Senior Fellow in Ethics at the Culture of Life Foundation, RJ Snell, considers the difficult choices facing health care providers in the time of Covid-19. How can Catholic moral teaching inform these choices and ensure they are made humanely?
Cy Kellett:
Hello and welcome again to Catholic Answers Focus. I am Cy Kellett, your host. And in the midst of this Coronavirus pandemic that we are all struggling through together, first of all, many blessings to you and your family and with lots of hope that you are getting through it all right and staying close to the Lord. But as we go through this, certain ethical and moral issues come up that don’t come up in ordinary life and ordinary times. So we thought we would take an episode of Focus to discuss some of those ethical and moral things that have come up. Dr. R.J. Snell has a piece currently called The Coronavirus Pandemic and the Ethics of Triage. It appears on the website of the Culture of Life Foundation. Dr. Snell, thank you for being with us.
R.J. Snell:
Oh, very good to be with you, Cy. Thank you for having me.
Cy Kellett:
Dr. Snell is the director of academic programs at the Witherspoon Institute in Princeton, New Jersey and academic director of the Aquinas Institute for Catholic Life at Princeton University. He’s a contributing editor of Public Discourse and serves on the editorial board of Method Journal of Lonergan Studies. He is also senior fellow in ethics at the Culture of Life Foundation and its institute of Ave Maria School of Law. I think your article caught a lot of people’s eye because on a normal day, we don’t expect this to be anything other than a hypothetical question, the question of triage. I’m glad you were prepared, but are you surprised that you’re encountering this in real life?
R.J. Snell:
Well, for most of us, or for many of us in the developed West, this is not something that we think about very often where we’re used to showing up at an urgent care clinic or showing up at the doctor’s office and the idea of scarcity rarely crosses our mind. Obviously there’s people who have exceptions to that, but it’s not part of the ordinary public conversation in the United States.
Cy Kellett:
As a matter of fact, I think we’re almost uncomfortable with the idea that triage exists at all. Sometimes when people say, well, choices have to be made, the response is almost being aghast at that as if it’s immoral to say that we have to make choices and in some cases, life and death choices.
R.J. Snell:
Well, it certainly is stunning and can often reveal that a tragic situation is underway. So being aghast at it is of course a normal human response, but it’s not outside of the realm of possibility and certainly in ordinary or extraordinary human experiences of wartime pandemic, hard decisions need to be made, which is not to suggest that immoral decisions need to be made. Even in a condition of triage, we’re bound by the laws of reason and morality, which is what I wanted to explore here.
Cy Kellett:
Now, normally when we think about triage, we think about wartime and we think about maybe a terrorist attack or something like that. We don’t usually think about the triage being something that happens in our community hospital, for example. So are the principles that might govern these decisions, the same principles as we would encounter in a battle zone or at the moment of a terrorist attack? Or do we have to apply different principles given that this is right in the heart of our communities?
R.J. Snell:
Well, of course it was conditioned like warfare assuming that we’re dealing with combatants, the situation is different in the sense that we’re dealing with those who are aware of the possibilities. They’re going into a war zone or something like that. When you’re dealing with terrorism, you have non-combatants and oftentimes in very short order, you already have a flood of people showing up at the hospital in ambulances worrying in and out. The situation here is somewhat different in the sense of the peace of admittances to the hospital or at least thus far and yet the principles or experiences that a physician or a doctor would face can be very similar. Short resources, short amount of time, and many people demanding care simultaneously.
Cy Kellett:
Well, so some might think, well then what you do is you save the young and the healthy. I think that’s a gut level response I suppose. But is that just dangerously simplistic?
R.J. Snell:
Well, I think we all, or certainly I will understand that as a gut level response. I’m the father of five young children and I could certainly imagine a scenario where I showed up at hospital with a young child laboring to breathe and the thought would cross my mind, help my young child first rather than that person over there who looks as if they’re not well and well on in years anyway. And yet that gut level response, while I can sympathize with it, is in fact not expressive or regulatory of the real moral principles which underline, sorry, which underlie the situation, let alone the teachings of the church. My own understanding here is that the teachings of the church and these sorts of matters and that which is demanded by reason are precisely the same. What the church teaches here is true.
