In yesterday’s post on parts of Idaho declaring that their hospital systems are on “crisis standards of care” which means triage of scarce resources of staff, stuff and space, there was a very robust discussion in comments. I want to engage with a few themes. But first I want to point everyone to White and Lo’s article in JAMA from March 2020 on how they envision a framework for rationing in a crisis.
Categorical exclusions are not necessary because less restrictive approaches are feasible, such as allowing all patients to be eligible and giving priority to those most likely to benefit.
Flea RN discusses their experience:
As an ED nurse, I do triage every day – we are the definitive destination for every sick person within 50 miles, and have limited resources. Most of the time, we are not close to the limit of what we *could* do, but when we are, those resources need to go to the people who can’t wait; in theory, a person with a ruptured appendix could wait for hours (with the proper antibiotics) before further treatment, but a person with a gunshot wound to their aorta will die if they don’t get surgery now – the gunshot victim goes to the head of the line.
I would just like to make a few points, expanding a bit on what some of you have already said:
- It’s frustrating to hear the press refer to “ICU beds,” as though we could just throw up a few cots and everything would be fixed. An ICU patient (or a very sick ED patient, which is the same thing, just earlier in their hospital course) requires a tremendous amount of resources – specialize Doctors (Intensivists, Nephrologists, Pulmonologists, Cardiologists, just to name a few,) specialized nurses, respiratory therapists, physical therapists. It takes years to train and recruit these people; you can’t just throw up an advertisement on a website and hire new ones….
- Triage happens *fast* – in the ER, by the time you speak to me, I’ve already watched you walk across the room, taken in your skin color and gait, and 95% of the time, I know what I’m going to do with you. I know how many beds are open, how busy the Doctors and Nurses are, how many ambulances are en route, and most of the time, I know where you’re going – the part where we’re talking is mostly filling out paperwork.
- Triage has to be protocolized well ahead of time, and it’s impersonal.
- It’s so tempting to want to push people to the end of the line for their lack of foresight, but that’s a really slippery slope, and even if it’s morally justifiable in the moment, there are powerful economic forces (to which David can speak better than I) which would like nothing better than to be able to deny care for “lifestyle choices” that are anything but. I certainly didn’t take an oath to treat anybody except for those who did something that I don’t agree with. Even if they yell at me when I leave work. If I burn out to the point where I can’t remember that, time for a new profession.
Barbara raises a great point about discretionary rule sets:
First and foremost, imperfect information makes any kind of treatment decision based on moral hazard to be really, really questionable. Does it matter if the guy in the car accident was wearing a seat belt or texting his office while driving? Does the answer change if he is working two jobs to support disabled dependents? And how would anyone with immediate responsibility for allocating resources know these things?
No, these judgments will be real time with virtually no clear context available for making them. Which raises the second problem: If you introduce this kind of value based judgment, they will not be systematic, but will seem and probably will be practically random. Random is not good and allows for personal bias that often penalizes marginal communities.
Speaking as a middle-aged, cis-gendered, white male with a lot of education and ability to navigate complex bureaucracies to access scarce resources, I should love discretion. Odds are that discretion is going to generate results that are more favorable to me than either random chance or systemic decision rules that take into account evidence and probabilities of desired outcomes. Conversely, marginalized populations that are already systematically screwed are likely to be screwed yet again when there is systemic discretion built into a critical set of decisions.
RSA highlights a Lancet article that outlines some of the potential decision frameworks.
Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing points systems, quality-adjusted life-years, and disability-adjusted life-years. We recommend an alternative system—the complete lives system—which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles.
We can design decision rules that maximize something that we deem important. That something can vary significantly as to who benefits.
Maximizing total lives saved in three weeks produces a very different population of people who may make the triage cut-off than a rule that emphasizes total lives saved in three years. The longer time horizon will prioritize people who have fewer competing risks for death which means prioritizing younger and healthier individuals compared to a short time horizon rule.
We can also prioritize on maximizing total Quality Adjusted Life Years which may again lead to the marginal person making the cut and getting a scarce resource to be younger and healthier than other allocation systems.
We can debate as to whether or not we should be engaged in complete maximization functions or should certain groups be targeted and prioritized. Early on in the pandemic, there was a robust discussion about whether or not medical personnel should be prioritized both as a recognition of the risks that they are taking and a more utilitarian argument that the promise of triage priority to medical personnel who get sick would keep more of the medical system operating as staff would be less likely to leave to protect themselves, and therefore an explicit prioritization of medical personnel for triage could potentially expand capacity and minimize the amount of time systems spent in critical triage.
There are other allocation schemas that prioritize different populations and will have a different marginal patient receiving the last available resource.
