In a recent article in The Atlantic on-line magazine (March 11) writer Yascha Mounk provided commentary on guidelines published by the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). Mounk explains that this document likens “the moral choices Italian doctors may face [concerning the COVID-19 virus epidemic] to the forms of wartime triage”. Mounk describes how the document recommends the utilization of “distributive justice” and “the appropriate allocation of limited health resources.”
Mounk declares that the methodology of justice applied by the college is “utilitarian”. This is the idea that the morally right action is the one which produces the most good. He quotes the college’s position on distributive justice to be: “those patients with the highest chance of therapeutic success will retain access to intensive care.”
Now if you are of a suspicious nature and the hair stands up on the back your neck when national doctors’ groups proclaim themselves ethicists, then you may have already guessed correctly what comes next: “It may become necessary to establish an age limit for access to intensive care.” Just in case the physician group’s statement remains unclear here is Mr. Mounk’s full translation of it: “Those who are too old… or who have too low a number of ‘life-years’… would be left to die”. Mounk informs us further that not only age but “comorbidity” – the presence of more than one illness occurring at the same time in the same person – will also be “carefully evaluated” by the doctor to determine who might be more likely to die. However, when the decision is made as to who lives or dies based on available resources, those who “require a greater share of scarce resources” i.e. “older or more fragile patients”, would be on the top of that list.
Mr. Mounk then proceeds to make his case in support of the doctors’ college. He does so by posing his argument in the form of question: “If you are an overworked nurse battling a novel disease under the most desperate circumstances, and you simply cannot treat everyone, however hard you try, whose life should you save?
This would seem a mind-bending question if it did not open with an entirely false assumption: that nurses, overworked or not, ought to be calculating who lives and who dies. The problem with Mr. Mounk’s thesis is that it presupposes that doctors and nurses have, by virtue of their profession, a right to decide who to save and who not to save. They don’t.
Let us begin with triage. Triage is not for deciding who lives or who dies. Triage is primarily for assessing the wounded, a lot of wounded, for the purpose of deciding the order of treatment, not the order of dying.
As for “utility” and “distributive justice” the college’s use of these terms is distortive. First of all, distributive justice is not solely about the distribution of resources to individuals based on someone’s determination, but about a guarantee to the individual that the privileges of society will be equitable and unbiased and that everyone in society will share not only in the common benefits but also in the common burdens. Further, the “utilitarian” concept is not only concerned with the greatest good for a society; it is also concerned with the impartial good of everyone. This is how the Stanford Encyclopedia of Philosophy explains utility: “Everyone’s happiness counts the same”.
Should there be an age limit on access to intensive care? Is this the way it really works in wartime? Are the older, wounded officers put at the bottom of the list for emergency surgery because they are older? Do the doctors stand around and say, “Well, this fifty-year old major is a chain-smoker with severe hypertension. Leave him to die and bring in the private first class”!
Is the doctors’ recommendation of screening-out who lives by age and pre-existing condition so preferable to “first come – first serve” as they claim? When an eighty-two year old man with diabetes presents with COPD needing a ventilator and three devices are still available, do you refuse him one because you are expecting a few younger COVID-19 patients to come through the door? Their “utilitarian” approach would say so.
We readily grant that doctors and nurses have an agonizing job in times of disaster and limited resources. I believe that in such circumstances they do their best to treat everyone. However, as healers they should not be strategizing beforehand about who lives and who dies over resources, especially as this strategy does not even mesh with the ideas of utility and distributive justice that make up their strategy. Doctors must decide in times of crisis. We want to trust their decisions. Yet they appear lest trustworthy when they are wont to withhold care based on a predetermination against age and fragility.
More than one week after reading Mounk’s commentary, I watched a video of intensivist doctors and nurses working in the busiest hospital in Bergamo, the Italian province hardest hit by COVID-19. I was impressed by the dedication of these caring professionals to treat every patient that comes to them. They may have been forced to turn their ER into an ICU, but they have not been moved to follow the guidelines of the SIAARTI.
If this Italian college of doctors is truly concerned about justice, it should rewrite its proposal and begin with communitive justice. This form of justice regulates the rights between one person and another. As a virtue it is most suited to the patient/doctor relationship: two human beings, meeting face-to-face, not hiding behind policy. Hence, through an honest, compassionate conversation about his terminal condition the critical care patient (or he holding proxy) may even decide to give up his just claim to a ventilator for the patient next to him, in exchange for the doctor’s pledge to try to keep him comfortable. Then, medicine will not only be about justice and utility, but about love and fidelity.
-Steve Guillotte, Director of Pastoral Services