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The cruelty of "triage" : The moment when corona doctors decide about death

In Italy, doctors, nurses and orderlies work on the verge of exhaustion - and sometimes beyond. The intensive care units are overloaded, there is a dramatic shortage of beds and ventilators, the mortality rate is very high, and 369 people infected with Covid-19 died on Sunday alone.

The resources are insufficient, the number of patients continues to grow: in order to help doctors with their decisions in this extreme emergency, the Italian Society for Anesthesia, Analgesia, Resuscitation and Intensive Care Medicine (SIAARTI) published some guidelines last Thursday.

The focus is on two recommendations. They are called “triage” in technical terms, which comes from the French word “trier” (to sort, to select). Treatment priority should be, firstly, patients with a higher probability of survival and, secondly, patients with a longer expected lifetime than others.

This means that young people without previous illnesses whose chances of recovery are good are given priority, while old people with previous illnesses whose chances of recovery are poor are given lower priority.

Bedside utility considerations?

Now people are never a means to an end. Every life is worth the same. Doctors are obliged to help all those in need. These are sentences that are self-evident in normal times because they belong to the moral foundation of our society.

Utilitarian considerations, guided by the question of which actions produce the greatest benefit to the greatest number of people, commonly have their limit where they clash with inalienable rights of people.

In moral philosophy, the validity of such innate rights is often illustrated with examples. One of them - the so-called trolley problem - is about a bus whose brakes fail and which is now rolling towards an abyss with the driver and five passengers.

You and a very overweight man are standing on a bridge under which the bus will pass. Chances are, if you pushed this man off the bridge, that man's weight would hold up the bus.

However, the man will almost certainly die in the process. Do it? One innocent life versus six innocent lives: for utilitarians, the matter is clear. You push the man off the bridge.

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Other strong moral intuitions speak against it. People must not be sacrificed for others: The Federal Constitutional Court also affirmed this principle in its ruling, according to which aircraft used as flying bombs with passengers on board must not be shot down, even if that would save the lives of thousands of people.

Equal treatment also falls by the wayside in wars and disasters

A triage cancels the principle of equality in individual medicine. It can be triggered by wars, disasters, pandemics or major accidents. Because it results from a dilemma.

Intensive medical measures for a few seriously injured people whose situation is precarious tie up personnel and material capacities (equipment, medication) that are urgently needed to care for many slightly injured people.

As a priority principle, triage instruments are also used in Germany in regular medicine, for example in emergency rooms. It is about the initial assessment of patients, whose condition is divided into categories ranging from slightly injured to "acute, vital threat".

In some emergency rooms there are casualty cards or wristbands with different colors. The diagnosis of the injury is often accompanied by an assessment of the urgency of the intervention and the degree of transportability.

Triage has its origins in wars. If the top priority is victory, first your own soldiers, then your own civilians and lastly the opposing soldiers must be provided for. It is about maximizing the benefits for the overall system. The medical officers are mostly particularly affected by the conflict of roles between medical and military ethics.

Serious selection decisions

A dilemma cannot be resolved. When resources are scarce and there is a sudden flood of people in need, medical professionals have to make very serious selection decisions in a very short space of time.

This includes treating people whose situation is hopeless with pain reliever rather than intensive care. This includes letting people die because it can save other people.

The first-come, first-come principle can, in an extreme situation such as Italy, lead to an multiplication of suffering. In a dilemma, no matter how they choose, people are guilty.

The consequences often range from remorse to post-traumatic disorders. The SIAARTI recommendations are intended to relieve medical professionals of their personal responsibility. The second recommendation in particular can be criticized in detail.

Maximizing the number of survivors seems a more plausible criterion than maximizing the years of life saved.

Background about the coronavirus:

But that does not change the need to set up a temporary moral framework in an extreme emergency like in Italy that gives the people involved orientation.

Each of them can meet relatives of people whom the doctor has had to let die. As a moral framework for a period of time, triage is justified. The anger it arouses should primarily be aimed at those responsible for the bottlenecks in the health system.

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