Smith discusses the facts of life:
The statistics are stark and convincing: Unvaccinated people are much less likely to survive a stint in ICU than vaccinated ones. Setting aside all moral judgments about personal choices, why wouldn’t this be part of the calculus in figuring out who is most likely to survive?
Yep, this is a major factor of any allocation decision that is not prioritizing sending resources to the worst off but is prioritizing maximizing lives saved with whatever time frame and prioritization window one chooses.
If there is one resource left and two patients who could potentially benefit from that resource, vaccination status is likely to be an underlying factor in the clinical decision making if we have good reason to believe that a vaccinated individual will do better than an unvaccinated individual on that resource. I don’t think vaccination status will be a surface causal factor in decision making but it could, quite plausibly, be a latent factor as it drives probability of survival.
And the Pale Scot
With limited resources the COVID infected unvaccinated DO HAVE the worse outcomes. Sedate them and roll them into a storage room.
All of my family are vacced. If I’m told my niece can’t get into ICU because willfully ignorant aggressively stupid goobers have taken all the slots, well…
Yeah, I get your anger and frustration and rage. I get it.
I am also scared shitless of a system built on subjective deservedness that is incredibly prone to both gaming and bias. Again as a straight, middle age, high SES cis-gendered white male, that system likely works really well for me but it is not a just system.
I have a step-son who spent about ten years from mid high school until well into his twenties with a serious drug addictions. He has been clean for years, but he is still on the other side of the deservedness cut-off. It is still very much there. It turns out he was self-medicating for some very real physical and emotional problems. With treatment he is much better. But when he gets anywhere near a new medical professional, they look at the chart, see the addiction in his past, and disregard any actual pain symptoms he brings up. So getting treatment is always a huge battle. Maybe with more attention to his health complaints in his teens the addictions wouldn’t have gone so far.
I am not criticizing the health professionals he dealt with. They were all acting within the constraints of the systems and resource limitations they were provided and with the training they had. It is why I appreciate so much your comments, Mayhew/Anderson, and those of Flea RN and Barbara. These automatic moral judgments are a very dangerous slippery slope.
Even “protocolized” triage that tries to apply neutral rules can lock in or perpetuate historical bias. I referred yesterday to organ allocation, where patients may sometimes get lower priority because they lack social supports or secure housing. These are not medical criteria, and they are not even really overt moral judgments about the person’s worth, but they will almost certainly disfavor poor people and ethnic minorities whose social capital is much lower than their majority peers.
@sab: Drug seeking in emergency and urgent care settings is so common that I do think these kinds of judgments result in suboptimal triage and care. My sister once accompanied a good friend with persistent, debilitating leg pain to an ED (his own physician was on vacation) and after doing a scan, they told him there was nothing wrong and made him leave. When she got upset because he — literally — could not walk because of pain, they threatened to call the police. What he was feeling was bone metastasis from laryngeal cancer. It occurred to me later that they reacted the way they did because his main symptom was pain, and they decided he was just trying to get pain medication.
Is it really a “slippery slope” to say that someone stupid enough to eat horse paste shouldn’t be prioritized over a gunshot victim or someone who’s suffered a stroke or heart attack – you may be aware that the horse paste eaters have so overwhelmed the ERs in Oklahoma that other patients aren’t getting care.
This is a really good discussion of a complex issue. I agree the most with the practicality aspect of the argument in favor of the current system as yielding overall more moral and just results. But practice is always complicated and conflicted. I do think that the way vaccine-resistant free riders are soaking up resources and externalizing their harms is not something to just hand-wave as something just obviously not addressable. Various schemes to limit the externalization of these harms may indeed be “unethical as hell, ” as stated briefly in the prior discussion, and very well expanded upon in this one. That doesn’t neccessarily mean the moral train wrecks that are resulting from the “ethical” way the system is operating aren’t happening. They are. We know they are. And we shouldn’t close our eyes to that in the name of clarity and simplicity. And I can certainly envision a situation where their combined weight overballances the dangers and harms it is avoiding.
Thank you for this post, I had thought Flea RN’s comment yesterday very illuminating. Thinking about it overnight I am firmly now on the side of take the person where they are, don’t make moral judgements on prior behavior. From personal experience I can appreciate triage prioritization. If you run into the ER holding your toddler and tell them they fell out of a window, you will be incredibly grateful that the nurse immediately stands up and takes you straight to a doctor for evaluation. Having been through that experience, I am no longer bothered with a long wait for care with less dramatic events.
@Barbara: I had a kidney stone a decade ago, and went to the ER. In retrospect, I probably looked like someone seeking drugs. “It’s just a bad pain, somewhere in my gut….”
My compromise would be this: treat without regard to any moral judgments on prior behavior.
But if your ICU is full and you’re having to send some patients to another hospital hundreds of miles away, send the unvaxxed Covid patients.
