Etikk i
praksis. Nordic Journal of Applied Ethics (2021), 15(2), 29-41 |
http://dx.doi.org/10.5324/eip.v15i2.4092 |
Early View
publication date: 17 December 2021 |
Reverse Triage and People
Whose Disabilities Render Them Dependent
on Ventilators: Phenomenology, Embodiment
and Homelikeness
Nathan
Emmericha
& Pat McConvilleb a Australian National University,
College of Health & Medicine
nathan.emmerich@anu.edu.au b Monash
University, Monash Bioethics Centre,
pat.mcconville@monash.edu
The Covid-19 pandemic has
occasioned a great deal of ethical
reflection both in general and on the
issue of reverse triage; a practice that
effectively reallocates resources from one
patient to another on the basis of the
latter having a more favourable clinical
prognosis. This paper addresses a specific
concern that has arisen in relation to
such proposals: the potential reallocation
of ventilators relied upon by disabled or
chronically ill patients. This issue is
examined via three morally parallel
scenarios. First, the standard
reallocation of a ventilator in accordance
with reverse triage protocols; second, the
reallocation of a personal ventilator from
a chronically ill patient ordinarily
reliant on it; and, third, the
reallocation of a personal ventilator
owned by a financially privileged
individual but who is not ordinarily
reliant on it. This paper suggests that
whilst property rights cannot resolve
these scenarios in a satisfactory manner,
it may be possible to do so if we draw on
the resources of phenomenology. However,
in contradistinction to a recent paper on
this topic (Reynolds et al. 2021), we
argue that ethical claims to ventilators
are not well grounded by the overly
demanding notion that they are embodied
objects. We suggest that the alternative
phenomenological notion of homelikeness
provides for a more plausible resolution
of the issue. The personal ventilators of
individuals who commonly rely upon them
become part of their ordinary, everyday or
homelike being. They are a necessary part
of the continuation or maintenance of
their basic state of health or wellbeing
and the reallocation of such objects is
unethical. Keywords: Phenomenology, COVID-19,
Pandemic, Triage, Reverse triage,
Ventilation, Chronic illness, Allocation of
resources
Introduction
As many researchers
have discussed, protocols for
reverse triage are likely to be
implemented if and when a
pandemic overwhelms healthcare
institutions and resources
(Emmerich 2011; Truog et al.
2020; Wilkinson 2020; Sprung et
al. 2020). The concept of
reverse triage encompasses two
distinct undertakings (Emmerich
2011, pp. 95–96). On the one
hand there are reverse triage
policies that free up resources
by discharging patients either
from the hospital or from
Intensive Care Units (ICUs). The
aim is to create additional
surge capacity in
anticipation of imminent
and potentially overwhelming
demand. The patients affected
will be those who are, perhaps,
not quite ready to be discharged
but who are highly unlikely to
be adversely impacted by such
decisions. This is not the kind
of reverse triage that concerns
us here.
Three Scenarios Let us suppose the following. In the midst of a pandemic the ICU in a hospital has reached capacity. All the beds are full, all the ventilators are in use. Protocols for reverse triage are now being implemented.6 A new patient who requires an escalated level of care arrives. Their condition is such that if they do not receive mechanical life support it is highly likely that they will die. Furthermore, they are more likely to recover than at least one of the patients currently receiving mechanical ventilation and they will likely recover in a shorter period of time. A. Although it remains possible that all those currently receiving treatment could recover, ventilation is nevertheless withdrawn from the patient with the least favourable prognosis in order to treat a newly arrived individual whose prognosis is better. B. Although it remains possible that all those currently receiving treatment could recover, the patient with the least favourable prognosis has a chronic condition. They are ordinarily supported by the ventilator to which they are currently attached. They brought this ventilator to the hospital with them and they commonly rely on it to maintain their everyday existence. Treatment is withdrawn from this patient in order that their ventilator can be used to treat the newly arrived individual who has a better prognosis. C. Although it remains possible that all those currently receiving treatment could recover, the patient with the least favourable prognosis happens to own the ventilator being used to treat them. Treatment is withdrawn from this patient in order that their ventilator can be used to treat the newly arrived individual who has a better prognosis. We suppose that it is permissible to act in the manner described by cases A and C, but not in B. However, if scenario B should be considered different to A, then it is not obvious why scenario C cannot be considered in similar terms. In setting forth an
argument for the moral
non-equivalence of withdrawing
and withholding, Sulmasy and
Sugarman appeal to Nozick's
Principle of Original
Acquisition of Holdings. They
seek to claim that ownership or
simple possession generates a
moral claim to an object and,
therefore, to its continued use.
