Forced abandonment and euthanasia: a question from Katrina

Social Research, Spring, 2007 by Kenneth Kipnis

No position is taken here on whether the argument from intractable suffering is sound or whether any of the listed objections constitute effective refutations. I now proceed to the second argument.

THE ARGUMENT FROM FORCED ABANDONMENT

Disaster Triage

In a disaster, there may not be enough to go around. The number of patients who present at a hospital can significantly exceed its carrying capacity and, moreover, it may not be possible to transfer them to other regional medical centers. Plane crashes, explosions, epidemics, and the release of toxic gas: all of these (and others) can overwhelm the resources of a community's hospitals.

Hospitals everywhere practice specialized procedures for these events. Disaster triage is the distinctive sorting method used in patient intake. Clinicians must narrow their attentions to patients who will probably live if treated but probably die if untreated. Using colored tags and rapid assessment techniques, they will set aside patients without life-threatening injuries (the "walking wounded") and those who will likely die despite treatment. Patients in this last group--sometimes termed "expectant" and identified with black tags--are not abandoned. They receive ongoing comfort care (pain medications) and medical reassessments, especially if they unexpectedly survive the period of scarcity. On an ordinary day, the patients who are set aside to die would usually be treated aggressively, and many might survive. What would be a serious wound in a hospital with an untapped surge capacity can become a fatal injury in a hospital coping with disaster.

These queuing procedures are intended to save the maximum number of lives. Because there is not enough to go around, it is imperative to avoid waste. Resources are wasted when they are expended on patients who are likely to die even if they receive treatment (the black-tagged, most severely injured) or likely to live even if treatment is withheld (the walking wounded, the least severely injured). But resources will be efficiently used if clinicians prioritize those who will live if treated but die if untreated, the group in the middle. And, within that subset, those who are both closest to death and most easily treated will receive medical attention first.

Notice that the reason for withholding life-prolonging treatment from black-tagged patients has nothing to do with intractable suffering nor with any decision these patients have made about having had enough. There is a dramatic shift in these situations from an individualized doctor-patient relationship to something more like a public health perspective, with attention refocused on the group rather than on the individuals making it up. Compassion and individualized commitment, so much the pride of everyday clinical practice, can cost lives during a disaster. A skilled emergency physician will complete a physical assessment in no more than 90 seconds. The colored tag is attached and it is on to the next patient. The goal is to have saved, at the end of the day, the maximum number of lives.