Fascinating post, thank you.
@Bupalos: I agree with your comment, and it really annoys me to read posts by ethicists full of high dudgeon on this issue. There is likely some point at which a demand for individual freedom will impose so many harmful externalities on the surrounding community that it will be considered a breach of the social contract that the “rule followers” will not be able to tolerate. Refusing to even admit that this makes the current situation very different from most “lifeboat ethics” dilemmas makes their analyses unsatisfying and incomplete.
As one who lives with chronic pain due to 35+ years of construction and caving, I can tell you that no body takes pain seriously.
When Ohio Dad went to the ER, doubled over in pain, the nurse asked a few questions, including, Where does it hurt?, he pointed to the spot, and she said, I think it’s a kidney stone. Which it was.
My neighbor the Family Practitioner expected and received many drug seekers when he first moved here and put up his shingle.
Cheryl from Maryland
My concern is that most of these triage discussions are based on the scenario of the patients arriving at approximately the same time. With unvaxxed COVID patients, they are already in the hospital using valuable resources for a lengthy period of time. Triage happens in that non-COVID patients have to wait for the unvaxxed COVID patients to free up resources.
I see a few people making implicit moral hazard arguments, that if you prioritize the sicker and riskier unvaxed people then you reduce the incentive to get vaxed (getting your shot moves you back in the queue for treatment if there’s a pinch)… but I don’t think any of that is really driving people’s decisions to get vaxed or not. It’s far more about identity or disengagement or generalized lack of trust, and people just are not gaming out what happens to them if they hypothetically go to the hospital in the future (especially young people who don’t think they’ll ever get sick).
But you could imagine two arguments from this same info:
Really you need more info. To pull hypothetical numbers out my ass:
If the probability of survival without the bed is zero for both of them, then you take the vaxed one (you’re losing one for sure, so might as well take the best available odds of saving the other).
If the probability of survival without help is 99% for the vaxed one, and 10% for the unvaxed one, then you are almost certainly admitting the one who is in the imminent mortal danger.
And if the odds are someone in between and partially unknowable, then… you’re probably down to choosing based on gait, skin colour, and oxygen levels.
@Barbara: I don’t see how keeping someone in great pain helps heal them. Pain causes stress, which is usually not helpful. Yet in terms of “moral” decisions made in the ERs of my experience, the war on drugs is invoked every day to deny pain medication. If we allow this kind of asinine value system to inform ER decisions, I am think we should consider a similar one for anti-vaxers.
@Barbara: Humans make snap decisions even when they know they shouldn’t. We really, really need good AI to try to get a handle on that.
My J spent ~ 36 hours in the hospital recently because she would get sudden feelings of her heart racing, slight woozy feeling while sitting, burning (like sunburn) sensations that would suddenly come and go for no obvious reason. She’s post-menopause and it wasn’t like earlier “hot flashes”. Went to the ER, they immediately started checking her for stroke/TIA. Lots of blood tests, urine tests, CAT scan, MRI, motion and strength tests, overnight monitoring.
All the tests are normal, even though she went through some of the same elevated pulse/BP cycles there. They don’t really know what’s going on, but it’s not a stroke!
She had her 2nd Pfizer shot a couple of months ago. We’re wondering if it maybe related to reports here and elsewhere of menstrual changes after vaccination. She’s going to try to see an endocrinologist next. The NPR story above says it generally goes away within a couple of months, but if she’s getting a booster she obviously wants to know if it’s related. If it’s a temporary thing, it’s easier to adjust to than if it isn’t…
I’m not really criticizing the actions of the doctors in this case – obviously they wanted to make sure that she wasn’t in immediate danger. But they didn’t really address her concerns and tell her “well, we don’t thin it’s hypoparathyroidism or pheochromocytoma because this and this look normal”, it’s the usual – here’s your test results, talk to your doctor. :-/
Bodies are complicated. Humans even moreso!
New Deal democrat
@Barbara: I agree with your comment, and disagree with the ethicists on this issue as applied to the pandemic.
Do I want ER doctors and nurses to be applying moral judgements where the decision is a close one, like a 60/40 likelihood that you will make the right decision and the moral issue is seriously in the gray zone? Hell no.
Do I want ER doctors and nurses to be applying moral judgments where the decision is not close, like a 95/5 likelihood you will make the right decision and the moral issue is close to but not quite black and white? Hell YES.
When a COVIDiot with a 50% chance of survival shows up right before little Johnny who was in a car accident and has a 25% chance of survival, little Johnny gets treated, period. The decision isn’t even a close one.
At some point philosophical ambiguity has to give way to practical clarity, and this is one of those cases.
@Cheryl from Maryland: I don’t think that’s necessarily true (that the unvaxed get sick first). Not unless the vaxed and unvaxed live largely separate social lives, so that it will spread widely through one detached community before coming into contact with the other.