Given that this claim applies
only once ownership or
possession has been established,
it is not relevant to decisions
to commence or withhold
treatment. However, it is a
relevant, albeit defeasible,
consideration in deciding
whether to withdraw treatment.
It is for this reason that
Sulmasy and Sugarman claim
withdrawing and withholding
cannot be considered morally
equivalent undertakings. Simple
possession carries some kind of
moral weight, thus withdrawing
treatment always removes
something of moral significance
whilst withholding does not.
Nevertheless, the claim is a
relatively weak one. Even if it
does militate against
withdrawing treatment for arbitrary
or clinically irrelevant
reasons, such as those raised by
Sulmasy and Sugarman’s thought
experiment, the imperatives
generated by clinical reality
can overcome moral claims to
continued treatment based on
ownership or simple possession.
Therefore, Nozick's principle
does not rule out the withdrawal
and reallocation of treatment
when doing so is justified by
sound clinical reasoning; it
does not rule out the practice
of reverse triage per se.
Health beyond the body: a phenomenology of homelikeness
In contrast
to the dualism of
Cartesian philosophy,
which imagines the world
separated into idealised
mental and material
substances, the
phenomenological tradition
takes as its starting
point the concrete
experience of embodied
beings (Smith 2018). Such
enquiries also demonstrate
the degree to which our
bodies are experienced as
cultural, and not simply
biological, objects
(Csordas 1999). They are
shaped, manipulated and
augmented in accordance
with social, cultural and
political norms (Shilling
2004). Today, we inhabit a
scientific, technological
and biomedical culture,
the achievements of which
allow us to intervene in
our bodies with increasing
degrees of precision.
Thus, we use running
machines, gyms and diets
to direct aspects of our
physicality, whilst using
smartphones to monitor our
progress. Equally, we
reshape ourselves with the
techniques of plastic
surgery. However, what is
of most significance, at
least for the present
purposes, are the ways in
which we integrate
technologies such that
they and their effects
become indistinguishable
from fundamental
attributes of our bodily
selves. We wear spectacles
or contact lenses in order
that we might perceive the
world more clearly,
enhancing our ability to
inhabit and navigate it.
Not only do we clothe
ourselves in garments, we
implant pacemakers to
regulate the beating of
our hearts and
Intra-Uterine Devices
(IUDs) to control our
fertility, and we merge
our bodies with devices
such as wheelchairs and
stoma bags, cochlear
implants and prosthetic
limbs.
A Final Objection
Whilst
this stance might
provide a
satisfying
explanation for
our differing
intuitions about
scenarios B and C,
we should also
consider what it
might mean for
scenario A. If our
social practices
should adopt the
view that the
chronically ill
patient’s
ventilator forms
part of their
embodiment or
their
homelikeness, then
perhaps something
similar could be
said of those who
are comatose or in
a Persistent
Vegetative State
(PVS) and attached
to such machines.
Accounts such as
those presented
here and by
Reynolds et al
(2021) might be
thought of as
calling into
question the
ethical
permissibility of
withdrawing
treatment from
such patients.
However, whilst
potential for
embodiment or
homelikeness
exists in relation
to chronic
patients, this is
not the case for
those who are in
PVS. It is not
possible for a
ventilator to
become an embodied
part of the
patient’s sense of
self or a facet of
homelikeness,
because these
patients have been
ventilated in
response to an
injury that has
rendered them
permanently
unconscious.
Furthermore, the
nature of such
injuries means a
continued lack of
consciousness.
Thus, the
condition of acute
patients is such
that their
first-person
perspective is necessarily
absent or
suspended. Whilst
the possibility of
phenomenological
or first-person
awareness remains
a topic of debate
when it comes to
those in Minimally
Conscious States
(MCS), it seems
legitimate to
suppose that
patients who
require acute
ventilation have
little ongoing
sense of their own
embodiment.
