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Triage: Deciding the Ethically Undecidable

María Antonia González Valerio and Rosaura Martínez RuizCovid-19

In Mexico, the worst is yet to come. Imagination fails us when we seek to picture what will happen in emergency rooms when, in triage situations, medical teams are forced to make the unbearable choice: who lives and who dies? They will have to make this choice over and over again.

Urgent discussions regarding standards for establishing and guiding triage have begun in responses to the current pandemic in Mexican mass media, politics, and academic spaces. A group of philosophers from the Universidad Nacional Autónoma de México (UNAM) has even taken a stand on the issue, attempting “philosophically” to defend a utilitarian approach to triage. It has been said that it is possible to determine which lives to save by referring to a table of quantifiers, using a score measured through a calculation of individual life expectancy, based on age and comorbidities. The philosophers at the UNAM have alluded to this decision’s being in keeping with international policies, including those of Italy and Spain, for example, where the disease has greatly exceeded hospitals’ capacities for care.

The question that stalks us is thus whether or not philosophy has any place in this particular discussion. What does philosophy have to say about the medical criteria used to decide how to allocate scarce resources in the care and supervision of patients suffering from this disease, when any parameters established to decide which lives matter more than others are ethically unjustifiable and must be resisted? No logic that seeks to decide who lives and who dies should be normalized. Producing tables and figures, reducing existence to a numeric value, and feigning a kind of objective “neutrality”: this cannot be the labor of philosophy. The question that philosophy is obligated to pose, insistently, goes beyond this: How did we get here? That is to say, what economic, social, and political conditions, what decisions, have led us to this state of resource scarcity in which we are forced to decide who lives and who dies, or who deserves good, life-protecting conditions and who does not?

It is also philosophically necessary to engage in existential reflection on old age, precarity, poverty, and death. But to turn philosophy into an instrument that provides reasons and arguments to justify barbarism is to reduce the possibilities for thought, and abruptly to turn philosophy itself into a hideous ideology of discrimination, exclusion, and necropolitics. What we need now, urgently, is critical reflection on what is happening in Mexico and throughout the world.

Are there ethical criteria that can be used to guide sovereign decisions regarding life and death? Will philosophy take on the job of executioner? Can philosophy build a set of justifications for a decision based on the most unjust and immoral principle? No. Categorically, no. The task of philosophy is to argue against the instrumentalization of supposedly universal criteria for deciding who lives and who dies. Philosophers must question our unacceptable present, a product of the cruelest inequalities, a present in which not all lives are valued and not all bodies receive timely or sufficient medical attention. In this country, economic conditions are a permanent triage in terms of health. This pandemic has become a magnifying glass, making what we already knew about inequality and our precarious public health system even clearer.

In the field of philosophy it falls to us to denounce these conditions, and to insist on the urgency of building a better future in which there is a universal healthcare system, and in which medical teams are never again forced to decide what no one should ever have to decide. Not in times of pandemic and, above all, not as a daily practice in the country’s poorest regions.

The task is not, then, to justify triage or argue for its inevitability, but to point to what lies behind and preconditions it, in order to begin a search for a corrective moral project where all lives and deaths will have dignity.

The fundamental criterion that has been established in several countries is ageist, which is to say that it privileges saving the lives of young people over those of the old. Fortunately, in Mexico “the complete lives system” (vidas-por-completarse), the criterion used in the Guía Bioética de Asignación de Recursos de Medicina Crítica (Bioethical Guide to Critical Care Resource Allocation) developed by the Consejo de Salubridad General (General Health Council), has been overturned.1 In this context, “completion” was defined as transit through developmental stages (childhood, adolescence, adulthood, and old age), although the criterion was of course far from transparent. The new criterion in Mexico, stated but not yet confirmed, will determine who will receive more benefits from the treatment, according to a Sequential Organ Failure Assessment Score. Here again, treatment is a matter of quantification and getting the right score.

There are, however, no ethics in deciding who lives and who is left to die. On the contrary, this practice is irresponsible: the announcement that young lives would be given priority in receiving medical attention has generated panicked reactions and fear. The population over seventy years of age should not have been told that their lives were worth less and would be sacrificed for the sake of saving younger lives. Where was the ethical discussion of this? How could we have contained what this provoked in the imaginations of older adults? How can we make the general population aware that access to health must be for everyone, without any kind of discrimination? How do we assuage the fears of those who suffer from diabetes, hypertension, cancer, HIV, and other chronic illnesses now classified as comorbidities that deduct points from the calculation of life expectancy? Will we do this by telling these people that a chart of quantifiers exists by which their destinies will be neutrally decided? Philosophy must be wise and rise to the challenge of the circumstances.