I suspect that most of the time vaxed and unvaxed people are fairly well mingled in their daily lives though, so it should just change the proportion of contacts with an infected person who translate into hospital visits, without there necessarily being a time lag built into that.
@topclimber: I don’t want to hijack this thread, but the quick answer is that when they could not find anything organically wrong they discounted his report of pain. They did not think they were being indifferent to his pain. This is a side effect of the opioid epidemic. Anyone who works in an emergency medical care setting knows what this is like.
@Another Scott: Remember the AI that denied vaccines to Stanford’s frontline residents in favor of the remote teleworking older physicians? AI automates and entrenches bias and is even more dangerous for the fact that its purveyors refuse to believe that it reflects their own bias. It’s really not the answer.
What Have the Romans Ever Done for Us?
@Cheryl from Maryland: To me this is the really the tough issue. The unvaxxed aren’t just using up ICU beds for a few days or a week. They’re there for weeks. Then someone more deserving comes along and, according to triage, that new person may be far more deserving of that ICU berth than the patient already occupying it. But that first patient is still there and it’s either take away their support (which doesn’t happen in many cases but arguably would be ethical) or let the more deserving patient wait and possibly die.
The point being when people are doing stupid or reckless things on a large scale at some point applying the ethical ranking that works in normal times breaks down and the normal decision making process, that in normal times results in ethical decisions, results in consequences that are not ethical.
What are the legal aspects of triage? To clarify, this is the US; of course someone is going to be sued over any triage decision. But what does the law say in these matters?
@Ken: It helps if you’ve been pissing blood for 12 hours or so. Blood *always* gets the attention of ER staffs and the morphine followed pretty quickly.
**well, almost always. I remember one time….
Well, that came out all wrong: Nobody, nobody, NOBODY…
@Barbara: Good point. GIGO, as the saying goes. It’s very hard to remove bias. But I think it should be attempted and well worth the effort. Not to have the ultimate decision, but as an adjunct to try to make sure all possibilities are considered and to try to keep decisions from heading down the wrong decision pathway at the start.
The NPR story makes the point that the vaccine trials didn’t ask specifically about menstrual changes, but instead asked about “adverse events” or similar nebulous things. Having more women involved in designing the trials could help in such situations. 60 year old white guys aren’t going to have issues like that in mind when designing surveys…
@Bupalos: Sorry, but that slippery slope is really and truly just one step out, because once you make it others can use it as a wedge.
So instead of the vaxx question, what if it’s attempted suicide? What if it’s someone in prison for a heinous crime? Or to demonstrate the wedge, what if it’s a botched back-alley abortion?
I don’t think I can discuss this issue rationally. Eligible unvaccinated people who show up at the ED needing ICU care should not receive it. Im probably a monster for feeling this way, but I’m just done with all of these jerks.They don’t care who they kill and I’d rather that care go to a cancer patient or someone who isn’t a sociopath.
The problem is that the pain is purely self-reported; there isn’t some objective test to tell how much pain someone is in. Because of that, people who abuse pain medication will pretend to be in pain to get a prescription, and doctors have been warned to be on the lookout for people behaving this way. It’s a lousy situation. Treating everyone who complains about pain will help the people who are genuinely in pain, but it will also tie up medical facilities and facilitate a lot of prescription drug abuse. Trying to filter out the abusers will unfortunately also exclude some people who are honestly in pain and may get a helpful diagnosis if someone takes them seriously. The real solution is to have better options available for the drug abusers, but that’s something that’s outside the purview of a single ER.
That was one of the weirder questions when I had that kidney stone. “On a scale of 1 to 10, how bad is your pain?” How am I supposed to calibrate that? Especially since you don’t really remember pain, thank goodness.
This whole issue should be irrelevant since vaccination shouldn’t be a choice; then this is all just an academic exercise and that is what it should be. But instead, these utter A/O’s are causing a massive surge in covid ICU patients for no reason but because fox news benefits as does the thug party. Talk about sick.
Self-reported pain level is apparently more accurate than you’d think, at least in the sense that people with similar problems wind up reporting similar levels of pain. And you can probably remember pain well enough to categorize it into broad categories: just annoying, something you can tough out, you need an OTC pain medication, OTC medication won’t be enough, OMG how can I be in this much pain without visible injury, just put me out of my misery. Yes, some people are more tolerant of pain than others, but just knowing a fairly broad pain category can be enough to help with diagnosis.
@Roger Moore: I don’t think control of pain drugs should be the purview of the ER. They should be very lenient in prescribing enough to give the patient relief until they can see their own PCP.