Cy Kellett:
Well, what about the person who might say, and even we might be this person depending on the level of panic we might be experiencing, look, normal moral law just doesn’t apply in situations like this? It’s negated really.
R.J. Snell:
My understanding and what I argue for in the piece is that every instance of human action, which is a voluntary action, not like respiration or something, but something that we are in control of is always governed by the moral law. And that because of God’s providence and because of the nature of human action, there is no situation possible on earth where the moral law is rendered nugatory or inoperative. We’re always bound by morality. Now, the question of what that means prudentially that can perhaps develop or alter somewhat, but the idea that morality is set to the side because of crisis, I would reject that. I would think that’s false. Understandable. And we in fact even have a kind of sympathy or pastoral awareness for people who would make such a judgment, but they would still be false.
Cy Kellett:
Okay. So what about the person who is… We’re all celebrating the front line people and I think it almost seems like a moment of return to health that is not celebrities or politicians currently being celebrated or wealthy people, but it’s people who put on the face mask and head into the emergency room. At what point do they not have to do that? What point can they just say, no, this isn’t what I signed up for?
R.J. Snell:
Well, everyone who is a medical care provider is just as an ordinary human being bound by the moral law. But there’s also professional codes of conduct and ethics which govern healthcare providers. And many of those guidelines have dealt with triage or scarcity situations long in advance and a well-prepared physician or a healthcare system or a hospital is aware of that. But one of the duties that a healthcare professional takes upon him or herself just by being a member of the guild or the profession is the duty to care. And in situations of crisis, that duty to care is not rescinded.
Cy Kellett:
Okay. So the basic morality can’t be thrown out. We can’t just say, no, you’re sick. I’m not coming to treat you if I’m a doctor or a nurse or something like that. But you go on to say that when we’re in these conditions, and by the way, I’m referring to the article, The Coronavirus Pandemic and the Ethics of Triage, which is available from the Culture of Life Foundation, you go on to say that providing care under conditions of triage or resource scarcity involves care for the patients and the system of care itself. What does that mean?
R.J. Snell:
So while, let’s say a nurse or a physician, both by the universal principles of morality and by their own professional code of ethics is duty bound to show up to provide care, they can’t stay home because they’re afraid. As sympathetic as we might be to that desire, they have young families and parents and so on, they’re humans just like the rest of us. It’s also the case that when you’re dealing with the triage situation, we don’t simply have the patients in the hospital today. We have the patients who’ll be coming in tomorrow or the patients who might be coming in next week or next month.
Healthcare providers and systems of health, like a hospital or an insurance company, their situation and the difficulty they have to decide is exacerbated because it is irresponsible for them to exhaust their resources in one day knowing that there will be the need for care tomorrow and next month as well. So they have to provide for the infrastructure itself. They can’t exhaust their resources nor can they exhaust their personnel or so risk their personnel that there wouldn’t be physicians or particularly those with specialized knowledge. So you can imagine someone who is an expert in the virus, we have to protect that person so that they can meet their duty to care tomorrow and next week. That’s their situation to be.
Cy Kellett:
All right. We see in the disaster movies, at some point somebody has to tell somebody, get some sleep. But that’s actually what you’re saying. Is that’s actually true? You can’t just have a doctor that you wear out. You’ve got to take care of the doctor as well as the patient.
R.J. Snell:
Part of meeting their own duty to care is providing for themselves so that they can continue to care.
Cy Kellett:
All right. Well, if we move on in your points in the piece, you say when we talk about triage, we’re prioritizing some over others and you say the standard should be greatest need. Explain why that should be the standard over another standard.
