What Do We Owe the Triaged-Out?

(Editor’s Note: Margaret Pabst Battin wrote the following article earlier in the COVID-19 pandemic and a slightly shorter version appeared in the Salt Lake Tribune. Battin is a medical ethicist, author, and a professor at the University of Utah who has worked extensively on ethical aspects of assisted dying. In 2008, Battin’s husband became a quadriplegic after a bicycle accident. He died in 2013 after requesting that his life support be shut off. You can watch her TEDMED talk or read about her on the TEDMED speakers page or in this New York Times article. — KTB)

Doctors, nurses, and policy-makers may face horrifying decisions if there are not enough ventilators or dialysis machines or high-volume oxygen supports or other components of coronavirus care to go around. Someone ultimately decides who gets the equipment and who doesn’t — who lives and who dies. These decisions may have been averted in the first stages of the COVID-19 pandemic, except in Italy; but it is not possible to tell whether a second stage  or another pandemic with a different pathogen will present the same dilemmas; in any case, we need to think about these issues in advance. This isn’t about cases where death is likely to occur anyway or where recovery is likely with or without treatment. It’s about cases where a decision to prioritize one person over another when both need treatment to survive means that the person triaged out will almost certainly die. We owe doctors respect for facing these terrible decisions.

But we also owe consideration to those patients who will be triaged out—who don’t get the ventilator, who aren’t admitted to the hospital, whose ventilators are withdrawn to favor other patients. What do we owe you if you get the short end of the triage stick?

You should have the right to information. You have the right to receive an honest account of why you are not being given access to treatment, including any relevant institutional triage plans or societal rationing policies. Each case should be considered on its merits, in an individualized assessment, not just as part of a group. You have the right to know about treatment options even if you are not considered a candidate for those options. As long as you’re not already so ill that you can no longer comprehend your situation, you have the right to know the best available prognostic information about the likely course of your disease.

You should have the right to personal choice. Being triaged-out shouldn’t rob you of choice. You should have the right to express consent to exclusion or to protest it. You should have the right to seek or refuse hospitalization. You should have the right to try alternative and unproven therapies, within reason. The safety and efficacy of those therapies may not be established, but you’re otherwise facing death in any case. Personal choice, as long as you are still capable of it, may include the right to enroll in or refuse to participate in clinical trials as relevant, and to know whether the treatment you’re being offered, if any, is really part of research, where being randomly selected to the non-treatment arm is equivalent to being triaged out.

You should have the right to communication. You should be allowed visits from family members (in protective clothing), and/or access to voice or video hookups with family members unable to travel or not admitted to your bedside. This includes a chance to say goodbye, make amends, engage in communication that grief counselors regard as highly important for patients and survivors. It also includes the right to visits (in person or by voice or video) from one’s own religious advisor (not just a hospital chaplain, however helpful they may be), personal attorney (perhaps to revise your will or execute a power of attorney for health care), coworkers (about how to continue important projects when you die), and significant others. Some of this may be difficult to achieve in a chaotic situation, but it should not be consigned to low priority. Video hookups should be considered an essential part of hospital equipment for a patient at risk of dying, as important in a way as the ventilator you did not get. Communication, especially when facing death, may be the most important of rights.

You should have the right to a humane death. What counts as humane end-of-life care? You should have the right to full information about palliative or hospice care and to be part of the conversation that determines whether such care would actually be available to you. Would you be given palliative sedation, even to unconsciousness, if your death is very difficult? In states where medical aid in dying is legal, COVID-19 may warrant that some requirements are waived, such as mandatory waiting periods and multiple assessments. But whoever you are and in whatever situation, if you’re triaged out, you should have the right to refuse discharge without supportive or palliative care reliably in place.

Even if you’re denied the most effective forms of care, you should still receive, indeed, you deserve, care. We must not simply kick you to the proverbial curb. After all, it is our societal choice, in our triage policies and practices, to prioritize someone else that means you will likely die. We—who could all be in the same situation some day in this or some future calamity—owe it to you, the triaged-against, and also to our future selves.

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