Downside: Oxy-heads get a few pills. If they try again at another ER, they are in the system and going to be asked: How come you haven’t gone to your doctor yet? So maybe they BS their way through a second time, but I guarantee you, three strikes and they are out.
Upside: the many non-addicts get relief that is not only mental, but therapeutic.
@Cermet: Mandates will help with that, if nothing else it’ll give some of the refusers a face-saving way of changing their minds. “I still don’t want to get the shot, but the assholes who run this company say I don’t have a choice”. Relatedly, Biden is going to announce today a “get vaccinated, with no opt-out-and-get-tested option” mandate for federal employees. Locally, the LA school board is going to vote today to impose a vaccination mandate on students over 12; I think they’re the first big school district to do that.
A nurse I know posted this on FB recently:
This isn’t sustainable, we can’t keep pushing healthcare workers to the brink because some idiots think they’re too special for a vaccine. Our legal system has failed, I don’t see any option besides triaging them out of the system. Yes it’s a slippery slope, but it isn’t overweight diabetes patients that are destroying our healthcare system. It’s these refuseniks.
@Barbara: There’s a good video out there on scarcity (a guy who’s been studying it and does ted talks and such) which touches on that point.
If you are going to triage things like organ transplants, it’s very likely to discriminate against the poor. For this reason: they are poor. So, their ability to process is compromised through having a lot of worries that rich folks just don’t experience with anything like that level of urgency and immediacy. And as a result, the poor are observably more harried and unable to stick to medication or self-care regimens when required to, and so the poor are measurably lots more likely to have organ transplants FAIL, with the whole effort totally wasted. And end up dying anyhow, after enormous effort is taken to save them.
Because they’re poor and can’t focus on what they must focus on: too many other life-threatening things are happening to them, too often, and it kills their ability to perform the selfcare they absolutely must do without fail. It’s a huge fatal distraction.
And so, it’s not only possible but a certain kind of sensible, even ‘necessary’? to discriminate against poor people for that type of healthcare. It requires resources from the person, to succeed. It’s possible to be a perfectly good, valid person who deserves to live, but sentenced to death by triage because it’s that likely you’ll not be able to handle the aftercare.
All this stuff is really tricky.
I have been really appreciating this whole discussion.
And so much of it is in light of my mom’s experience! She finally got the docs to agree to fuse seven of her vertabrae, because she could not stand or walk for more than a couple of minutes w/o excruciating pain, and nothing at all worked other than that surgery. She was able to get a kidney transplant, in her 70s, in part because she’d managed her diet so well for the preceding years and had good insurance (and has lived with that kidney for nearly 12 years, so I’m certainly happy about it!). When she had her knee replaced, they had to NAG her to take painkillers, because she is so afraid of becoming addicted.
She is such an edge case in so many ways, and I appreciate seeing the thinking behind it, and thinking about how to think about the ICU cases that the folks here have outlined so well.
@Roger Moore: The other issue is the pain medications themselves are problematic and frequently cause addictions which can be worse than the pain. There also are always potential side effects and compatibility with other needed medications. I don’t think doctors actually have enough “good” pain killing meds. Those that work, wear out after awhile, so docs don’t want to prescribe too soon. It is always better if they can cure the cause of the pain. Sure it’s not always possible, but the real problem is they don’t have enough options that work. Oxycontin promised docs it wasn’t addictive, and because other options were, it got prescribed a lot. That has happened before too.
@Another Scott: I would be very careful, AI can just as easily systematize biases. There is no magic in technology. There have been plenty of cases where facial recognition and other AI’s end up resulting in the same discrimination. In some ways it can be more insidious.
@Chris Johnson: Exactly. I recognize that my mom is and was fortunate and privileged, and I want to live in a world that recognizes that and tries to make what she was able to get more accessible to others.
Who says they have a PCP? Despite our best efforts, plenty of people still don’t have health insurance. Under EMTALA, ERs still have to treat them, so the patients seen in a typical ER skew very heavily toward people who don’t have a PCP. It gets back to the underlying problem that our medical system is awful. Like so many other problems we see, it’s really a reflection of a deeper, more fundamental flaw in the system as a whole.
@Roger Moore: Pending some numbers of who actually lacks a PCP and how many are addicts, you get the last word.
@narya: On painkillers – my FIL was a little over 90 when he had some pain issue come up and the doc thought opiates would best manage it. FIL was worried about addiction and the doc suggested that past 90, he wasn’t at risk of being a long-term addict.
@Wapiti: Hah! yes. My dad will be 91 on Sunday, and, as he says, most people his age are dead.
