Lifeboat ethics #2 – Ventilators and PPE

It seems like a lifetime ago, but it was only near the beginning of March that I wrote a post about the literal application of lifeboat ethics that was being forced onto passengers on two cruise ships denied docking privileges to offload passengers still uninfected by the Coronavirus. At that point, only nineteen people had died of COVID-19 in the U.S. This number will surpass 10,000 today, a tragic lesson in exponential math for Presidents who skated through those courses in college. And since that post, several more cruise ships and one aircraft carrier have become “Coronavirus lifeboats” at least for a time.

As hospitalizations mount, we hear more talk invoking variants of lifeboat ethics as hospitals confront critical shortages of ventilators and personal protective equipment (PPE). When you have one ventilator left, which patient gets it? And when should you take one person off a ventilator in order to save another person?

Most hospitals have likely adopted some kind of “triage” system to be implemented in this event, but few have made their systems public. They never look good. One transparent exception is at a Pittsburgh hospital that has adopted a triage “point system” primarily based on two factors: (1) saving the most lives, and (2) saving the most life-years, or the expected “unlived life” of a sick person.

All of the options stink

I have to reiterate that I do not like lifeboat ethics discussions, which are a staple of classes on the subject of ethical theory. I never used them when I taught ethics. Here are my main reasons:

  1. If you are to the point of talking about who gets “thrown out of the lifeboat,” then you have already lost the exercise. Especially in this rich and creative United States, the correct answer is “Build some more damn lifeboats!” At this moment we are failing badly at “lifeboat making.”
  2. If you are looking for “THE right answer” here, again, you have lost the plot. There is no “best” answer about who to toss overboard. There is no “Christian” answer and no “logical” answer, either. All of the options are terrible, and to guilt trip the people in the lifeboat who choose one crappy “solution” over another is to lay on them moral rules that cannot withstand an unwinnable test. All these lifeboat ethics rationale do is try to find options that “stink less” in the minds of more people.

In that earlier post, and in a series of past posts about “the moral conversation,” I have outlined my view that these times when “good people disagree” about important decisions really stem from different parts of our brain “fighting” over at least four very different, long-evolved survival instincts. Each method of survival strategy has sometimes been successful and sometimes not. And in the math of evolution, that sometimes is often enough to pass its success down to the next generation.

The moral conversation

The moral conversation

Over the centuries we have hung volumes of religious “God language” on all four of these decision modes through scriptures and the writings of revered theologians, as well as moral philosophers. Which of these writings speak to you the best is a question of personal faith and tradition, but objectively, “good religious people” also disagree with each other over just about every important moral decision. You can find a scriptural passage to defend any one of these four approaches, and more.

Classic medical triage and teleology

We can see these four parts of our brain “in conversation with each other” in the strengths and weaknesses of the various triage systems set up for these situations. Classic medical triage tries to define some simple “rules and duties” to constrain a very hard-edged “end goal” assumption. The classic end goal is to save as many people as possible given limited skilled medical personnel available. In that traditional model, the “rule” is that the sickest people are left to die (or perhaps given only palliative care). The “walking wounded” are minimally stabilized and left to wait, even if in pain. Medical attention is then focused on those who “can be saved” through prompt intervention, but would otherwise die without that effort. This is classic utilitarianism. Maximize one utility factor (the number of people alive) as the “end goal” (that’s teleology).

The Pittsburgh model cited earlier adds some more complexr point-based rules to this system. In this case, the patients with lower scores, out of a range from 1 to 8, get the priority treatment:

SOFA in this diagram stands for “Sequential Organ Failure Assessment,” a standard measure of mortality probability used in hospital intensive care units. A higher score here means that you are less likely to survive.

Note that primarily what this tool does is to add one more end-goal utility factor (one which disfavors us older folks), combined with a more complicated quasi-mathematical rule substitution for moral judgement. “The point score says you gotta die!”

That statement is a bit facetious, but my point is that there is no inherent “morality” in systems like these. This is more amoral economics than theology or humanist philosophy. Instead, we are trying to establish a consensus “fairness” measure that keeps the decision-makers from being “thrown overboard” themselves by objecting fellow passengers.

