Sunday, June 28, 2009

Thinking About Swine Flu (2)

It’s always interesting when we are suddenly, often entirely unexpectedly, obliged actually to test the slogans and platitudes we offer up almost automatically to resolve whatever moral dilemmas life throws at us. The concept behind the use of those platitudes is clear enough: preferring not to think of ourselves as the kind of people who sidestep the obligation to resolve moral challenges, but also not really wanting to think through issues that risk rocking our personal boats by making us think too carefully about the way we behave in the world, we solve our problem by mouthing shopworn truths that sound as if they must be right, but which we haven’t really thought through carefully in years, if ever.

Just lately, I’ve been thinking about the concept of triage. (Triage is the term that denotes the obligation to establish the order in which too many people receive too few services—or too little food or too few drugs—not because all the individuals involved are not worthy recipients, but simply because there is not enough to go around. Someone will end up without, therefore…and the concept of triage, from the French word meaning “to sort” or “to divide up,” is applied to the effort to ensure that the distribution of said drugs or food or services be undertaken according to some reasonable principle, ideally one worked out far in advance and universally, or at least almost universally, agreed upon by the potentially affected.) Possibly, I’ve been prompted to think in this direction by the discussion surrounding swine flu—or rather influenza A(H1N1), as the World Health Organization has now begun more delicately to call it—and the specter of there being an effective vaccine available by this fall, but not in large enough quantities for everybody to receive a dose. But it’s also possible that I’ve had triage on my mind in the wake of seeing all those mutants doing battle to the death in the X-Men Origins: Wolverine movie and being prompted to wonder how exactly it is we can go about developing a hierarchy of value that celebrates human life in all its variations and subcategories without inevitably, if arbitrarily, concluding that some are more worthy than others.

The platitude I had in mind when I wrote what I did about moral sloganeering is the notion that all human life is of inestimable value. We say that—and we mean it, more or less—because it feels right, because it must be right to assert that no human life is inherently possessed of greater value than any other. Moving on from that truth, however, we would have to suppose that it will always be irrational to rank human lives in terms of their worth or their worthiness: the life of an elderly Alzheimer’s patient in the eleventh decade of life would have to be presumed to possess precisely the same value as the life of a healthy newborn. On some level, we do think that. I counsel people all the time not to devalue the worth of an elderly patient’s life merely because the prognosis is grim. One of the reasons I feel so queasy about the concept of euthanasia is precisely because it is predicated on the supposition that there is a point at which human life can become so utterly valueless that, even in a society that unambiguously condemns murder as a crime, the act of taking that specific life should not be considered a criminal act at all. But when forced to evaluate that idea in terms of the concept of triage, I come up against a kind of moral brick wall: if I really do think that all human life is of inestimable, therefore unrankable, value, I should find it not reprehensible or sinful but simply impossible to decide in advance who should get a dose of a vaccine that is not available in large enough quantities for all. And that is where I get into trouble, because, in the end, I can’t imagine that it could really be impossible to determine logically and ethically who should be vaccinated in such a situation.

Our tradition offers some counsel, but little comfort. In a different context entirely, the Talmud quotes Rav Nachman as noting that there are circumstances in which the fairest way for the court to proceed is simply to do nothing at all, to refuse to make a decision, and to step back and let the more powerful party prevail. Surely that cannot be the answer here, that we should just auction the vaccine off and let it be bought by whomever can pay the most! (That strikes me as being only slightly less absurd than letting people fight it out physically and then giving the vaccine to the winners.)

Another passage in the Talmud posits the situation of two travelers far from home who have only enough water for one of them to survive the rest of the journey. The situation is morally challenging in the extreme. If they split the water, they will both die. If one party drinks the water, he will live and the other will die. That surely sounds like the better plan in that it involves one death instead of two, but how exactly do the travelers decide which of them gets to live? One ancient sage, Ben Patura, taught that they should split the water and face their fates because it is preferable for them both to die than for one of them to be responsible for the death of the other. But Rabbi Akiba, taking a different approach, starts off by supposing that the canteen must be in the possession of one of them and not the other. That one, Rabbi Akiba teaches, has no obligation to give the water away because the Torah teaches that, in the end, every individual’s primary responsibility is to preserve his or her own life. To give the water away is tantamount to suicide, therefore a forbidden act. That another will die because one has safeguarded one’s own life is the less bad alternative. And sometimes, Rabbi Akiba implies, “less bad” is the best you can manage!

Do we really think that whoever happens to have the canteen in his possession should live? Even if we do, the situations are not really analogous. Those who do not take the swine flu vaccine will not necessarily die. There will be way more than enough for just the manufacturers themselves—the equivalent of the traveler in possession of the canteen—to be vaccinated. And other sources suggest other approaches. There is a passage in the Mishnah (in the tractate called Horayot), for example, that discusses the more analogous issue of saving lives or redeeming captives being held for ransom when there are not funds available to save or to ransom them all. The lesson is complicated, but the general principle appears to have to do with a two fundamental concepts: the number of people the death or the protracted imprisonment of an individual will affect, and also the human dignity of the individual in question. Therefore, if the choice is between saving a man’s life and a woman’s, the man should be redeemed first, presumably because his entire family depends on his income and will be made destitute by his death. But if we are talking about redeeming a captive specifically, then a woman should be redeemed first because she is considered at greater risk to be abused sexually while being held in confinement. The Mishnah even goes so far as to note that, in a situation where the captors are known not to distinguish between men and women as objects of abuse and violation, the man should be redeemed first (presumably for the reason given above—because, absent the ability to spare the one at greater risk from the degradation of rape, preference should be given to the one upon whom the largest number of people depend).

This last passage is the most promising, I think, in terms of thinking about triage issues as they relate to modern medicine. Obviously, the text reflects a world in which women were totally dependent on men financially and in which women could not be expected to go to work to support their families. But we can look past that detail at the underlying principles involved and find some interesting lessons to ponder. The Mishnah teaches that there is always a moral bottom line and that the specter of ultimate degradation trumps everything. But when we are speaking about saving people’s lives, the rational choice should depend on that person’s place in society.

I think we can combine these two approaches to begin to develop our moral thinking on the issue of triage as it might potentially have to be developed with reference to vaccination against the H1N1 flu this year. The most vulnerable should have precedence. That would probably include the very young and the very old, but it might also include all sorts of others who can claim to have greater reason to fear the flu than others. But the other criterion, the one of societal importance, should also be brought to bear and people whose contribution is critical for the orderly functioning of society—police officers, for example, or firemen—should be given precedence. Best of all, of course, would be for a way to be found to produce enough vaccine for all. Possibly, even, that is what is going to happen and we will never have to have this discussion about triage in earnest. But there isn’t always enough vaccine and sometimes there really is only enough water in the canteen to save one traveler.

I don’t know what the future will bring, whether this specter of a worldwide pandemic of flu will turn into something truly horrific or end up as a mere footnote in the history of epidemiology. Eventually, we will all know! But honing our ability to confront even most ethically ambiguous situations is precisely what makes us into moral beings, and that can never be a waste of time. (May 8, 2009)

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