@Kirk Spencer: I’m not denying the problematic, “slippery slope” nature of making that call. I just think we have to acknowledge this slope slants both ways, acknowledge that there is a point of medical scarcity combined with expected disease progression and course at which a different standard would be appropriate. Especially given that there is a moral hazard effect at play, in allowing non-vacers to be free-riders and externalizing their harms. Variables like the marginal cost of those externalized harms are changing daily, by region, and I can easily imagine a combination of new variant and total medical system overload and burnout that would make different schemas that more explicitly favor the vaccinated to be more just, moral and practical. But again, I fundamentally agree with the judgement and frame of reference being defended in the post. For now. Given today’s realities. I think it’s an excellent analysis as far as it goes. Just maybe a bit too sure of itself. Too sure that the other side is primarily characterized by its rage and neccesarily represents the greater danger.
Indeed! And even if he got hooked and lived past 100, so what? As long as the doc didn’t cut him off from his meds, the consequences would be….?
This isn’t about triage but a different related issue that has come up recently: doctors severing their relationships with unvaccinated patients.
This article contains the text of a quite long, quite compelling letter on this topic from a Dr. Marraccini, a family practice physician in South Miami, to her patients. It’s hard to excerpt, because it’s the march of fact after fact that makes it work. From an ethics perspective, I think her argument is mostly about reducing risk to most of her patients, to maximize overall benefit.
Agreed. A hospital is a machine. It’s not just “a bed”. It’s staff to care for that patient, and there are more staff needed per patient in ICU. It’s more space, for more clinicians at bedside and more equipment, which requires more power and more medical gas. It’s more pharmacy and more foodservice and more supplies and maybe more blood bank and certainly more body storage. All of these things are finite and expansion has to be holistic.
Thanks for shepherding these practical ethics discussions, David. They’re thought-provoking. The subject is important and I’ve learned a good bit from what others have written.
It seems to me that any set of criteria for prioritizing scarce medical resources that uses the prospects for survival or years of quality life has built-in biases that disfavor certain groups. It’s not just the huge burden of poverty as discussed above, but the constellation of characteristics that are highly correlated with class and race. As an example, a system that favors patients with higher chances of survival would certainly consider Type II Diabetes and its common sequelae such as kidney failure in making that decision. You could say that this is a moral judgment of the prior behavoir of choosing a poor diet, or you could say it’s a value-free judgment based solely on the prospect of survival. But of course Type II Diabetes is correlated with poverty and the limited food choices poor people have, and is also more common among some minority groups. Pretending this isn’t true just takes those underlying biases backstage, but the practical result is the same. As with almost every other problem in our society this stems from deep systemic injustices that are baked in for certain people from birth.
This is one reason I am comfortable with sending anti-vaxxers to the end of the line. There has been a huge concerted effort to ensure that our usual systemic injustice doesn’t apply to access to covid vaccines. For an adult who is not so seriously immunocompromised as to have to forego vaccination who remains unvacccinated it is almost always a matter of choice and not circumstance.
@Ken: The laws (the Americans with Disabilities Act and to some extent the Rehabilitation Act of 1973) say no discrimination against people with disabilities.
This is a reasonable approach. The typical machine learning system these days requires enormous amounts of training data; it’s common for the instances in the training data to be categorized by human beings, at significant cost. That said, such a corpus need not only be used for training a system to make autonomous decisions; the corpus is valuable on its own. The data can be analyzed, with results informing the decisions made by human beings, for example. This is also pretty common in different AI domains where we care about the overall outcome rather than the performance of the model/algorithm.
I usually give a benchmark. For sharp stabbing-type pain, I say, “if stepping on a Lego is a 1, and getting burned by a piece of red hot steel is a 7, then I am feeling a 5.” (I leave 10 for “can’t talk or move I’m in so much pain.”)
Regarding triage and discretion: I agree that discretion lends itself to perpetuating bias. As a POC, I have seen and experienced this A LOT. Including for life-saving care. But with health care systems overwhelmed currently, the systems need some sort of explicit triaging or we end up minimizing positive outcomes (saving lives), rather than maximizing them.
@Bupalos: Good point. There’s a potential for great insidious evil in “it’s too soon” ( see for example gun control).
I just don’t like morality tests, especially in life and death circumstances, because every morality test I’ve seen has come to be abused.
I know someone who works on the healthcare AI side, for certain cancers. From what she tells me, and what I’ve read elsewhere is that what’s scary is that the output of the AI becomes standard of care, so if the AI systematizes bias, then bias is baked into care. And also the payer – insurance company – refuses to pay when the clinician doesn’t follow the AI/SoC….even when it’s not appropriate for a particular patient.
@markregan: I meant in the context of triage. To take an example:
Is there a legal basis for B to sue the hospital? Is there a legal basis for C’s estate to sue the hospital?
And again, this being the US they can sue, and with a jury might even be awarded something. But is there any law that would hold the hospital liable?
I’d put stepping on a lego at a 4 or 5 for a few minutes, then back to zero.
