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Four ventilators, seven patients: is triage consequentialism with a human face, or something else?

Tsion Bekele Fellow
· 6 replies
BioethicsAfrican & AfricanaAnalyticIslamicUtilitarianismAmartya SenJeremy BenthamMartha Nussbaum#disability#qalys#resource-allocation#triage
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During the worst weeks of an outbreak, our hospital in Addis Ababa had four ventilators and, on one night, seven patients who needed them. We used a triage protocol: allocate to those most likely to survive with treatment, and, among similar cases, to those with more expected life-years.

I watched the team follow the protocol, and I think they were right to. But I have been unable to stop thinking about what kind of reasoning it was.

On its face it is plain consequentialism: maximise lives saved, then life-years. Health economists formalise this with quality-adjusted life-years, QALYs, which weight years by health status. It is Bentham's calculus with better data.

And yet the protocol also had constraints that were not consequentialist at all. We were forbidden to consider wealth, social status or ethnicity, even if (to take an ugly example) a wealthy patient's family would have funded more equipment afterwards. Many protocols forbid lotteries in some cases and require them in others. Patients already on a ventilator were not removed simply because a slightly better candidate arrived, at least not in ours.

So is triage consequentialism constrained by rights, or some different moral logic altogether? And for those who know the critiques, are QALYs fair to patients whose life-years count for less because of a disability they would have had anyway?

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6 replies

  1. Dima Nasser

    Fellow

    Since you ask, Tsion: no, they are not fair, and I say that as someone who has used a wheelchair since fourteen. If quality adjustment counts a year of my life as worth less than a year of yours, then in a tie the protocol gives the ventilator to you because I am disabled, not because I am less likely to survive. That is a judgement about the value of my life presented as arithmetic. The capabilities approach of Sen and Nussbaum is not a triage algorithm, but it starts from the right question: what is this person able to do and be, and what would treatment restore?

    Helpful · 3
  2. Elin Hedqvist

    Fellow

    Sweden adopted an ethical platform for priority setting in health care in the late 1990s that ranks three principles: human dignity first, then need and solidarity, then cost-effectiveness. Cost-effectiveness is allowed, but only after the first two. It is an explicit answer to your question: consequentialist reasoning operating inside non-consequentialist constraints. I have worked under it and it does not dissolve the hard cases, but it tells you which arguments are allowed to win.

  3. Omar Ragab

    Fellow

    From Cairo, the constraint about not removing a patient already on the ventilator was the one that troubled the doctors I know most, because it is hard to defend in pure outcome terms. If the new patient has a much better chance, removal saves more expected life. Yet almost everyone feels the difference between withdrawing and withholding. Even if that difference is not decisive in principle, it seems to me to reflect the idea that the patient on the machine has something like a claim, not just a probability.

    Helpful · 1
  4. Bilal Rashid

    Fellow

    In Islamic bioethics the verse that saving one life is like saving all of humanity is often quoted in triage debates, and people read it in two ways. One reading supports maximising: save as many as you can. The other stresses that each life is like the whole of humanity, which forbids weighing one life against another as if they were units. Muslim jurists have historically allowed some prioritisation in emergencies under the principle of necessity, but always with discomfort. I think that discomfort is the right response, not something to be engineered away.

    Helpful · 2
  5. Nadia Haddad

    Fellow

    From the palliative side, I would add the people the protocol did not mention: the three who did not get ventilators. Your hospital's protocol was consequentialist about who got the machine and, I hope, unconditionally committed to caring for those who did not. That second commitment is not about outcomes at all; most of them died. It is where the moral logic of medicine is clearest to me.

    Helpful · 3
  6. Tsion Bekele

    Fellow

    Thank you. Dima's point is one I had not let myself see clearly: the quality adjustment brings in a judgement about disability that survival odds alone do not. I think Elin's Swedish ordering describes what we actually did, consequences inside constraints, and Nadia is right that the constraints extended to those who lost out. Perhaps triage is not one theory but a negotiated settlement between several, written in advance so that nobody has to invent it at three in the morning.