Triage: a blessing or a curse? And the art of playing God
As you embark on this reading experience, I invite you to take a moment to answer this question:
There are 10 COVID-19 patients that need medical attention and an antidote. Unfortunately, what you have at your disposal can only be enough for 3 patients.
How do you decide who to give it to –or better still– who would you give it to?
(Don’t rush, actually think it through).
I sent this question to a series of friends, health practitioners, teachers and comics. Some took days to reply, others hours and a few took just seconds to respond. Nonetheless, their responses revolved around three key points:
- The first focused around giving the antidote to children;
- The second focused on those on the verge of death;
- The third on those with higher chances of survival.
As I looked at that list, I felt that one category was out of place. The first category shouldn’t be there, mainly because children can be found in both the second and the third category. Hence, let us give a blind eye to the first category and focus on the last two.
Who then would you save?
The reason I insist on this question is mainly that on Saturday, March 21, 2020, Italian doctors had to make this call. They had very few amounts of resources (ventilators, nurses and drugs) and a very large amount of patients in need of those resources. In almost every pandemic, this decision has had to be taken. Pundits call it the art of playing God – since it is only God that has the right to take such decisions. Nonetheless, when the worst comes to the worst, doctors are called to make that call.
This piece is an attempt to look at how it was applied in a previous pandemic and what the research has concluded on the art of playing God.
I hope you thought that question through? Let’s now jump right into the piece.
Playing God with the Katrina Hurricane
On August 29, 2005, a hurricane struck the Gulf Coast of the United States. It was one of the most horrifying hazards of the early 21st century – widely known as the Katrina Hurricane. It did a great deal of damage and was dubbed a catastrophically horrific event in American history. The affected areas (Louisiana, Mississippi and Alabama) experienced massive floods with hundreds of thousands of people forced to abandon their home. The total damage caused by the Katrina amounted to more than 100 billion dollars in monetary terms –only.
As devastating as the hurricane could be, it is really just a backdrop in this piece. Our main interest is on the hospital dubbed the Memorial Medical Centre. This was an 8 storied-tall building, erected in 1926 – in one of the lowest parts of the city of New Orleans. This hospital was the safest place for a brief period of time during hurricane Katrina. And every affected person both critically and slightly injured was rushed to this specific hospital. After an effortful count, the hospital reported the presence of 250 patients and 2,000 people (staff and visitors) in the building.
What follows is a brief summary of what unfolded in Memorial Medical Centre during Katrina.
Day 1: Monday, August 29 2005
After Katrina hit the city, every patient was rushed to this hospital. It wasn’t that long before the whole city lost all electrical power. The Memorial Medical Centre, fortunately, had some backup power, but because of the flood, they decided to move the generators from the first to the second floor to prevent the rising water from getting to them. Unfortunately, electricity is mostly about circuits and since important elements of that backup power were abandoned on the first floor, the backup power couldn’t hold for long. The day ended in relative calm.
Day 2: Tuesday. August 30 2005
Mid-morning of day two, the hospital officials noticed that water had surrounded the whole city, and it had started rising to considerable levels around the hospital. It was at that point that the hospital administration knew they were in big trouble. They ordered that everyone is taken out of the hospital to a spot opposite the street where few helicopters were to evacuate them. But to do so, they needed a system – a system of whom goes first.
Without any hesitation, they decided that babies were to be taken out first, followed by the ICU patients, and finally the walking patients. To that effect, the medical personnel started placing babies in incubators and ICU patients on wheelchairs.
In the course of transportation, a second problem emerged. The helicopters could only carry two patients max at a time. Hence, the total amount of patients they were able to evacuate out of the city was 60. It was very slow going, especially for the 1,990 people left.
Day 3: Wednesday, August 31st 2005
At 2 am the sound of the generators went off. The rising water had reached the electrical switches on the first floor and was gradually ascending to the second. There was total panic and chaos in the hospital – it was an absolute emergency. The chaos was massive, everyone had to be rushed out; close to 50 patients relied on ventilators to breathe. In less than an hour, 15 of the 50 patients who relied on ventilators had died.
The nurses tried to transport some of the patients to the spot where the helicopters were expected to come to carry them. They waited and waited, but no helicopter came. The helicopters were very slow to arrive. Why? Because the helicopters were doing their own triage. (Triage will be explained soon)
Hence, the hospital administration decided to create a system, so that when those helicopters showed up, they won’t waste any time.