For me a 1 is like when your stomach just doesn’t feel quite right, but you can’t put your finger on it, and 5 is the lego or getting whacked in the knee, 7 is the red hot metal, and 10 is “make it all end now”.
So my high points are in the same place, but I start the low end lower
My understanding is that part of the problem is a failure to properly distinguish acute from chronic pain. Opiates are supposed to be fantastic for acute pain, with very good effectiveness and low risk of dependency. People can easily stop the opiates when the underlying condition gets better. The problem is when they’re prescribed for chronic pain. They can be effective in managing it in the short term, but in the longer term they have serious problems with dependency and people needing stronger and stronger doses as they develop a tolerance. That tolerance is especially nasty because it’s only to their pain-relieving effect, not to their worst side effects.
@Butch: Yes, it most definitely is.
The health system is not a good vehicle for revenge. People with gunshot wounds may have made bad choices, too. That should not be among our principal concerns at the point of treatment, and one’s grievances are a poor point of departure for the formulation of policy. As this country continues to demonstrate along a wide variety of dimensions.
My best friend had sickle cell. She had to go to a hospital that knew her otherwise she was always considered to be looking for drugs. I have visited her in ICU on more than one occasion while she was having an attack. She often got care by being involved in experimentation for Sickle cell and therefore being known with the disease and because it was often the only way she could get more than minimal care. She died when a doctor at the last hospital she was admitted to either had no idea how to care for sickle cell or didn’t give a damn that she would die. Even I know better than to do what he did. Other docs at the hospital told her partner to sue him.
I don’t know if other medical systems are better than ours but I get my healthcare from a better source than most people have, the VA. Yes it can feel like you are being treated like a number some days, but if a doc thinks I need an MRI, I get one and no one questions the decision or the cost. No system is perfect but this is better than how the system works for most people. I know because I lived within that system for a long time, with good healthcare insurance. Without that insurance healthcare in this country is abysmal. We pay the most and while we often get OK, we just as often get dismal.
The AI is already on it
Do you know what your Epic Deterioration Index is?
Well this obviously isn’t any kind of normal situation. We are in a pandemic and have 3 vaccines available in this country, given for free, to anyone over the age of 12. Deciding that you will take an unapproved, unproven, ineffective, horse medication to medicate a disease for which we have those 3 vaccines, which have been more than proven to work and be safe, says to me that your regard for your own and others health is minimal to negative at best, that maybe you shouldn’t be given the benefit of the doubt when needing healthcare, especially emergency healthcare. If that healthcare system is past the breaking point because of people who can’t seem to care even one shit about themselves, what is the possibility that we shouldn’t give them that second shit?
You said it a lot better than I did above. But the sentiment is the same. This is not a “Take 2 aspirin and drink lots of water” kind of healthcare issue. This is an all hands, throw all possible things we have at each patient kind. And we have a simple concept that would have stopped the pandemic here if only those with all the common sense required to take horse dewormer in place of actual medicine (none) would have actually done. New Zealand has done rather well. Yes the majority of the country is spread out but there are towns and cities with lots of people and they didn’t need horse dewormer because they seem to have that one thing we seem to have buried here, actual common sense. We have uncommon sense in a large part of our country, highly reenforced by a segment of our political system with all the intellectual power of concrete.
I’m with Ruckus at post #62. It’s very unjust that people’s who refuse to take one reasonably simple and easy measure are wrecking the system for the rest of us. Perhaps instead of all the fussing about slippery slopes, someone could apply that brain power to finding a method that’s less unjust than the current mess.
@Kirk Spencer: I agree it should really never be openly posed as a question of who “deserves” the care in a personal moral sense. I’m not comfortable with that either, even as these folks do anger me. There is a cultural and circumstance element to every choice people make, however stupid and antisocial.
So even if the time comes where it is appropriate to basically screen out the unvaxxed as a class, I would see that as running through David’s maximization of resource utility. Not as a kind of moral judgement or punishment. Although of course it would likely be received that way by most of those being excluded. And would likely be celebrated as such by most of those who have been vaxxed that are feeling punitive or have a greater belief in “free will” than I do.
@Ken: As another commenter already stated, this is a common question that can be useful. When I asked patients (in the past) this question, I would always clarify it by stating that giving birth without an epidural would be a 7. But that isn’t helpful for men.