R.J. Snell:
Yeah. In the literature you’ll see various options batted back and forth. For instance, one example would be greatest need. So you have someone who comes in who is very near death and you have another person comes in who is in extreme discomfort. Under ordinary conditions, we already make those distinctions. You show up at an emergency room and the person who is hemorrhaging, you care for before the person who is just in some minor pain. Obviously that gets exacerbated when everyone is in great need, but the principle of greatest need is you care for those who are in the worst shape as it were. But other options that people suggest or entertain when it comes to triage, situations of scarcity would be first-come. Whoever shows up first gets first care and if you happen to be last in line, you’re last in care. Or another option that some people suggest is lottery. You have 10 people show up and you assign everyone a number or you pick a straw and whoever wins, wins. Lottery and first come, while they have a kind of intuitive sense to them, they seem to appeal to a kind of fairness.
The child says first come first serve and lottery seems to be blind. Then in many ways it doesn’t seem to smack or privilege. Neither of those are full exercises of intelligence or reason. Just as in the ordinary emergency room we make judgements of caring for those who have greatest need just as the ordinary demand of intelligence, that’s what we do in triage as well. Now, of course we have to trust the expertise and good judgment of physicians and nurses to make those sorts of judgments. There is not, as far as I know, a universal moral code to determine greatest need. That relies upon the expertise and the judgments of those who are well-formed at a particular field. Eyes and ethicist can’t answer that question, that physician has to.
Cy Kellett:
Right. So maybe an example might be someone’s struggling so hard for breath that their blood oxygen level is very low. You know that if you don’t put a tube in them, they’re likely to die and then the next person struggling for breath, but their blood oxygen level is fine. You’re actually taking a lot of practical considerations of how long can the person go without care to determine this. The underlying moral principle stays the same. Whoever needs me the most as the doctor, as the nurse, I’ve got to attend to that person first. A tremendous number of practical considerations come in in order to make that evaluation.
R.J. Snell:
That’s the practical judgment of the physician or the nurse, someone who would know. The physician needs to judge who wound to attend to first. What they’re not morally entitled to do is to refuse care or to withhold care. But there is this caveat or this difficulty in a situation like triage. They’re not allowed to withhold or to refuse available care. If care isn’t available, there’s not a ventilator. If care isn’t available, there’s not a physician ready to hand. One is not refusing treatment or withholding it. You need to prioritize the available care that you have.
Cy Kellett:
Could you just say something about our limits even in making practical decisions in these situations? Because the experience we all have of someone that we’ve seen in a movie or we’ve met is that they were in an intense situation where a practical decision had to be made and they feel now that they made the wrong decision and they can’t let go of it. But if you ask them about their will, they wanted to do the best they could but they just can’t let go with the fact that they got it wrong. So could you just address the idea of limits and the fact that we’re probably going to have healthcare providers in a few months who really are scarred from the fact that they didn’t get it right in a situation or maybe in multiple situations?
R.J. Snell:
Yeah, it’s such a great question. As someone who’s a believer and a Catholic, it seems to me that we have a remarkable opportunity to provide pastoral care to those who in a few months from now maybe wrestling with their decisions and the grief of losing patients and so on. Both in extraordinary situations and in everyday mundane situations, we make mistakes. I’m a parent of five children and there are occasions when I’m trying to provide advice or counsel or correction for a young child and I’m operating out of goodwill. I’m not operating out of culpable ignorance. I’ve done my work, I’ve learned the situation, I’ve done what I think is correct and a week later, an hour later you realize, yeah, I really miss handled that. It makes sense that we feel a subjective level of guilt about that. I was wrong or I made the wrong decision.
It could have been otherwise. And yet in the situation like this, if a physician is acting out of goodwill, not intending or knowingly violating the moral law, is following the best of his or her medical knowledge and expertise and has previously done his or her homework, they’re well trained, they kept up to date, they knew the options available to them, the feeling of guilt that they may have while understandable, there’s not much culpability for their action. They should feel relieved of their guilt. Although it’s of course an utterly understandable human reaction to feel that way.
Cy Kellett:
Well, there’s another problem with the greatest need thing however, in making practical choices on that level and that is that someone might come in who only he’s got a few miles left on the tires so to speak. Or maybe this person already has underlying disabilities and deficits in their life that you see the healthy 12-year-old otherwise. I mean, healthy 12-year-old come in and all things being equal. It seems like you prefer the 12-year-old. What am I getting wrong there or am I getting anything wrong there?
