Choosing who lives, who dies

AS THE number of Covid-19 infections grow and as we see how our health services struggle, the health services are faced with a prospect that many might find disturbing: Who lives, who dies? In short, triage.

Triage is a system of three categories that prioritises who gets treated.

First, those needing immediate attention to recover. Second, those who can wait. Third, those whose prospects of recovery are so small that they would be made as comfortable as possible and then left to die.

The South African triage scale is based on the international four-point scale for treatment. Although stages 3 and 4 indicate a longer wait, there is no explicit code for those who will most probably die.

In medical ethics there is a category called “medical futility”. There are times when treatment is futile, offering patients and families false hope, and wasteful of resources. Many ethical systems and religions recognise this.

The Catholic Church, for example, draws a distinction between direct killing and letting die. While direct killing is wrong, there is no obligation to keep people alive by artificial means.

The only moral obligation in such a case, Catholic medical ethics insists, is that one keeps the person as comfortable as possible. Even if such treatment may speed up the patient’s demise.

For some this may seem a strange claim, that a moral evil – letting someone die – is right. But this is often what ethics is about, not so much the rigid pursuit of moral absolutes but the practical struggle to move towards an ideal, even though one does never live up to it. Sometimes one may even find the “best” is not the “good”.

Imagine an attempt to constantly share limited ventilators and oxygen among all Covid-19 patients in a ward.

Everyone gets a few minutes in rotation. That may seem fair, according to distributive justice. But the effect is that no one gets enough to benefit. Result: in all probably more people die.

Many may feel that government is failing if it does not treat all patients.

They imagine that they have an automatic right to health care – even though in the Bill of Rights this is subject to the principle of “progressive realisation”.

Progressive realisation reminds us of the limits on resources.

This limitation is made worse by high levels of corruption, where resources have been drained by corrupt officials. Recent reports suggest that this happened even during the time of Covid-19 emergency. Today, more than ever before, we can see that corruption is never a “victimless” crime.

Insofar as corruption undermines Covid-19 treatment, making triage necessary and more deaths inevitable, one could argue that it constitutes murder. Will it be treated as such?

Or even face public anger? Based on past evidence, probably not.

What is not disputed is that healthcare professionals may be forced to allow some patients to die.

Although the deaths will be recorded as yet another Covid-19 statistic and the circumstances never revealed, health-care professionals will know that they could not treat every patient. Families of those who will die under such circumstances should show compassion to brave and overstretched people working with limited resources.

If anything, anger should be directed to the corrupt who have forced health-care professionals into such a situation.