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Triage- The Doctor’s Dilemma

It is 2020 and you are a medical practitioner. 40 years later, you return to this spot. You are much older and have made many decisions in your lifetime, but this is the only one that haunts you. It was an impossible situation, an unwinnable conundrum. Even though you tell yourself you made the right choice, you continue to wrestle with the decision. Perhaps, in another life, you would feel differently. But this is not another life, this is reality. The reality with the conclusion you chose.

Was it the right thing to do? Was triage the only option at your disposal? It is believed that triage had its origin in the American Civil War (1861-65) and is derived from the French word “trier” meaning “to sort”. This system of grouping patients based on the severity of their injuries and the likelihood of their survival called triage was first organized by a surgeon in revolutionary France, Dominique-Jean Larrey, who later became surgeon in-charge of Napolean’s Imperial Guard in the early 1800s.[1] He reasoned that the severity of wounds accompanied with the best chances of survival mattered, and thus decided the order of treatment accordingly. This is the 21st century and it is, to quote Martin Gak, “not only a return to the age of plagues, perhaps even more difficult to believe, but a return to the age of human sacrifices”.

As per the Centre for Disease Dynamics, Economics & Policy (CDDEP), the total number of ICU beds and ventilators in India has been estimated to be 96,485 and 48,242 respectively (as on April 21st, 2020) with confirmed cases over 970,000 and counting.[2] We want to provide the best possible care for all the coronavirus affected patients but there simply aren’t enough ventilators or intensive care beds for all of them. The medical personnel is being forced to make excruciating choices along with the overwhelming caseload to ensure the survival of patients. Choosing which of the two critically ill patients receives a life-saving treatment poses a moral dilemma and not choosing at all will likely result in the death of both patients, thus causing harm to a larger influx of people. The doctors’ dilemma resembles a classic clash between two schools of ethics, one that promotes actions maximizing happiness and well-being of affected individuals and the other which iterates that morality of action itself is right or wrong under a series of rules, rather than based on the consequences of the action, more commonly referred to as, “The Trolley Problem”. A runaway trolley is hurtling towards five unsuspecting workers. Do you pull a switch to divert the trolley onto another track, where only one man stands alone? Do you sacrifice one to save five? Or do you do nothing?

Since there is no answer to the question that is morally correct, we need to make a decision like an economist, who usually takes into consideration the cost-benefit-analysis before making any choice. Under normal circumstances, we always allocate resources based on urgency. Those who are severely ill have access to the most intensive resources. However, in situations where we no longer have sufficient capacity, we progressively move to “success-oriented” allocation. The cost-benefit-analysis also leads us to switch from a patient-centered approach to a population-oriented approach, thereby mitigating the incidence of illness and death within a group to as low as possible instead of adjusting treatment to ensure the well-being of an individual patient. Daniel Callahan, an expert on bioethics argues that solving the current crisis in our healthcare system requires replacing the current “ethic of individual rights” with an “ethic of the common good.” Consider a situation as suggested by Jonathan B. Wight in the Handbook of Economics and Ethics where you have two sets with an equal number of patients, namely, Set A with seriously-ill patients having a survival rate of 50% and Set B with slightly-ill patients having a survival rate of 100%. It does not mean that the lives of patients of Set A are less valuable, but there is a greater advantage in providing treatment with limited resources to Set B patients, thereby accepting the greater good approach that benefits masses.

The pecuniary cost involved here is inconsequential because money and lives cannot be equated. However, when doctors are faced with the agonizing decision of having to choose patients for treatment, it engenders a bigger cost, the biggest actually, the “opportunity cost”. Factoring in opportunity costs or the unparalleled forgone opportunity allows you to weigh the benefits from alternative courses of action better. Now, consider a situation with the same sets of patients with survival rates as mentioned above. Set A, however, consists of really young patients with an average age of say, 10 years. While Set B consists of elderly patients with an average age of 75 years. Even with a 50% survival rate, choosing Set A over Set B would be more favorable. Why? Because the opportunity cost of saving patients with a 50% survival rate is lower than saving those with a 100% survival rate. Why again? Because young patients are likely to live more than those with an average age of 75 years. And this is when you realize that it is not just about saving masses over an individual but also about saving life-years for the greater good. So, does that mean elderly and critically-ill patients with lower extended life-years should be left to die?

To answer this question better, consider the debates over rent control and minimum wages. Economists agree that such policies are not merely zero-sum, as their advocates intend, but rather negative-sum. Zero-sum is a situation in which one person’s gain is equivalent to another’s loss, so the net change in wealth or benefit is zero. On the other hand, negative-sum is a situation in which the total of gains and losses is less than zero, agents involved in such a dynamic will lose in comparison to what they currently have. It is argued that rent control causes landlords a loss and also causes housing shortages that harm some of the poorest renters the most. Minimum wages cause employers a loss and also destroy jobs for the unskilled laborers. These unintended consequences are well known among economists but there is a little sign that minimum wages and rent controls will be abandoned anytime soon. Why so? Public Interest. Because landlords and employers are richer and tenants and employees are poorer, and thus rich should be willing to sacrifice profits to help out the poor, if necessary. Consider the industrial revolution-because of the continuing suffering of industrial labor and the vast wealth accumulated by some capitalists- there arose a conviction on the part of many that industrialization should be controlled by the state and its products should be distributed equally. It was after the industrial revolution that people learned how to increase productivity rapidly. In fact, industrialization develops most efficiently and to the greatest benefit of all when it operates within a free market whereas bureaucratic controls always and inevitably lead to distortions. Hence, the free market exists.

Drawing comparisons between these economic decisions and the current pandemic is absolutely redundant. But what’s not impractical is beholding the guiding principles behind all those decisions. What all these arguments have in common is the assertion that the majority should be benefitted. We are doing everything we can to avoid making appalling decisions but if it does come to that, should we let the elderly, the unproductive, the socially and economically unfit die? There is no definite moral solution but if you let economics decide, then yes. Economics doesn’t justify it, nothing does. But does it alleviate destruction? Yes. It does now, it did when Britishers brought Dominique-Jean Larrey’s Triage into practice, it did when market forces took control after industrialization, it did when United Airlines Flight 93, one of the four flights, got hijacked by Al-Qaeda terrorists on board, as part of the September 11, 2001 attacks. After the hijackers took control of the plane, several passengers and flight attendants learned that suicide attacks had already been made by hijacked airliners on the World Trade Centre in New York and the Pentagon in Virginia. Many passengers then attempted to regain control of the aircraft. The plane crashed into a field near Shanksville, the only aircraft that did not reach its hijackers’ intended target. All 44 of them died including the hijackers, thus saving a thousand others. Of all the choices they had, they chose to do something for the greater good. They chose to be a part of something bigger than themselves.
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