R.J. Snell:
Well, again, it makes so much sense in some ways with our gut level instinct and yet I do think that isn’t an incorrect position, not just reasonably but something which violates the moral demands. Several weeks ago already, there were some statements and guidelines released by various organizations in which age and disability emerged as preeminent factors for determining who to prioritize and who to restrict care from. And you can imagine that there were some responses to that which thought of those as being untoward responses. Someone with a disability comes in and you don’t provide care for them. You can imagine why disability groups were unhappy about that. I think morality is also unhappy with that position. Age and disability are not relevant standards for determining priority of care. I would argue and I think the moral position is that greatest need is the standard and that while comorbidities are perfectly moral to consider when determining greatest needs.
R.J. Snell:
If I have two patients, they’re on identical circumstances, but one is very unlikely to recover even with the provision of care and the second person is very likely to recover. Then in triage, we first provide care for the one who’s likely to recover. But that’s about likelihood of recovery, not about any judgments about quality of life or length of life or how much life they have to live. It’s not the doctor’s judgment and envied it’s not a moral judgment in my argument to suggest that because someone is cognitively disabled, their quality of life is such that we can allow them to die. I reject that as a position. So we have two patients who come in. One is severely cognitively disabled but likely to recover with care and in great need. Second patient is likely to recover, it is in great need but has no disability. Those are people in identical situations and disability is itself not a relevant criteria. [crosstalk 00:19:18].
Cy Kellett:
This strikes me as something that, this is very ground level really at a fault line in our culture where some life is more important than other life. It seems to me almost that the argument that you’re making could be an argument that people would have over abortion just as much as it would be over who’s going to get to go on the ventilator. Somehow the disability of the child changes the calculus. In this case, [inaudible 00:19:55].
R.J. Snell:
We shouldn’t be surprised, although sadly and tragically we shouldn’t be surprised to see that in our own society where abortion and euthanasia and assisted suicide is either accepted or growing in acceptance either legally or just through societal attitudes. We wouldn’t be surprised to find people in situations of triage suggesting that there are some who are more persons than others. And that the unborn is less a person, the very old is less a person or someone who’s disabled physically or cognitively is less a person. I reject that and the church rejects that and I think reason rejects that. Dr. Seuss knew it already. A person is a person no matter how small, a person is a person no matter how old or no matter how incapable of walking or thinking at that moment. Personhood resides with and in and as the human being. It’s not an accident which comes and goes. Every human being is a person and every human being is equally a person. So judgments of disability or age are to be avoided as morally reprehensible when we’re dealing with triage.
Cy Kellett:
Would that same standard apply to the moral quality of a person’s life? Say a pornographer and a, I don’t know, a school teacher come in, we can’t consider our judgements about their moral character either. Am I correct in saying that?
R.J. Snell:
That is certainly true. Just as we would think that distinctions of our race or gender or creed would be morally wrong to use if you’re a physician in this situation, so to the moral character of the patient. Again, we can think of the film situation where the murderer comes in and is in one bed and the person who they’ve attempted to murder, who’s on their last heartbeat is in the bed next to them. Those are morally equivalent persons with respect to healthcare.
Cy Kellett:
Okay. We’ve talked about when to commence treatment, but what about, look, you put somebody on a respirator and they’re not doing well. That respirator remains a scarce resource to someone or to this hospital. Say we’re a hospital in Spain. We’ve only got this number of respirators, we’ve got this growing number of patients. This guy has been on a respirator for a week and showing all the signs of approaching death. What’s the calculus there?
R.J. Snell:
Yeah, it’s very similar to greatest need. Just as when patients come in in triage, physicians would need to adjudicate who is most likely to recover and who’s in most need to have recovery. And there’s a complicated calculus there. So too, once treatment has commenced, there are periods of re-evaluation. So if we only have one ventilator and one person is in terminal decline despite our best efforts at their recovery, while we can never remove normal basic care from them, we can’t remove a feeding tube for instance, we can’t under conditions of scarcity remove a ventilator. Because we’re not withholding care, we are making available the care that we have and so we’re providing care to the one who now needs it and is likely to recover.
