. But there was a problem. Nathalie needed oxygen, and the hospital (indeed, the nation) did not have enough to go around. Because she was suffering heart failure, the triage nurses had decided she should receive no more oxygen and return to a local Haitian-run hospital, most likely to die. Fink mentions ruefully that the nurse who made the call had never met Nathalie, as if that makes any difference at all. Fink rides in the ambulance with her to the new hospital, where she coughs and sputters and receives no oxygen to help. Fink’s heart breaks. But when Nathalie gets to the Haitian hospital, a clever doctor does what he can to drain the fluid from her lungs and manages to get her through the crisis without supplemental oxygen.

This story reinforces for Fink the fantasy that you never have to choose– that agreeing to choose is already going too far. Fink was so moved by Nathalie that she helped her to get a humanitarian visa to the US. It turned out Nathalie needed a heart transplant, and she died before she could get one. But, Fink says, she was a delight to everyone she met in those hospitals, and she even took up a collection for the other patients back in Haiti. So who were the doctors to say that she didn’t deserve every chance?

This is, of course, the wrong question. Of course Nathalie deserved every chance. No one should have to suffer heart failure in the first place. But did she deserve the oxygen more than all the other people who needed oxygen in that hospital? No. Did Nathalie’s time alive matter more than the greater amount of time the doctors could give other patients by employing the oxygen carefully? Absolutely not.

Nowhere in the episode were the beneficiaries of the triage discussed. There was no attempt to determine how many more people were saved because hospital staff took difficult, decisive action. There is no discussion of who should have died in that situation if not Nathalie– someone with many healthy years ahead of them? two people who could have been saved with the same amount of oxygen?– only denial that anyone had to die at all. There is no gratitude for the extra lives saved– only loss aversion. There is no acknowledgement that Fink would very likely not have wanted any other patient to die, either, had she met them, much less an acknowledgement that people matter whether you have personally met them or not.

Making better choices through conscious triage is no more “playing God” than blithely abdicating responsibility for the effects of our actions. Both choices are choices to let some live and others die. The only difference is that the person who embraces triage has a chance to use their brain to improve the outcome. The suffering of the person who doesn’t receive the scarce resource is no less because you, personally, haven’t witnessed it. When Fink saw Nathalie’s suffering, it should only have informed her as to the gravity of the situation both for Nathalie and for those who did receive the oxygen.

I understand that it’s hard, that we will always instinctively care more for the people we see than those we don’t. There’s no shame in Fink’s deep feelings for Nathalie. They are a key component of compassion. But there should be great shame in letting more people suffer and die than needed to because you can’t look past your own feelings. This is the kind of narrow empathy that Paul Bloom is against.

There are millions of people around the world dying of entirely preventable causes. Why should it make any difference that they aren’t in front of us? You know they are there. They know the suffering they feel. Poverty is a major culprit, as are neglected tropical diseases that could be cured for pennies per person per year. Money that you won’t even miss could be saving lives right now if you put it to that purpose instead of, say, home improvement or collecting action figures. Every decision we make bears on the lives of the myriad others we might be able to help.

We are always in triage. I fervently hope that one day we will be able to save everyone. In the meantime, it is irresponsible to pretend that we aren’t making life and death decisions with the allocation of our resources. Pretending there is no choice only makes our decisions worse.

4 thoughts on “We are in triage every second of every day

  1. A few thoughts. I haven’t listened the the episode, but from the points you covered in this post I don’t understand what it is that you liked about it. Did you like it because it is an important topic, even if poorly covered?

    People are not very good at evaluating trade-offs when emotions are involved. This is not an excuse for poor decisions, but it is a fact about people. Ask people “is child labour always wrong?” and many will answer “Yes, it is”. People more accustomed to thinking about trade-offs in the domain of people will say something like “Well, it depends. What is the cost of a particular child not being allowed to work? Give me an example”. The people in the first group aren’t even under immediate stress, but their emotional reaction results in an answer that will be (arguably) wrong in some circumstances. In general, people also outright dislike assigning value to lives. This is easiest to see around safety policies. We know, for example, that street lighting makes driving at night safer, yet we don’t provide coverage on every single road in the country, because the costs are prohibitive versus the benefits. It’s easy to get folks to agree on a policy that will save lives, but not to see that the very same decision costs lives at the margin.