In an argument that recalls Aristotle’s Nicomachean Ethics, Arnoldo Kraus considers the possibility of analyzing the value of a life by referring to the past.2 He suggests that a possible determining question could be: what has this person done for the lives of others? Have they maintained a social commitment or been indifferent in the face of other people? Kraus does not defend this criterion but only raises it for discussion. Regardless, we can readily question an argument that assigns value to a life by prioritizing its past over the value of its possible future. We have seen that the activist whose life Kraus takes to be exemplary may commit feminicidio tomorrow, and we have also seen that the ex-convict may well become a hero. There are no universal ethical criteria that can be used to determine who lives and who dies.

We cannot deny the reality that is about to reach us. Soon, medical teams will have to decide ethically undecidable matters in the midst of this devastating crisis. But we must remember that this abuse that we are about to ask of medical teams is a product of a societal failure, of a fractured health system. We are indebted to healthcare professionals and should demand that after the crisis, in addition to providing them with bonuses and benefits, the state should care for their mental and moral health. Deciding the undecidable will cost them, and it will be up to us as a society to support them in what is to come.

In this context, it will also be important to resist and condemn the foreseeable and immoral global battle for resources to fight COVID-19. We hope that Mexico’s proposal to the UN, meant to avoid the hoarding of supplies, will lead to actions in keeping with the spirit of international solidarity. This, in some way, might allow for a more equitable distribution of materials for the treatment of the disease and minimize the practice of triage.

We therefore call on philosophy to deconstruct the historical conditions that made this humanitarian crisis possible and to consider normative horizons that would allow us to aspire to a better future. In this sense, philosophy’s task is not the justification of the ethically unjustifiable, but instead the critique of history and of the naturalization of inequities that the nation’s neoliberal project has promoted, leading to this apocalyptic scenario. This scenario was not inevitable but was created over time, in and through a national project that never treated health as a common good or a universal, free, public right.

In Mexico, corruption has reached scandalous and exterminatory levels. Funds have been diverted, and the health sector has been stripped bare for decades without state investment. Let us never forget the children in the state of Veracruz given water in place of chemotherapy. Let us never forget that Seguro Popular (Popular Health Insurance), which is in fact neither popular nor reliable, exacerbated health inequalities between states and reproduced deficiencies and privileges (while also functioning corruptly as petty cash for governors who should be in prison). We mention these examples in order to call to mind only two events in the ongoing infrastructural and moral disaster that has destroyed the Mexican healthcare system.

The instrumental rationalization of triage is unethical. It is a utilitarian ideological mechanism that we cannot condone. The justification that supports this scenario compares it to a war and claims that in war these kinds of difficult decisions must be made; but no one can make this decision and pretend it is philosophically justified. This is a pristine example of the perversion of reason that naturalizes violence and forgets that the decision about who lives and who dies is one that, on moral principle, one must resist and speak out against.

About the Author

María Antonia González Valerio and Rosaura Martínez Ruiz

María Antonia González Valerio is Professor in the Faculty of Philosophy and Literature and teaches in the postgraduate programs in Philosophy, Philosophy of Science, Art History and Fine Arts at the Universidad Nacional Autónoma de México (UNAM). She is the author of the books Cabe los límites. Escritos sobre filosofía natural desde la ontología estética (México: UNAM/Herder, 2016), Un tratado de ficción (México: Herder, 2010) and El arte develado (México: Herder, 2005).

Rosaura Martínez Ruiz is Associate Professor of Philosophy at the Universidad Nacional Autónoma de México (UNAM). She is the author of Eros: más allá de la pulsión de muerte (2018), Freud y Derrida: escritura y psique (2013) and the editor of Filósofos después de Freud (2016).

  1. The criterion discussed in Mexico was taken from G. Persad, A. Wertheimer, & E. J. Emanuel, “Principles for Allocation of Scarce Medical Interventions,” The Lancet 373 (2009): 423-431. []
  2. See Denise Maerker’s interview with Arnoldo Kraus on Atando Cabos, https://www.radioformula.com.mx/audio-y-video/audio/20200415/el-triage-no-es-algo-nuevo-en-los-protocolos-de-medicina-en-mexico-arnoldo-kraus/. []

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