More important is that I’d watch the patient carefully. The one man that I actually believed underreported his pain spoke quietly and slowly and then had to stop mid-sentence to breathe shallowly until the episode stopped, and then said “7”. Saying that your pain is a 9 while texting on your phone or talking easily means that you’re trying to game the system. Exaggerating the rating would definitely make me discount what you’re saying (as does stating that you have a high pain tolerance).
and while Flea RN pointed out the personnel deficit that Hospitals encounter, that’s not the ONLY one…
I work on the other side of that coin…
ICU capable beds aren’t just sitting in a huge warehouse ready to be delivered upon need
Those beds need… space, electrical hookups, network connections, phones, TV’s…
I can also assure you that hospital infrastructure is being stretched because all of this infrastructure takes people to jury rig all of this into functionality…
Then there’s the “soft” side of all of this… you have to set up these new beds in various software applications because the staff has to be able to accurately identify where each patient is and what needs to be done for each patient, especially so when every bed is filled with a body and we now have more bodies than ever before… so that also impacts not just Nursing and Physicians, but custodial staff, dietary, radiology, pathology and lab… new tests to be done, instrumentation to be able to run it, those instruments need media on which to run the tests… the downstream agencies like the local and state departments of health that need to track numbers, what type of testing was performed on which patient, on which instrumentation… all of which gets eventually distilled to the CDC…
and while you see the providers and the nurses doing all of these herculean efforts up front, behind the scenes there is just as heavy a lift being made to give them the opportunity to do so…. and all of this is also operating under fact that hospitals are always taking live new products, new procedures and upgrades to various and sundry items throughout and none of that is stopping either because to remain static is to fall behind.
This may be to change the argument a bit, but I’m not sure we can draw the one from the other. It isn’t necessarily that they don’t care for their own health. It’s more that they don’t trust us eeevil scheming liberals with their health. So they’re convinced they need to find the secret medication we’re hiding from them, because of course we all want them to die and/or populate our reeducation camps.
And that’s absolutely ALL kinds of stupid fucked-up nonsense, born (at the least) of a a simmering resentment and inability to think critically and assess sources. But it’s also so self-sabotaging and so widespread that I have little problem also seeing these people as victims, as folks that need help. But again, I’m not big into “free will.” Germans on the streets of Berlin in 1938 are mostly going to think Jews drink children’s blood. Lots of Americans on State Route 52 in Bumblepatch NC in 2021 are going to eat horse paste. It’s not like they come up with this stuff on their own and it’s not like they’re actually provided the social resources to resist it.
So while I do very much support keeping the consequences for this kind of stupidity from harming others, I can’t really make it about moral just-deserts.
I think you need to be careful about the way you use the word “addiction.”
@glc:Where did this stuff about revenge and grievance come from? We’re dealing with a scarce resource, a medical system that is near collapse if it hasn’t already collapsed; we are talking about a rational allocation of resources.
I am wondering what effect the widespread, heavy, damage in southern Louisiana is going to have on COVID cases increasing, and on numbers of people who are going to die due to non-COVID illnesses and injuries. I am NOT talking about New Orleans. I am talking about the bayou parishes. There is one functioning hospital for all of Terrebonne and Lafourche parishes. That’s about 207,0000 people total. The only two hospitals in Terrebonne parish were so badly damaged by the hurricane they had to be closed for repairs. 2 of the 3 hospitals in Lafourche parish also had to be closed due to damage.
There are people living with little or no running water in many places, there is no power to run some of the lift stations for parts of the sewer systems(they have generators but some of those were also damaged), so if you do have water you have to limit the amount you use. There is no power many places and there will be no power for some until the end of September or longer. There are people on oxygen and dialysis who have to find oxygen tanks/refill, find somewhere to get dialysis and a way to get there, as gas for cars and generators, and open gas stations are also hard to find in some places. People are getting hurt cutting and clearing trees, trying to put tarps on their homes (or what’s left of their homes) and having heart attacks due to the stress.
“Patients at Terrebonne General Health were immediately transferred to other health facilities. The health system did not specify which facilities patients were taken to.
The Chabert Medical only has a small emergency room operating at it’s center while all other patients were transferred to other Ochsner Health facilities.
Houma Today reported that officials are in the process of setting up a portable hospital in place of Terrebonne General and Chabert Medical which both experienced some roof damage.
Terrebonne General said its facilities have no running water supply as of now. “
Terrebonne parish hospitals damaged, closed.
Addition to my previous comment:
“On Wednesday morning, for example, Ochsner Medical Center’s hospital in Kenner was holding 30 patients in the emergency department because officials didn’t have enough open inpatient beds in the hospital to admit them. That’s not the norm.”
Bayou region lost at least 200 -300 beds due to Ida
@unknown known: I am absolutely furious at the people whose stupidity and stubbornness have resulted in them refusing to be vaccinated — but, practically speaking, I don’t how unvaccinated status could be used as a criterion in triage. 1) There is no “vaccine passport”. 2) Proof of vaccination can be and is being faked. 3) These people lie. 4) There are a small number of medical conditions that would prevent a person from being vaccinated. I’d like to see these people go die along in a cave, but, I don’t see a practical way to shun them in a hospital environment.