The key question the hospital officials had to contend with was: who are those going up first?
This is was the first time this question was asked with great seriousness. How should we triage, asked the hospital administration?
Triage is a French word that means to sort or better still sort for quality. Etymologically, the word only referred to beans and rice, but a few hundred years ago it started being applied to people. Its application to people was mostly in contexts where one had to sort between who to help first when different casualties presented themselves in a desperate situation. Lately, triage has been used to answer a very difficult question, like the one I asked at the very beginning.
There are two conceptual ways of looking at this:
The first conception is widely regarded as the Napoleon Bonaparte model: 1n 1719, Napoleon’s surgeon made a rule in battlefields. This rule was to take those combatants with acute needs, first. So, the sickest are to be treated first, with the most resources. In our contemporary time, this is the way it works in most hospitals and emergencies. The emergency cases get the first and best attention. If there are two cases to pick from, a heart attack or fever, almost every hospital in Cameroon will go for the former.
The second conception is widely known as the Utilitarian Model. This model got its start with philosophers in the 18th and 19th century. The core of the model suggests that we should aim at doing the greatest good for the whole population. Hence, instead of thinking about what one individual needs, you should think about how to save the most number of lives or the most number of years of life. The utilitarian insists that we chose those with the highest chance of survival over one specific case. This is usually seen in war zones; if there is a bomb, they try to save the most number of lives and not just a General’s life.
Triage doesn’t just end in medicine, triage has been used to dampen the war against poverty. For example, Neo-Malthusians regard poverty as a natural disaster impossible to avoid. They offer metaphors that suggest that human population growth is a “time bomb”; and that the developed world is presented as a “lifeboat” that can only take on board a few more passengers without risking the lives of those already aboard. They then go further to conclude that Planet Earth’s capacity to withstand the weight of so many human beings is finite, and will be damaged if excessively overburdened. Garret Hardin, one of the best-known neo-Malthusians, states:
If poor countries received no food aid from outside, the rate of their growth would be periodically checked by crop failures and famines. But if they can always draw on a world food bank in time of need, their population can continue to grow unchecked, and so will their need for aid. In the short run, a world food bank may diminish their need, but in the long run, it actually increases that need without limit.
The second argument on the war against poverty is to apply plain triage: that is to look keenly at the gap between the scarcity of resources and a superabundance of poor countries. Once the observation is done, these countries should be segmented into three categories
1st those who will probably survive without assistance
2nd those who might survive if they received it
3rd those who with the best possible assistance will still be poor anyway.
From this analysis, only those who fall into the second category will receive assistance. The idea underlying the principle of triage is to use resources in the most efficient way possible. To that effect, those in the first category would surely survive without help, and since it is most unlikely that those in the third category would benefit from the resources, it would be wasteful to apply them. Hence, the best possible shot at fighting poverty will be to assist those in the second category (those who might survive if they received it).
If you become a millionaire and wish to help friends or family, how will you proceed? By assisting those of category 1, 2 or 3?
Back to the Memorial Medical Centre, the hospital administration decided to group patients in groups called: Ones, Twos and Threes.
All the patients were asked to be taken to the third floor. At the door of the main entrance to this floor stood two doctors. They were there to issue specific numbers to each patient brought in. It could either be one, two or three.
The One’s stood for healthy patients. Ex. those with appendicitis. They were to be rescued by boat and were to be placed in the helicopters first.
The Two’s were the most typical hospital patient. Ex a patient who had a heart attack and hadn’t fully recovered. Such patients needed ongoing care and were to go by helicopter second.
The Three’s were the most severe cases. Ex. Those with terminal diseases. They were to be the last to be taken out. They considered such patients as having less to lose because even with the best medical care, they could still die.
This hospital had chosen the utilitarian model in managing their crisis.
Day 4: Thursday, September 1st 2005
There was overheating, the three’s started coughing, vomiting and dying one by one. Some doctors concerted and decided to quicken the death of these patients.
During pandemics, the rapid transition by which a hospital can go from a normal functioning hospital where lives are saved to one in which lives are taken is often very short.
