Christian ethics and the dilemma of triage during a pandemic by Margaret B. Adam and David L. Clough

“In the current COVID-19 pandemic, many patients need artificial ventilation in order to survive and hospitals around the globe are struggling to treat them. Many hospitals have more patients who need ventilators than they have beds, equipment and staffing in Intensive Care Units (ICUs). As a result, medical staff are making triage decisions about who will be saved by artificial ventilation and who will be allowed to die as a result of not receiving the life-saving treatment they need.

“These are not merely clinical decisions; they are ethical decisions that bear on fundamental issues of care for the vulnerable, justice and discrimination against members of particular social groups. They are decisions made in the context of tragedy: no one wants to be in the situation of not being able to save all those in need of medical help. Yet the triage decisions still need to be made.

“Doctors should not be left to confront these choices alone. Christian ethicists among others have a responsibility to contribute to the development of appropriate policies to guide their practice.

“One widely used strategy is to aim to save the most lives. The key objection to such an approach is that the strategy requires prioritizing those who can benefit quickly from treatment. This means that those with significant pre-existing health conditions are likely to be excluded from treatment. This discriminates — at least, indirectly — against social groups who are disproportionately likely to have such health conditions: the elderly, persons with disabilities, and in many societies the poor, socially excluded and members of ethnic minorities. As a result, members of these groups and their advocates are protesting that the value of their lives is being discounted by these triage policies.

“A leading alternative strategy would be to adopt a ‘first-come, first-served’ approach in which each person is given the treatment they need based entirely on medical criteria. The key objection to this approach is that it is likely to mean saving fewer lives. The question we explore in this article is which of these two approaches Christians have reasons to support...

“At the moment, there is nothing to be done about the scarcity of ICU beds and ventilators except find, create and add more, as quickly as possible. It is easy to forget that this scarcity was not necessary. Instead, it demonstrates that ordinary budgeting priorities undervalue non-discriminatory protection of life. Now it should be clear that preparation can prevent triage discrimination. If there were enough medical resources, a 'first-come, first-served' approach, which requires somewhat less discrimination, would be feasible. The expense of such preparation would certainly compete with other national budget commitments…

“The COVID-19 pandemic crisis is a tragedy. It demonstrates the effects of the combination of a new virus, global unreadiness, scarcity of medical resources, and the temptation to limit — rather than increase — efforts to support all lives. While the virus is new, human actions make it a tragedy. Our use and abuse of animals brought about the virus and its spread. Our misplaced self-confidence caused the lack of preparation for the predicted pandemic. Our resistance to the just distribution of resources led to the current scarcity. Our discriminatory practices render us insensitive to the intensification of discrimination in a crisis…

“In the current COVID-19 pandemic, at times the demand for life-saving treatment in particular contexts exceeds the capacity of all available health care resources. In such circumstances, [we] should support the adoption of a ‘save the most lives’ approach such as that recommended in the 2015 Ventilator Allocation Guidelines of the New York State Task Force on Life and the Law. The reason to adopt this strategy is that it will result in more people receiving life-saving treatment than alternative strategies, while rejecting any direct discrimination together with any consideration of future life span or quality of life, and protecting access to ventilators by those in chronic care facilities.

“To prioritize treating those who can benefit from treatment quickly in such a strategy is not to judge that their lives are of more value or to claim that the lives of those who would need more resource-intensive treatment are of less value. Nonetheless, we have to recognize the inevitable indirect discrimination of this approach towards those disproportionately likely to suffer from pre-existing health conditions — such as the elderly, persons with disabilities, and members of racial and socio-economic groups denied access to adequate housing, nutrition, and lifestyles necessary to maintain good health.

“The judgment that, despite these implications, the ‘save the most lives’ approach is the best we can do in the context of triage highlights the crucial importance of committing to work alongside others for health care systems that are adequate to the foreseeable needs of all members of the societies they serve.”

Margaret B. Adam is a Visiting Lecturer at the University of Chester, and a Visiting Tutor in Contemporary Moral Issues at St. Stephen’s House, Oxford. She is Project Editor for CreatureKind. David L. Clough is Professor of Theological Ethics at the University of Chester. He recently completed a landmark two-volume theological project “On Animals”: Volume I: Systematic Theology and Volume II: Theological Ethics.

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