We are in triage every second of every day

(Cross-posted from this blog post.)

Spoilers ahead — listen to the episode beforehand if you don’t want to hear a rough summary first.

I quite liked the “Playing God” episode of RadioLab.

The topic is triage, the practice of assigning priority to different patients in emergency medicine. By extension, to triage means to ration scarce resources. The episode treats triage as a rare phenomenon– in fact, it suggests that medical triage protocols were not taken very seriously in the US until after Hurricane Katrina– but triage is not a rare phenomenon at all. We are engaging in triage with every decision we make.

The stories in “Playing God” are gripping, particularly the story of a New Orleans hospital thrown into hell in a matter of days after losing power during Hurricane Katrina. Sheri Fink from the New York Times discusses the events she reported in her book, Five Days at Memorial. The close-up details are difficult to stomach. After evacuating the intensive care unit, the hospital staff are forced to rank the remaining patients for evacuation; moving the patients is backbreaking labor without the elevators, and helicopters and boats are only coming sporadically to take them away. Sewage is backing up into the hospital and the extreme heat is causing some patients and pets to have seizures.

Meanwhile, on the news, the staff hears exaggerated reports of looting and lawlessness in the city. Believing they have no choice, some of the staff begin to think euthanizing the sickest patients (and those hardest to transport for evacuation) may be the merciful thing to do. It is alleged that some patients were euthanized, though no one involved was ever charged. Tragically, the possible killings took place on the same day that the rescue vehicles returned.

The crux of this story is that giving in to the logic of triage put the hospital staff on a slippery slope to “playing God”. The episode goes on to discuss ways of formalizing triage so people don’t have to rely on their own judgment at such a fraught time. (Utilitarian triage is discussed, and you can almost hear the speakers holding their noses.) Very often, concerns for the caregiver’s conscience take center stage, though no one acknowledges how selfish this is. Triage is portrayed very unsympathetically throughout, as if the people being forced to make the choice must be at fault somehow for having gotten in the situation.

But it was the last story that made me want to write this. Sheri Fink, the guest reporter, describes a woman she met in a American-run disaster-relief hospital in Haiti. Nathalie was a charming middle-aged woman whose life was spared because she went to the hospital for difficulty breathing. When the earthquake struck, her entire family was at their home, which collapsed and killed them all. Nathalie was putting on a brave face, just glad to be alive, and she radiated gratitude for the care she had received.

But there was a problem. Nathalie needed oxygen, and the hospital (indeed, the nation) did not have enough to go around. Because she was suffering heart failure, the triage nurses had decided she should receive no more oxygen and return to a local Haitian-run hospital, most likely to die. Fink mentions ruefully that the nurse who made the call had never met Nathalie, as if that makes any difference at all.

Fink rides in the ambulance with her to the new hospital, where she coughs and sputters and receives no oxygen to help. Fink’s heart breaks. But when Nathalie gets to the Haitian hospital, a clever doctor does what he can to drain the fluid from her lungs and manages to get her through the crisis without supplemental oxygen.

This story reinforces for Fink the fantasy that you never have to choose — that agreeing to choose is already going too far. Fink was so moved by Nathalie that she helped her to get a humanitarian visa to the US. It turned out Nathalie needed a heart transplant, and she died before she could get one. But, Fink says, she was a delight to everyone she met in those hospital; she even took up a collection for the other patients back in Haiti. So who were the doctors to say that she didn’t deserve every chance?

This is, of course, the wrong question. Of course Nathalie deserved every chance. No one should have to suffer heart failure in the first place. But did she deserve the oxygen more than all the other people who needed oxygen in that hospital? No. Did Nathalie’s time alive matter more than the greater amount of time the doctors could give other patients by employing the oxygen carefully? Absolutely not.

Nowhere in the episode were the beneficiaries of the triage discussed. There was no attempt to determine how many more people were saved because hospital staff took difficult, decisive action. There is no discussion of who should have died in that situation if not Nathalie — someone with many healthy years ahead of them? Two people who could have been saved with the same amount of oxygen? There is only denial that anyone had to die at all. There is no gratitude for the extra lives saved — only loss aversion. There is no acknowledgement that Fink would very likely not have wanted any other patient to die, either, had she met them, much less an acknowledgement that people matter whether you have personally met them or not.

Making better choices through conscious triage is no more “playing God” than blithely abdicating responsibility for the effects of our actions. Both choices are choices to let some live and others die. The only difference is that the person who embraces triage has a chance to use their brain to improve the outcome. The suffering of the person who doesn’t receive the scarce resource is no less because you, personally, haven’t witnessed it. When Fink saw Nathalie’s suffering, it should only have informed her as to the gravity of the situation — both for Nathalie and for those who did receive the oxygen.

I understand that it’s hard, that we will always instinctively care more for the people we see than those we don’t. There’s no shame in Fink’s deep feelings for Nathalie. They are a key component of compassion. But there should be great shame in letting more people suffer and die than you need to because you can’t look past your own feelings. This is the kind of narrow empathy that Paul Bloom is against.

There are millions of people around the world dying of entirely preventable causes. Why should it make any difference that they aren’t in front of us? You know they are there. They know the suffering they feel. Poverty is a major culprit, as are neglected tropical diseases that could be cured for pennies per person per year. Money that you won’t even miss could be saving lives right now if you put it to that purpose instead of, say, home improvement or collecting action figures. Every decision we make bears on the lives of the myriad others we might be able to help.

We are always in triage. I fervently hope that one day we will be able to save everyone. In the meantime, it is irresponsible to pretend that we aren’t making life and death decisions with the allocation of our resources. Pretending there is no choice only makes our decisions worse.