Cy Kellett:
This seems to me to require an act of differentiation in the mind that is very precise and that we are virtually incapable of doing in our society. That there’s a distinction between removing the ventilator from the dying person to save the next person and killing the person who’s on the respirator. That many people cannot make that distinction. So help me with that.
R.J. Snell:
Yeah. Catholic social thought is deeply informed by a principle, which is called double effect. Which I’ll try not to get lost in jargon here, but essentially means this, if you knowingly engage in an action which would result in a consequence that you do not itself wish, it will happen, but do not intend or wish for it to occur. That may be objectively a tragedy, but your intention is morally fine. So if I’m a physician and I need to take a ventilator from one patient and give it to the next, knowing that that first patient may very well suffer or even die as a result but I do not intend for that to occur, nor am I intending to withhold care from them. In fact, I’m going to provide all the available care that I have. Then there’s two effects of my action.
One which I’m choosing directly, which is to provide care and the ventilator to the second patient. And there was a second consequence, which I’m not intending and I’m not choosing, even though my action will lead to that result, which is perhaps the death of the first. So long as I’m not knowingly and directly intending to withhold care from that first, I have a tragedy but not a moral wrong. And that’s quite different from euthanasia say where I knowingly and directly withhold care so that the patient dies.
Cy Kellett:
Well, actually this is a point where the euthanasia advocate might say, look, you take that person off the ventilator, they’re going to drown in their own lungs here. That’s cruel. Even if you agree with the moral calculus that it’s okay to take that respirator because you have someone who is probably going to make it, why are you just going to let this person drown? Why not just fill the syringe with morphine and get it over with?
R.J. Snell:
Yeah. It’s certainly the case that normal basic care includes palliative care and so someone who is, let’s say drowning, which is certainly the horrifying situation that some are facing and will be facing. Palliative care can include all forms, all normal forms of mitigation of risk and pain, but still one may never knowingly indirectly take a human life. It is a universal principle that it is wrong to knowingly take a human life even to minimize suffering. One can, however, attempt every available normal available moral form of reducing their suffering. Even knowing that the medication that one provides that reduce suffering may shorten life, but you may not provide the medication in order to shorten life.
Cy Kellett:
The dose that may have the propensity to hasten, but it’s actually providing pain relief is what your intention is then we’re back to double effect. Is that right?
R.J. Snell:
We’re back to double effect. But there can’t be any cheating. There can’t be a sort of, Oh, I’m going to pretend to hear that what I’m trying to do is minimize pain, but what I’m really trying to do is hasten death. But you may certainly and morally attempt to reduce pain knowing that administering this medicine may shorten life, but you’d have to not wish that were the case. You’d have to not choose that. Again, we’re dealing with a tragic situation here. This is not an ordinary circumstance. This is an end of life situation where death is imminent and you are providing care to preserve their life as best you can.
Cy Kellett:
Okay. I don’t know if you heard about this, but there was a story about a priest who was on a ventilator and a young person came in who clearly needed the ventilator. The priest asked to be taken off the ventilator so that it could be given to this other young person and the priest subsequently died. Did he do something wrong by refusing the ventilator at that point?
R.J. Snell:
Yeah. I suspect that we’re going to hear story after story of people who act out of charity. People who in some sense give their life for another and there’s no greater love than this than to lay down your life for a friend or for a neighbor. Justice does not demand. There is no demand of justice, that if I were on a ventilator that I give it up for another. But charity allows me to give up a ventilator for another and that charitable act may be praiseworthy for me giving it up.
With this caveat, so long as I am not intending my death, so long as I’m not deciding this is now unendurable, I’m going to give up my ventilator so that I will quickly die. That would be impermissible. But giving up a ventilator, knowing that it may result in your own death so that another may live is not just permissible, but praiseworthy is inactive charity, but it’s not required by justice. It’s in ethics, what we would call a superogatory act. It goes beyond justice. Goes even beyond the minimal demands of morality and is inactive of real and praiseworthy charity.
