Is there right and wrong in triage, Ms. Salloch?
Hanover. The Bundestag passed the so-called triage law last week. It regulates which patients are treated in the event of supply bottlenecks in intensive care units during pandemics – and which are not. This is primarily intended to counteract discrimination against people with disabilities, those with previous illnesses and the elderly. Professor Sabine Salloch, Head of the Institute for Ethics, History and Philosophy of Medicine at the Hannover Medical School, on the possibilities and limitations of this decision.
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Professor Salloch, does the new law protect people with disabilities from being disadvantaged when there is little treatment capacity in intensive care units?
First of all, it is important that the prerequisite for the application of this triage law is a pandemic. It’s not about a lack of capacity in intensive care in general, we have that consistently in many areas. We must also not forget: There are enough beds and medical equipment – what is missing is the staff, especially the nursing staff. I hope and assume that the law will no longer apply in this pandemic. After a lawsuit by those affected, the focus is on the disability. The concern is justified to a large extent, there are demonstrable disadvantages for people with disabilities, including in health care. It is important that the allocation decision, which most people call triage, does not discriminate on the basis of characteristics such as age, gender, disability, etc. But these requirements for equal treatment are also in the Basic Law. The details make it complicated.
What do you mean by that?
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For example, I find the ban on so-called ex-post triage difficult. The ban means that even when new patients are admitted, treatment of patients who have already been treated must not be discontinued. Anyone who also has a seat on a ventilator keeps it. Opinions differ on this, many doctors and scientists consider this to be wrong. It’s important to realize that triage is a real moral dilemma.
What is this?
The term is otherwise often used in an inflationary manner for less serious conflicts of action. In the case of a real moral dilemma, such as in the exceptional situation of a triage, however, the following applies: Whatever you do, you are doing something wrong. The physician cannot fully justify his moral duty to save lives due to the scarcity of resources. But he can’t change that either. Such situations are also referred to as “tragic conflict”.
MHH medical ethicist Prof. Sabine Salloch: “It’s a real moral dilemma.”
© Source: MHH/Karin Kaiser
How then should it be decided who should be treated?
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Ending the treatment of a person in the sense of ex-post-triage – without being able to safely transfer him to a normal ward – is an approach that is hardly justifiable, especially politically. speak important reasons for nevertheless allowing the ex-post-triage in an ethical consideration.
Which?
It is often difficult for the intensive care doctor to make a prognosis directly when the patient is admitted – because you actually have to observe a certain course. Another argument against a ban on ex-post triage is the fact that endangered patient groups often arrive at the hospital later. They would then be disadvantaged by the ban on ex-post triage, as provided for by the law. Ex-post triage instead in the pandemic Not the special case, but the normal case, since we almost never have the situation that there are several free beds available that then have to be occupied. The beds are already occupied, and then a decision must be made.
A passage of the law states that the person concerned may only be decided on the basis of the current and short-term probability of survival. Doesn’t this formulation leave a lot of room for interpretation?
It is expressly about a short-term probability of survival, not a prognosis for the longer future, in which, for example, comorbidities and age would then carry more weight. From an ethical point of view, it is generally very difficult to formulate criteria for triage. Since general equal treatment is a prerequisite, there is little left for us to discuss. In the case of an acute Covid illness in the pandemic situation, the short-term chance of survival must be defined – in practice, two to three doctors should take over. Including a patient’s long-term perspectives in the decision must not initially play a role.
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Are there objective criteria for a prognosis?
Different factors come into play when doctors make a prognosis, including medical experience and intuition. From my point of view, however, the consideration of meaningful scientific studies is central at this point. It has been scientifically proven, for example, that frail people have a higher risk of dying from Covid 19. That would be a proven criterion for making the forecast. But such aspects are expressly excluded by the new triage law. This makes it practically impossible to make a prognosis on a valid scientific basis.
If disability, age or the degree of infirmity cannot be taken into account during triage – what then?
Some advocate randomization – i.e. rescuing patients in an extreme situation by chance. I don’t think that’s the right way. From an ethical point of view, we cannot really do justice to the individual rights of all people with triage as a moral dilemma. With the extreme scarcity of resources described, we cannot save everyone, and that is tragic. However, should randomness prevail, I am sure that we would save fewer people than we could save. And the principle of “first come, first served” is also not fair for the reasons just mentioned, so ultimately only the medical prognosis for short-term survival remains.
How would that look in practice?
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According to the new law, two qualified doctors decide. If there is no consensus, a third party is called in, as well as people with special expertise in people with disabilities. At the MHH we would manage this procedure in practice, but it would look more critical in smaller clinics. So far, there have been no set rules for triage. Now there is a law. The situation is extremely stressful anyway, and now doctors can officially make mistakes and be held liable – if someone complains.