The Covid-19 pandemic is forcing us to look again at the ancient dilemma of triage. Which patients should get priority when there is a shortage of medical equipment and personnel?
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Two preliminary comments. First, it is totally unacceptable that a rich country like the U.S. would have a shortage of ventilators, protective clothing, diagnostic tests, and other medical provisions. In a society deluged with consumer goods, there is absolutely no excuse for a shortage of swabs for Covid-19 tests. Worse, we seem unable to address the shortage adequately even after several weeks. In the meantime, those on the front line—including medical workers, cleaners, grocery employees, warehouse workers, and delivery persons—must risk their health and even their lives to perform their duties. This is outrageous and unforgivable.
Second, ethics does not answer all our questions. It can only provide a few necessary conditions for conduct that enables us to live together. Even when ethics has something to say about triage, a detailed policy requires medical expertise I don’t have. I can only suggest some features that would characterize an ethical policy. Click here for a deeper discussion of triage from my book, Taking Ethics Seriously.
The autonomy and utilitarian principles are most relevant here. The autonomy principle implies that patients who we are sure would die or suffer permanent impairment without treatment, and who we are sure can be saved from death or permanent impairment with treatment, should receive absolute priority over other patients. If there are not enough resources to treat all patients in this category, ethics provides no guidance for prioritizing them, except that saving lives is generally more important than avoiding impairment.
The utilitarian principle applies to patients who are not in the category just described. Roughly put, the classical principle asks us to prioritize patients in a way that is most likely to maximize total net benefit. This means we must take into account the probability that a treatment will benefit a given patient, and how much net benefit will result. However, there is no ethical imperative to maximize utility in a thoroughgoing and strict sense. For example, curing millions of people of the sniffles may create more net utility than curing a few people of malaria, but it is not the ethical choice. Also, there is no clear ethical imperative to maximize total quality-adjusted life years, which could give priority to younger patients. This may be an appropriate consideration for long-term policy planning, but not necessarily for triage situations.