Cy Kellett:
So I don’t do an evil by staying on the respirator when other people also need that respirator. I don’t do any evil in that case, but if I do surrender the respirator, in that case, it may well be that I’m so long as motives and things are correct, that I’m acting out of love. But no one should require that of me or look at me askance if I continue to breathe so to speak, stay on respirator.
R.J. Snell:
It would be a hard truth and it’s something we’re thinking about that if I and my 13-year-old were in the hospital beds beside each other, I would have charity immediately give up my ventilator for her and there would be something praiseworthy about that. But in terms of justice, those two lives are equal, mine and hers. But of course, I would give it up.
Cy Kellett:
I think my wife’s listening probably, so I would too. I’ll go go if I would too. You conclude your points. I want to give this to folks again, the name of the article and I think you will find it very helpful is The Coronavirus Pandemic and the Ethics of Triage. You can find it for yourself or share it with others at the Culture of Life Foundation. That’s culture-of-life.org, which is the Culture of Life Foundation and you’ll find it. And then the author you’re looking for is our guest, Dr. R.J. Snell.
You conclude your 14 points there with something that we spoke about a little bit, but I like to circle back to it again because I was very impressed that it was here. Let me just read to you what you wrote and then get your commentary on it. Point number 14 is, “Moral demands remain human and humane. Actions which may be objectively wrong in themselves may entail very little or no subjective culpability if the agent acted in ignorance or without full consent or in confusion or crisis when it would be unreasonable to expect the agent to have full knowledge or ability. That is, morality is not unkind or unfeeling to those who act in moments of grave difficulty even though the demands of morality remain in full effect.” Can you explain what that means?
R.J. Snell:
So when it comes to morality, we make a distinction between the objectivity of the act itself and the subjective culpability of the actor, the agent. I can imagine many, many physicians, nurses, healthcare providers, just as in the example that you mentioned earlier, two months from now, second guessing themselves feeling guilt of what they’ve done. We can just make a distinction between a physician who acted wrongly in an objective sense and who intended to do so.
That person, their action was wrong and their own disposition and subjective culpability is wrong. As opposed to a physician who with great earnestness in a position of great difficulty, a crisis bells and alarms going off and ambulance is showing up, acted in the best manner that they knew how, but who made an objective mistake. They made the wrong choice and yet we would think of their subjective culpability as very low or negligible or even non-existent. We wouldn’t offer any moral blame to them. We would offer them a sense that morality itself is kind, that we offer them our companionship, our care, our sympathy, but not our condemnation in any way whatsoever. The same wrong action objectively from a point of view of one who knows from the outside can result either in our blame or our praise to an agent, or at least our forgiveness of an agent.
Cy Kellett:
Dr. R.J. Snell is director of academic programs at the Witherspoon Institute in Princeton, New Jersey and academic director of the Aquinas Institute for Catholic Life at Princeton University. He’s also a senior fellow in ethics at the Culture of Life Foundation and its institute at the Ave Maria School of Law. You can find his article once again, I’ll just repeat it for you. The Coronavirus Pandemic and the Ethics of Triage at the Culture of Life Foundation. Dr. Snell, thank you very much for taking the time to have this important discussion with us.
R.J. Snell:
Oh, thank you so much for having me on. We’re in a difficult situation and it’s important for all of us to think ahead of time about what is good and not good to do so that in a moment of crisis we’re well informed.
Cy Kellett:
Amen. Amen to that and thank you for all that you do to make sure that our society and those in it remember dignity and the value of every single human life. It’s a great inspiration to get to talk with you about these things. And thank you to our listeners. Again, we persevere together. God bless you and I know many people are facing very, very difficult circumstances. We’re praying for you every day at Catholic Answers. Please pray for us. We’ll all pray for one another and soon, I am sure in God’s good time, we will be through this. We’ll see you next time God willing right here on Catholic Answers Focus.