Doctors, nurses and policy-makers may face horrifying decisions if there are not enough ventilators, dialysis machines, high-volume oxygen supports or other components of coronavirus care to go around: whom to give them to and whom to let die.
This isn’t about cases where death is likely to occur anyway or where recovery is likely with or without treatment. It’s about cases where a decision to prioritize one person over another when both need treatment to survive means that the person triaged out will almost certainly die. We owe doctors in Italy respect for facing these terrible decisions, and recognize that shortages could recur in repeated spikes of the COVID-19 coronavirus pandemic here in Utah.
We also owe those patients who will be triaged out – who don’t get the ventilator, who aren’t admitted to the ICU, whose ventilator is withdrawn to favor another patient – consideration, too. What do we owe people who get the short end of the triage stick?
Rights to information: The right to receive an honest account of why you are not being given access to treatment, including any relevant institutional triage plans or societal rationing policies; the right to have your own case considered on its merits, in an individualized assessment, not just as part of a group and the right to current information about rescue therapies and treatment even if you are not being granted access to them. As long as you’re not already so ill that you can no longer comprehend it, the right to know, if you wish, the best available prognostic information about the likely course of your disease.
Rights to personal choice. The right to express consent to exclusion or to protest it; the right to try alternative and unproven therapies, within reason – their safety and efficacy may not be established, but you’re otherwise facing death in any case. Personal choice, as long as you are still capable of it, may include the right to try to enroll in or refuse to participate in clinical trials as relevant, and to know whether treatment you’re being offered, if any, is really part of research, where being randomized to the nontreatment arm is equivalent to being triaged out.
Rights to communication. The right to visits from family members (in protective clothing). This includes a chance to say goodbye, make amends, engage in communication that grief counselors regard as highly important for patients and survivors as well. It also includes the right to visits (in person or by voice or video) from one’s own religious advisor (not just the hospital chaplains, however helpful they may be), from one’s personal attorney, from your coworkers and significant others. Video hookups should be considered an essential part of hospital equipment for a patient at risk of dying. Communication, especially if you are facing death, may be the most important of rights.
The right to a humane death. What counts as humane end-of-life care? There’s hospice and palliative care, and you may want the right to full information about what these involve and whether they would actually be available to you. Would you be given palliative sedation, even to unconsciousness, if your death is very difficult? In some states, there’s medical aid in dying: if this is something you’d want, you’d want full information, waived waiting periods, waived multiple assessments of terminality, and to receive expert assistance in dying. But whoever you are, if you’re triaged against, you’d want no discharge without supportive or palliative care in place.
Even if you’re denied the most effective forms of care, you still want, indeed deserve, care. You must not be simply kicked to the proverbial curb. After all, it is our societal choice, in our triage policies and practices, to prioritize someone else that means you will likely die. We – who could all be in the same situation some day in this or some future calamity – owe it to you, the triaged-against, and also to our future selves.
Margaret Pabst Battin
Margaret Pabst Battin, is an American philosopher, medical ethicist, author and a current distinguished professor at the University of Utah.