The process of triage in an emergency medical situation is inherently complex and typically insoluble to any truly satisfactory degree, when resources are limited and need exceeds them. Choices must be made urgently, and these decisions are literally of a life-and-death order. Such choices involve medically-based ethical considerations which in turn are tempered by the larger realm of societal ethics, along with a necessarily pragmatic assessment of immediate viability and estimations of outcomes.
The scenario presented deals with an influenza pandemic in a major, metropolitan hospital. Ventilators are in short supply; two are available, but four patients require them. Meanwhile, four other patients have been on ventilators for ten days, and it must be determined which, if any, of them may be removed from the desperately needed machines. The following will address all cases and renders decisions based on both medically specific and ethical concerns.
Existing Cases on Ventilators
A stroke victim, a near-drowning victim, a patient with traumatic brain injury, and an elderly female with drug-resistant pneumonia comprise those currently using ventilators. As will be evident, any dichotomy between actual medical states of the patients and the relevant ethics becomes blurred upon the examinations of these cases.
For instance, despite a few influential factors, it is clearly not advisable to remove any of these patients from the existing treatment. Circumstances, however, compel that selections be made, or at least seriously considered in this situation wherein two ventilators are required. Before taking into account the needs of the new patients, then, it is best to assess these four; the issues are complex enough, without the additional burden of the exact and pronounced needs waiting.
The first assessment made goes to the elderly woman, and her age is very much a factor. While the ethics of triage would prefer to not distinguish by age, the reality is that virtually every culture exerts more efforts to better care for the young: “Priority should be given to protect people with the most years of life ahead of them” (Boylon, 2008, p. 11). It is not that the elderly are viewed as disposable, but the hard pragmatic realities of a society are unavoidably utilitarian to some degree, and the elderly have essentially fulfilled the greater part of their role in the society.
It must be stressed, again, that this determination to remove the woman from the ventilator is not based on known, individual factors of the waiting patients, for such influences would compromise already undesirable ethical considerations. It is merely necessary here to rely on the accepted, if disagreeable, necessity as acknowledged by the global medical community. It may be that “…The limited value placed on the elderly and their corresponding limited access
to certain lifesaving medical resources are largely the product of various cultural
and religious values” (Kilner, 1988, p. 413), but the consequence is unaltered, as those values must vastly influence the medical ethics.
Also of note in this decision is that the woman does not respond to drug treatment. This component has, in fact, been identified as a deciding factor in such emergency cases. Dr. John Hick of the Hennepin County Medical Canter in Minneapolis was among the first to isolate triage specifications and utilization criteria in cases of ventilator shortages, and he developed a Ventilator Triage Tool. The criteria are relatively basic, and point to extreme circumstances where the probability of survival is small, but this situation is referred to in it: “…Multisystem organ failure, failure to respond to mechanical ventilation and antibiotics after 72 hours in context of a biological pathogen…” (Reilly, Markenson, 2011, p. 416).
Having enabled another ventilator, three are now available for the four new cases. At this stage, then, with only an urgent need for one more ventilator, the wisest course is to now examine the needs of those new cases. The gaining of that single ventilator allows for an ethical “breathing space” of sorts; in so difficult an arena, the only just process is to then survey and contrast the seven remaining cases and identify the greatest need within them.
New Cases and Comparisons
In terms of ethics, one situation is rendered relatively easy here: a six year-old child needs a ventilator, and this child will be put on the machine formerly used by the elderly female. As noted earlier, the single element typically agreed upon in cases of triage is that youth takes priority, and no society does not automatically do its utmost to protect the health of its children.
This leaves a nineteen year-old currently in leukemia remission, a thirty-year-old mother of three, and a middle-aged man with no family. Further information is provided, in that the older man owns a business, the leukemia victim has a history of extremely poor performance in school,
and the mother is unemployed.
Unfortunately, once extremes of age are dealt with, the issues of quality of life and societal value come into play, and these are intrinsically ethical dilemmas. It is invariably an unsatisfactory process, as the ethics are seemingly self-defeating; a greater, humane good is being sought through a clinical, matter-of-fact evaluation: “In contrast to the ethical basis of other aspects of health care…the ethics of triage is widely considered to be utilitarian” (Ashcroft, et al., 2007, p. 634).
This understood, it appears that the next candidate for a ventilator should be the mother of three. That she is unemployed is not especially relevant, as caring for three children would, in fact, make employment detrimental to this more vital role. In terms of society’s values, it is essential that she be cared for, before the nineteen year-old and the businessman.
Of those two remaining new and urgent cases, then, the question becomes: which, if either, of them is more entitled to the single, remaining ventilator, or is more deserving than the existing cases? Beginning with the young Leukemia victim, school performance seems an extraneous factor; illness may have played a role in that, nor is it necessarily indicative of the individual’s potential. So, too, is the middle-aged man’s business not especially relevant. It is useful to society but should not be a determinant in assessing his need for care, as his business practices may be personally mercenary and not of great societal value.
Of the existing cases, it is evident from an ethical standpoint that the drowning victim should be maintained on the ventilator. That was a life-saving measure, and it would be unconscionable to withdraw it. As regards the other victims of stroke and traumatic brain injury, nothing else is known. There is, again, no ethical “happy ending” here. However, considering all relevant factors, the most ethical course to take is to leave the remaining original three patients on the ventilators and to assign the last free one to the nineteen year-old, by virtue of the age factor. Moreover, that the leukemia is in remission greatly lessens its potential for being fatal in so young a person.
None of this decision-making is to imply a greater notion of “worth” in these patients, nor to determine that they are inherently more valuable than the business owner. Ultimately, and as with the drowning victim, the first two people on ventilators evince signs of recovery. Treatment has been administered and, the urgency of new cases notwithstanding, to remove their ventilators would in fact imply a choice made based upon speculated qualities of life which cannot, in these cases, be sufficiently ascertained.