Dr Anna Pol (watch her interview on 60 minutes) started moving around with syringes, telling these patients she was giving them something good. Meanwhile, these were morphine and power sedatives. She was actually committing euthanasia.
Dr Anna Pol declared in her 60 Minutes interview that there were two choices: quicken their death or abandon them. She went a little further to explain that: “In medicine what is comfort and what is murder depends in a large degree on the intention of the doctor. It’s called the principle of the double effect credited to Saint Thomas Aquinas.” The principle of double effect is this idea that an act that can cause harm, if performed with the intention to do good is to be considered ethical in medicine.
Needless to say, that Thursday was a bloody Thursday. Almost all those patients were killed and the sad part of the story is that once they were all killed, a lot of empty helicopters came to evacuate them.
Years after the Katrina, given the total dissatisfaction on how the crisis was managed in New Orleans, a protocol was set up to help make triage acceptable. This protocol was to follow a process of Deliberate Democracy. This entailed putting mature and willing inhabitant of the city in a particular building. This building was a Church basement. Researchers wanted the population to guide them on how to make the decision of who gets lifesaving resources in a situation where everyone can’t be saved. In order words, how could they better manage pandemic influence?
This is the exact question they posed:
“Imaging a flu sweeps the country and people are couching and dying and the only way to safe them is through a ventilator. The problem is there aren’t enough. There are too many patients, but very few resources.”
What should we do?
They received three categories of reply (and you’ll begin to notice the pattern)
Answer 1: save the babies and healthier people (i.e. the most lives or years of life)
Option 2: save the first respondents, health care providers, vaccine workers etc. (The people who are the most helpful in the pandemic)
Option 3: Carry out a Lottery (Leave it up to fate)
The crowd was in total disagreement. Some insisted on their point by shouting “give it to kids”, others replied; “if you give it to kids, who would raise them?” Another crowd settled that it be given to the most useful people in society. But defining who is useful seemed even more difficult: “it is better to give it to a pastor than to a notorious criminal. The pastor does more good to the society”, someone rebuked with the reply: “my hairdresser does more good to me than your fake pastor. I am an atheist”
Most people settled for option three: the lottery. But in the room were people saying they won’t accept it. How can an old man of 90 be given medical care over a kid of 6?
The last set of objections wanted a case by case judgement. “Unfortunately, in times of crisis there aren’t emotions, we can’t go case by case, because those are emotions.” Replied the researchers.
The researchers came back to the room to present a set of caveats since the conversation had gone awry. No decisions should be based on race (black or white), gender (male or female), economic status (rich or poor), citizenship status (citizen or undocumented immigrant).
After two days of talking, they couldn’t come to a conclusion. These were rational people struggling with tough questions. Or better still mere humans struggling with Godly decisions.
What do you think the researchers took out? Nothing!
No one is trained to take such decisions and feel right about himself. On the 22nd of March 2020, I listened to the New York Times podcast and felt very bad, when the GS of the Italian hospital, where 700+ patients had died, explained how he had had to play God. In his case, due to unpreparedness, he went for the Bonaparte Model, rescuing the lives of some over many.
Either by commission or omission, triage is going to be abled; it is inevitable.
What if Cameroon gets struck by the fierce pandemic influence? And the health minister is asked to make that call, what model do you think he would implement? Save the lives of the masses or that of important State officials?
The truth is no one knows and to be sincere, we don’t wish to know. The best game to play at this point in time is keeping yourself safe and healthy. You don’t want to be the one on whom others will play God.
Remember to drop your comments
Leslie Michael Ace
That was a good one?.
If that decision is to be taken by Africans then hmmm
Great Article, Learn alot and My question is; Was the decision of Medical personnel in Katrina Hurricane Good according to you ?
Great write up ACE…if the principle of Double Effect is quite ethical in medicine then it’s ok because all lives can’t be saved at the same time right..But with this present pandemic lets all stay safe as I said.
Thanks sooo much
At least i learned a lot .
Great write up ACE…if the principle of Double Effect is quite ethical in medicine then it’s ok because all lives can’t be saved at the same time right..But with this present pandemic lets all stay safe as you said.
Thanks sooo much
At least i learned a lot .
Good job ACE.I just learnt a lot from this article.You always have something new and very unique to share.Keep up the good work.You are an inspiration.