Therefore, they
cannot be thought
of as adopting the
machines they are
attached to into
their corporeal
schema or their
sense of
homelikeness. Conclusion
The analysis
offered in this article
proceeded in light of what we
take to be common moral
responses to the three scenarios
outlined. First, if we accept
the implementation of reverse
triage policies that withdraw
treatment from those who will
not survive without it, we
acknowledge the propriety of
reallocating ventilators to
patients with a better chance of
recovery. Second, we question
the propriety of reallocating a
ventilator belonging to a
chronically ill patient who is
reliant upon it in an ongoing
manner. We feel they should have
priority over its use even if
its reallocation would likely
mean that another patient would
derive greater benefit. Third,
we accept the propriety of
allocating a privately owned
ventilator in accordance with
established protocols, meaning
that its owner need not be given
priority access if and when they
need to be ventilated. We have
argued that the moral
significance of property rights,
such as those elucidated by
Sulmasy and Sugarman, do not
resolve these three scenarios
satisfactorily.
Notes
1 This kind of reverse
triage is sometimes called Selective
Limitation of Treatment (SLT) or
Selective Withdrawal of Treatment
(SWT) (Emmerich 2011, n. 20), whilst
a document published by the
Deutscher Ethikrat in response to
the emerging pandemic distinguishes
refers to it as Triage in ex
post situations (Deutscher
Ethikrat 2020, p. 4). In a recent
paper focused on COVID-19, Emmerich
(2020) has also recently argued that
there may be a case for the
acceptance of conscientious refusals
to reverse triage. Again, this only
concerns the kind of reverse triage
that involves withdrawing treatment
from those who may yet derive
benefit from its continued provision
in order to treat another who is
more likely to do so. 2 What ‘potential for
recovery’ means will be a matter
for local policies and triage
protocols. Suffice to say that in
recent discussions the focus has
generally been on the likelihood
of survival and recovery in the
short term (i.e. being discharged
from hospital) and the number of
days ventilation will be required.
The patient’s prior and subsequent
quality of life is generally seen
as not being a relevant factor
although, as is made clear in the
penultimate section of this paper,
some kind of continued
biographical life is a
prerequisite. 3 Although see the
rejoinder by Fins (2020), a member
of the Taskforce. 4 Although it is common
to speak of a ventilator as
something that ‘belongs to’ the
chronic user what is meant is that
it is in their possession and they
have exclusive use of it, or so we
would suggest. Chronic users may
or may not own the machines they
rely on and it seems more likely
that they in fact belong to a
company providing care services.
Indeed, the point in this essay is
that chronic users can extend a
moral claim to the continued use
of such machines and that this has
greater significance than mere
property claims. 5 Let
us suppose that the machine was
purchased as a kind of doomsday
preparation and at a time when the
global demand for such machines did
not outstrip the supply available.
Thus, the obvious ethical issues one
might raise about the purchase
of such an item—stockpiling and/ or
attempted price-gouging—are
circumvented. There may be a further
issue regarding its retention in
circumstances when its owner had no
immediate use for it and when others
were in need or when hospitals were
trying to increase their stock of
such machines. However, we leave
this to one side. 6 It is worth noting
that most triage protocols that
emerged in the early stages of the
pandemic generally focus on the
prognosis of each patient vis-à-vis
their immediate clinical status and
do not take account of a patient’s
life expectancy or their (perceived)
quality of life (Riva and Petrini
2021). Nevertheless, there are those
that suggest age or life expectancy
ought to be considered relevant, if
only as second order or tie breaker
criteria (Vinay et al. 2021).
7 One might
point out that sufficient
financial privilege may allow one
to buy a hospital and employ the
staff required to run it. However,
this would raise additional
ethical or, perhaps,
ethico-political issues and so we
leave it to one side. 8 Thus phenomenological
perspectives have particular
significance when it comes to fully
grasping the social reality or
‘lived experience’ of illness (Zaner
1981; Leder 1990; Toombs 1993; Carel
2008, 2016; Svenaeus 2019) including
work that has focused on conditions
that affect our ability to breathe
(Toombs 2001; Carel 2010; Williams
and Carel 2018). 9 An account of the
distinction between body schema and
body image can be found in Gallagher
(1986). 10 An objection might be
that homelikeness is inappropriate
to expect of or pursue for
chronically ill persons. Svenaeus
recognises that homelikeness implies
neither happiness nor stability, but
‘…the normal, unapparent,
things-as-usual ways of everyday
life’ (2011, p. 337). The term’s use
in critical phenomenology
acknowledges that comforts can be
found in the touchstones of home and
practices of homemaking without
requiring the reification of the
mythic home (Ortega 2020).
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