Friday, January 20, 2012

Triage

There has been some discussion of the recent case in which the Children's Hospital of Philadelphia was accused of denying a three-year-old girl a kidney transplant solely on the basis of mental retardation. (The Hospital has apologized, and the parents have since suggested that it was perhaps merely one doctor rather than the hospital as a whole.) One thing I have noticed is that several people have raised the issue of triage as a defense of the original decision; some of these are interesting arguments, but unfortunately most of these appeals to triage principles don't show an understanding of what triage actually is.

The entire point of triage is that only need is considered. Triage systems were originally developed in a military context when field doctors started giving medical treatment not on the basis of rank but on the basis of need, as determined by purely medical criteria. This is what genuine triage is: it is a system, operating under a scarcity of resources significant enough to require careful discrimination of who actually receives those resources (most clearly in emergency or disaster, but resources do not necessarily have to be anywhere near that scarce to become an issue), where distribution of those resources is done purely on the basis of actual medical need according to established principles that only consider medical issues. Remember, it has always been the case that doctors have had to make hard choices based on scarce resources. Actual triage systems only developed when the principles governing those choices were no longer official rank, social status, subjective assessment, or any other nonmedical criterion. We can call those other resource-management systems 'triage' in a loose sense, but they are radically different for moral purposes, and cannot all be lumped together as if the justification for one were justification for another. Just as genuine triage management cannot, by its nature, be indiscriminate in the use of medical resources, so it cannot, by its nature, take into account anything other than medical need. And precisely the reason why triage is an important ethical as well as medical concept is that it operates in conditions of necessity according to principles wholly geared to dealing with the necessity; it's the medical necessity, and the proportion of means to the end of dealing with that particular necessity, that justifies triage decisions.

Precisely one of the worries in this case -- and whether it is right or not, the issue needs to be taken seriously -- is that we here have a case in which the discriminatory principles were not purely concerned with medical need, but involved making subjective or merely pseudo-objective judgments about something like future quality of life. If this were in fact true, it would mean that the system was not a genuine triage system, and that triage principles could not justify the action. Mere scarcity of resources and the need to make hard decisions is not enough; and you can only defend an action on the basis of triage principles if the principles involved were real triage principles. This is something that requires investigation, and cannot be merely assumed.

2 comments:

  1. alqpr3:52 AM

    <span>I think of triage more as referring to the general process of resource allocation than to the principles of a particular triage system, so I don't think it is correct to refer to triage based on principles one disagrees with as "not a genuine triage system".  </span>
    <span> </span>
    <span>Also, the principles of triage that I was taught to apply many years ago when I took an EMT course, and which I believe are still current, include probability of survival as well as need. Since temporary stabilization to briefly defer an almost certain death would not rank highly as a priority in this scheme it actually includes expected duration of survival as a criterion. Quality of survival is not far beyond that - ie do I attend to the non-breathing broken neck who given artificial respiration may well survive as a quadraplegic on a heart lung machine over the torn femoral artery which needs an immediate tourniquet and might well die from loss of blood before I can complete it? And the slippery slope soon leads to prospective quality of life on other  "medical" grounds as well. To include such things might not be what we want to do, and that is definitely worth discussing. But the important issue is what we should consider the right thing to do, not whether it's right to call it "triage". </span>

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  2. branemrys9:39 AM

    Yes, that is a common figurative use of the term. It is not, however, historically correct -- triage was historically a deviation from prior resource allocation approaches, and therefore this figurative use of the term ends up including the very systems that triage was developed in order to replace. And it is equivocal in two ways. The first is that it equivocates among endlessly many completely different systems. And the second is that it equivocates between descriptive and normative uses; your comment in fact brings this out quite clearly, since it leads to make a mistake that would be obvious with more careful use of terms. If triage was only of interest as a matter of medical economics, then it would make no moral difference whether one uses the term strictly or loosely. But triage is also itself a matter of ethics, as is shown (among many other things) by the fact that it was used in the way it was in this case. Triage decisions were originally justified because medical necessity is in almost every case a superior justification to every other -- there are arguably superior ways of allocating resources, but they are very hard to do on a large scale. And thus triage is itself an ethical as well as a medical concept, and the ethically relevant triage is distinctive from other resource allocations. This ends up being important in a number of ways, perhaps the most important of which is that there are no slippery slopes in triage in the proper sense: every slippery slope is blocked by practical medical necessity arising from the immediate problem. There are still hard choices; but it's only the same medical necessity that makes the luxury of slippery slope impossible that justifies them ethically. You can't have both, and this is true even outside of this particular case: you can't have slippery slopes if your reasoning is governed principles about what is necessary. No form of necessity, whether strict logical necessity, or deontic, or any other kind, involves slippery slopes; it's just a logical category mistake to put them together.

    In any case, it is silly, and with all due respect, it is really, really silly, to claim that it doesn't matter "<span>whether it's right to call it 'triage'" when the explicit occasion of the post was that people were justifying the decision by classifying it as triage. But it shows again why it is often better to use the term correctly instead of sloppily; it leads intelligent participants like yourself to make the (frankly absurd) mistake of confusing loose figurative and strictly ethical senses of the term, as you do here in refusing to make the distinction between the ethically justifying sense of triage, which was explicitly in view, and loose senses of triage arising from the fact that they are ways of dealing with situations associated with triage in the proper sense.
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