By Dr Catherine Kavanagh
The current crisis of care in nursing homes is explained by some as simply an exercise in triage, necessary because there are not enough resources to go around, and it is alarming how many people simply shrug it off as inevitable. However, before capitulating completely to the law of the jungle, it might be worth thinking about what triage is, and asking if this is truly inevitable.
The definition of triage is “the sorting of and allocation of treatment to patients and especially battle and disaster victims according to a system of priorities designed to maximise the number of
survivors” (Merriam Webster) The original use is military, and in emergency civilian situations which present problems logistically akin to those of a battlefield, we also talk about triage.
All systems of triage presume an immediate emergency, needing quick decisions. The goal is to maximise the number of survivors, to ensure that those who need it most get treated first, and that those who can afford to wait, wait.
There are those who will not be treated: those who are already dying, and are unlikely to benefit from treatment, will give place to those who are seriously injured, but will benefit from treatment.
It is difficult to see how DNRs (do not resuscitate orders) feature here, since triage means applying certain principles in an ongoing situation, and one cannot say for certain that any given old person or disabled person will necessarily be in a situation where there is another patient who will benefit more from treatment, which then becomes unavailable to them as a result.
What seems to be the motivation behind DNR orders is rather “quality of life”. As F. J. Fitzpatrick points out, “quality of life” is a dangerously ambivalent term: “…the phrase ‘quality of life’ can be used to intimate that some people’s lives are worthless, and therefore that we should act with a view to bringing about their death”. Compulsory DNR orders for disabled and elderly people indicate an excessively narrow conception of “quality of life”: the thinking behind them can only be that these people do not have “quality of life” anyhow, and that death from Covid-19 would be a good thing for them. That does not look like triage, since that aims to save life as much as possible, is not concerned so much with broader “quality of life” issues as with immediate benefit given the resources available, and is not concerned with long-term disability or age. If the patient would benefit, and the resources are available, there is no reason not to treat a patient of 90 years of age, or a patient with Down Syndrome, and so on.
To sum up: we can all imagine tragic emergency situations where some people cannot be treated because they will not benefit from treatment, or because, given resources, they may have to yield to someone else who will benefit more: that is triage. We can all sympathise with medical personnel who have to make such judgements. However, we cannot assume in principle that some people’s quality of life does not merit access to treatment and therefore exclude the possibility of treatment absolutely for such people.
Catherine Kavanagh is Acting Head and Senior Lecturer in the Deparment of Philosophy, Mary Immaculate College. She taught medical ethics in the School of Nursing, University of Limerick, for six years, and was formerly the MIC member on the Committee for Philosophy and Ethics at the Royal Irish Academy, before it was absorbed into the current Ethical Legal, Political and Philosophical Studies Committee.