Should the flip of a coin or roll of a dice determine fate?
In this two part blog Jane Morris (Evidentiary Bio-ethicist) will consider an ethical insight into Triage initially looking at the concept of Triage in the Health Sector and in the second blog the ethical considerations of Triage in Conservation.
Part 1 – Medical Triage
Imagine the occurrence of an epidemic of a transmissible and lethal cancer, similar to that affecting the Tassie Devil, affecting humans here in Australia. In a short time this virulent liver cancer is estimated to have affected 100,000 people. The Government announces that it will allocate $10million to deal with this catastrophe. An Ethics Committee is set up to determine how this money should be most prudently spent.
It is later determined that scientists have discovered a ‘treatment’ that would enable all those affected to extend their survival time by 6 months. However, the same scientists have also found that if this treatment is administered in concentrated amounts to 1,000 of these people their prognosis would extend by 10 years, but these years would be considered to be of a markedly inferior quality to the quality of life led by these individuals pre-diagnosis. To further complicate matters, it is estimated that 50 people could be provided with healthy livers, as a result of donor organ liver transplantation, and would subsequently be given a normal life expectancy. The costs of the transplantations could be covered by the allocated funds. The CSIRO then informs the government that if they were allocated the funds, they would most likely be able to producing a vaccine to protect unaffected individuals. It is now up to the ethics committee to decide what ‘ought’ to be done.
Which approach should our Ethics Committee adopt or should they simply advise the Government that the money should be spread amongst all interested parties despite their acknowledgement that such action would highly unlikely achieve what could be considered a successful outcome.
There is no definitive right or wrong answer in Ethics. The best answer is founded upon arguments that are presented and supported by the soundest reasoning. Our Ethics Committee engage in lengthy discourse and eventually decide that the best use of the available resources would be to invest in the liver transplantation alternative.
So now our Ethics Committee is confronted with the unenviable and invidious choice of “Whom do we save?” The concept of Triage is probably one of the most complicated and contentious issues in Medicine. There exist a limited number of medical resources and finite financial aid. It is often suggested that a Utilitarian approach to medical care should be adopted in which the intention is to provide the best treatment for the largest number of people using these limited resources. This approach also embraces the bioethical principle of Justice as each human live should be considered equally. However attempting to simultaneously address the needs of all people is not always practical. In the Emergency Department decisions on provision of medical care are often made dependent upon the severity of one’s condition but when several individuals present with symptoms of equivalent severity, choices must be made as to which patient should be prioritized. It may then be decided that these patients require admission to the Intensive Care Ward where only one bed is available. How should it be determined which individual should be admitted? Obviously there are numerous criteria to consider but amongst the common considerations are age of the patient, the likelihood of medical success, how many others are dependent upon that individual (for example children, husband or parents), has the person somehow contributed to society in a beneficial way or are they likely to in the future and what quality of life is envisaged for the patient post-treatment. More contentiously is the consideration of the economic value of lives in regard to the possibility of decreased future earning potential, the ability to pay for ongoing medical care and the cost of medical treatment for that one individual.
If an individual is provided with a particular treatment, it may increase their life span but not necessarily the quality of their life, and for many people it is the quality of their life that they deem to be most important. The concept of QALY’s, Quality Adjusted Life Years, has been formulated to enable care providers to assess the quality versus the quantity of years a patient may be expected to be provided with if a particular medical course of action is adopted. This obviously leads to further discussion concerning the various interpretations of how ‘quality of life’ may be defined. It is considered a cost effective approach and favoured over the cost benefit approach.
There are so many issues to consider and the course of action recommended by our Ethics Committee, as I have said, will be that supported by the best arguments. Of course we cannot expect uniform agreement but that is the nature of ethical discussion and unless they can suggest a course of action based on sounder arguments, the Ethics Committee will recommend the action they feel should be followed.
So, I am afraid there is no answer to our ethical conundrum. However what should stand out most significantly from this blog is the necessity and importance of Ethics Committees which are absolutely integral to the decision making process. Without such guidance we may as well simply toss a coin or roll a dice in the Emergency Department to determine who lives and who dies. I can’t even begin to think about the ethical implications of such action.
In medicine we attempt to embrace an egalitarian approach to patient care but how do we compare the worth of the Orange Bellied Parrot to that of the Black Rhino, a river to a forest and a sacred burial site to a potentially lucrative mining site? In the next blog we will discuss the ethical conundrums in environmental management and how we may attempt to deal with these.
What are your thoughts on the system of Medical Triage? I would love to hear your views about Conservation Triage before I present my next blog.
For further reading about QALY’s see –
Beauchamp T. and Childress J. 2009, Principles of Biomedical Ethics, Sixth Edition, Oxford University Press, Oxford.