Mrs. Penfire gets fired up!
A week ago Sunday, April 26th, the Los Angeles Times ran an editorial entitled “The brutality of coronavirus triage.”
This piece acknowledges a terrible reality—the incomprehensible dilemma that doctors face when emergency rooms are overwhelmed with more desperately sick people than they can possibly help. “The most harrowing instances have been in the northern Italian region of Lombardy, where…hospital hallways filled with the sick and dying…and medical staff [were forced to make] unthinkable decisions about how to allocate…care….”
And that’s the reason, of course, for lockdown rules. “The idea is to ‘flatten the curve’—to spread the most urgent cases over a longer period of time and avoid masses of patients competing all at once for a finite supply of ventilators and medical specialists.
The editorial reiterated the reason for stay-at-home orders—“[to hold] off the predicted flood of patients that threatened to overwhelm [the] capacity to treat them—and summarized the efforts that have been made to provide guidance for medical staffs confronting the most horrible what-if scenarios. Bottom line: When it comes to triage, “the process of deciding whom to treat when resources are overtaxed…” there are no good answers.
What happens “when cataclysmic events cause more people to need lifesaving resources than are available?” Based on a draft policy, “many states [are] prepared to assign patients their place in line based on ‘life-years’… how much longer the patient is likely to survive after recovery…with some states adjusting this calculation to ‘quality adjusted life years’…making “co-morbidity” factors part of the equation. Thus, preexisting illness, obesity, physical or intellectual disability might be considered. (Some economists suggest that those whose recovery “will contribute the most economic or intellectual value” should be saved first—a suggestion that has been universally rejected.)
Sad to say, no matter how decision-tree is sliced and diced, it is inevitably “marginalized people—the poor, the disabled, people of color” who are the ones shuffled to the back of the line. Because they are the ones whose jobs put them in harm’s way, which means they are more likely to contract contagious disease such as COVID-19. And they are also the ones more likely to have underlying conditions that indicate shorter life spans.
The long and short of it: Coming up with a triage plan that treats every patient fairly is simply impossible. And that is the reason for the stay-at-home orders.
The editorial concludes: “The economic and social costs are huge. But we pay them in order to reject the process of assigning a different value to different human beings, and to reject the affront to human dignity that such calculations entail.”
Fast forward four days:
A spate of Letters to the Editor appeared under the headline “Unjust triage.”
One was from a former Congressman who helped write the “Americans with Disabilities Act.” He thanked the Times for “opposing any triage system that takes disability, age or wealth” into account.”
Another was from the Executive Director of the Disability Rights Education and Defense Fund. She complained that “discrimination base on age is baked in” to California’s draft guidelines.
One thoughtful gentleman pointed out that there’s a big difference between “crisis triage” and routine triage (which comes into play daily in hospitals everywhere). He argued that if two patients with severe COVID-19 infections required ventilation—one had a chronic respiratory condition and the other did not—“the ventilator would be allocated to the person most likely to survive;” otherwise, “both patients would die.”
An 84-year-old physician felt that it was “unethical and odious” to be labeled “disposable,” asserting that COVID-19 treatments should proceed in the same way as all other treatment decisions. (I guess he simply refuses to ponder the possibility that equipment or personnel might not be available to treat everyone simultaneously, which is the whole point of developing a triage plan.)
But the letter that pushed me—or should I say, my alter ego, Mrs. Penfire—over the edge, was from a woman who described herself as “a senior who is a contributing member of society both from a philanthropic and a volunteering perspective.” She stated “I strongly object to a COVID-19 crisis triage protocol that takes a person’s remaining years into account when making decisions on allocating ventilators.” Based on “what a patient has contributed to society and will continue to contribute,” she argues, “many seniors would ‘outrank’ teenagers.” (So, look out, teenagers!) This woman said she is now 70 and plans to live to be 100. And woe betide anyone who tries to stop her!
Thus, I was prompted to sit down and write my own letter to the Editor, expressing gratitude that Fate has spared me to this point and acknowledging that I would not want to see a much younger person sacrificed so that I might continue my philanthropic and volunteer contributions to society…impressive as they may…or may not…be!
I’m happy to report the Times printed my letter last Sunday. Here’s what I wrote:
When I was 27 years old, a friend’s brother died in a plane crash. He was 23. When I was 46 a boy in my daughter’s school died in a swimming pool accident. He was 17. When I was 50 a friend the same age suffered a cerebral aneurysm and was dead within 24 hours.
When I was 52 my brother-in-law died at age 61. My mother was dismayed, “He’s gone, and I’m still here? That’s just ridiculous!”
I’m with her.
I am now 73 and lucky to still be here. I’d love to live for a while longer, but if it comes to a choice between me and a younger person with COVID-19, then I’m okay with not being given the last ventilator.
Triage is the process by which medical personnel figure out how they can best save the most people. Let’s allow them to base the decision on which patients have the best chance of surviving.
Having said her piece about triage, and the reason we’re all sheltering-in-place, keeping our distance, wearing masks, and all the rest, Mrs. Penfire now feels compelled to take to task the demonstrators who think all these rules violate their rights. But that is a topic for another day!