As that “moral conversation” diagram above suggests, life is more than rigid rules and “expeditious good ends.” Humans are also empathetic creatures, and indeed “spirituality” in all of history’s faith traditions invariably brings in this often-irrational question of “What about that other person?” (In this case the poor sap with the high score.)

That fourth box in the “moral conversation” is a luxury that we typically do not have in “lifeboat” situations, which is to be contemplating “higher things” like principles, values, and “Big Questions” like “Who am I?” Am I the kind of person who will sacrifice an older person for a younger one? Maybe, if need be, but the point is that this “meta” thinking goes out the window when you stop building new lifeboats.

Legality versus morality

I have also written in the past about our general confusion, on matters of ethics, between legality and morality. In real life, these are two separate, but sometimes overlapping “spheres” of thinking. We might consider some things both illegal and immoral, but these situations are rarer than you might think, and they are rarely the point of disputes.

Legality vs. Morality

There are lots of actions that large segments of society might deem immoral, but yet are perfectly legal, and some of our great heroes have committed blatantly illegal actions that history has judged to be of “higher good.” A recent New York Times article discusses the need for a clarification of the legal liabilities that doctors face in these new “lifeboat” medical decisions.

I would personally classify the “Pittsburgh Triage” criteria discussed above as more of a framework for defending the legality of these difficult medical decisions rather than their morality. The former is necessary for continued societal functioning; it demonstrates logic and prudent decision-making. The latter is much more personal, and it involves seeing all COVID-19 patients as persons of worth, rather than as a platform for nightly TV ratings.

Speaking as an aging person…

I know statistics pretty well, and I do have to say that invoking this math as a moral criterion is walking on pretty shaky ground. The Pittsburgh triage model invokes “life-years,” a statistical measure of expected future “unlived life,” to give priority to younger people in their model. Most people do not realize, however, that a 70-year-old American woman still has, on average, over sixteen years of life remaining. Once you have made it this far, the odds of you still being alive tomorrow (absent COVID-19) are actually pretty good, even if you are 90 years old.

In any case, all life expectancy numbers are “dice throws.” That teenager that you save from Coronavirus could very easily run his motorcycle into a tree tomorrow. My point is that “morality” is about more than crap shoots betting who will live longer.

And about those ventilators..

At the same time, neither my spouse nor I are naive about how the odds of that “crap shoot” change once you are put on a ventilator because of COVID-19 complications. Reports indicate that some people put on ventilators stay on them up to 30 days. We don’t have good statistics yet as to what proportion of COVID-19 patients put on a ventilator are successfully weaned off, but early indications are not good. Is this intervention a “life-sustaining treatment” in the language of advanced healthcare directives (“living wills”)?

One disturbing study has shown that 38% of those admitted to an ICU with an in-place advanced healthcare directive received some level of last-ditch resuscitation regardless of the language of that directive. Don’t take legal advice from a non-lawyer’s blog, but my spouse and I have put on file with our two closest hospitals a more comprehensive “General Durable Power of Attorney.” This document, drafted by our estate attorney, not only includes the traditional language of healthcare directives, but also expands on that language to give the spouse more direct and explicit legal control over these decisions. It legally protects both the doctors and the spouse if the decision is to “pull the plug” rather than spend three weeks on a ventilator with the same end result.

Humankind has created a new, very unnatural “limbo” through which far too many of us must pass on the way to “a better place.” I personally would rather not spend time there. But, importantly, that is my decision to make.

Probably inappropriate, but let’s end this with an old joke. Two guys are flying on an airplane, one a very nervous flyer in the aisle seat and one smiling , having a great time looking out the window. The happy flyer tells his grim seatmate, “I’m never afraid to fly. I figure that when it is my time to go, it’s just my time to go.” The nervous guy replies, “That’s what I’m worried about. What if today is your time to go?”

In the “lifeboat ethics” situation in which we currently find ourselves, I am likewise not as concerned about whether it is “my time to go,” rather I am concerned that the captain of this lifeboat cheated his way through college science classes and likely couldn’t find “Two Corinthians” in a Bible either if his life depended on it.

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