    I wouldn’t go as far as claiming a materially wrong decision under great stress is shameful, though.

    “Very often, concerns for the caregiver’s conscience take center stage, though no one acknowledges how selfish this is”.

    Clearly the caregiver’s concience shouldn’t take center stage, but it should be part of the equation. The trolley problem comes to mind. In the classic problem, you have to decide whether to pull the switch, resulting in the death of one person and five others surviving that would otherwise have died. Taking that action is a tough choice. You didn’t create the problem in the first place, and so some argue that there is no moral imperative to pull the switch. But let’s say all agree that pulling the switch is the right decision. In a modified version there is no switch, but you can save the five by pushing a bystander in front of the trolley, which is otherwise heading for a calamitious collision. Same arithmetic, but pushing someone in front of the trolley might be much more damaging to the mind of the decision maker than is pulling the switch. The psychic consequences should be taken into account, but that is a more difficult arithmetic.

    Doctors, nurses, and paramedics are trained to carefully conduct triage, beyond their other medical training. Why is there a need for this – they already have the physical medical training? Because it is not easy, and it seems we’re not built for it.

    Even when fairly confident that you know what is the rational thing to do in a given situation, actually doing it when confronted with that situation can be extremely difficult. In fact, it may not even be your fault, having momentarily lost your rational faculties. This seems to be a real phenomenon – it’s ‘fight- or flight- response’, not ‘fight – or flight- or make careful, ethically sound rational decision- response’.

    So, making rational decisions is hard in general, owing in part to our biology. Making rational decisions in dangerous, or otherwise extreme, situations may be even more difficult. Training works, and so we should train people who will find themselves in highly stressful situations to calmly make rational decisions around trade-offs. But it seems we already do that.

    The final couple of paragraphs of yours deal with a related, but different, type of decision – making rational decisions about trade-offs from a distance and when not under extreme emotional stress. They are more like the street lighting and child-labour decisions, for which, of course, slow, careful, ethical decisions can and should be made with high expectations attached to them.

    Good post

    Liked by 1 person

    1. I liked the stories, which were very well-reported. I just thought they were missing the crucial perspectives of *everyone else* involved in each triage situation.

      I wouldn’t go as far as claiming a materially wrong decision under great stress is shameful, though.

      Agreed. Fink wasn’t making the decision about Nathalie, but she was, after months to reflect, condemning the decision of the triage nurses without providing any real alternative. And for healthcare professionals, I would argue, not being prepared to triage is as irresponsible as performing medical procedures for which you were never trained.

      I agree the caregiver’s feelings are *part* of the equation, but rarely enough to change what the outcome should be. The other people involved have their lives on the line, after all. It’s more understandable if a caregiver fails in an emotionally tough situation, of course. But that’s just more reason to hammer home rational, compassionate reasoning before the situation comes up– so that the caregiver’s emotions will be more in line with what they know is right.

      Even when fairly confident that you know what is the rational thing to do in a given situation, actually doing it when confronted with that situation can be extremely difficult. In fact, it may not even be your fault, having momentarily lost your rational faculties. This seems to be a real phenomenon – it’s ‘fight- or flight- response’, not ‘fight – or flight- or make careful, ethically sound rational decision- response’.

      I completely agree. This is why our focus when doctors and nurses are not in fraught situations should be reasoning through what the right decision would have been, not excusing their behavior as compassionate human instincts. That may be true, and people who err in such a situation should forgive themselves, but in the interest of the lives that these people will be responsible for in the future, we can’t just leave it there.

      Training works, and so we should train people who will find themselves in highly stressful situations to calmly make rational decisions around trade-offs. But it seems we already do that.

      We don’t already do this in a satisfactory way. The podcast reflects about the level of ethics training medical professionals receive. It is overly concerned with the welfare of the patient in front of you and very iffy about population level thinking. It encourages doctors to think in irrational, loss averse terms (like it’s worse to “take away” care from someone than it is to never give it to someone else).

      Like

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