In light of recent natural disasters, attention has been drawn to the practice of “absolute triage” (the decision to treat some injured persons first, based on an assessment of their likelihood of survival, with the knowledge that delaying or denying treatment to others will likely result in their deaths).
A. How might a utilitarian argument justify the practice of absolute triage? For the purposes of this question, utilitarianism may be understood as the view that we ought to do those things that promote human happiness and reduce human suffering for the most people.
B. How might a Christian moral theological argument justify the same practice? In this part of your answer explain the relevant facts of the case, and the principles, criteria, and authorities, including Holy Scripture, that you would bring to bear on the way in which you approach the question. Explain how these authorities relate to each other.
Tragedy is an innate aspect of human existence; to be embodied is to risk the attendant pain and tragedy. Nothing highlights this reality more acutely than the series of natural disasters that have struck various parts of the globe over the past few years; from the tsunami to hurricanes to earth quakes, the fragility of human life and our inability to exert supreme control over our environment has been dramatically displayed. In the midst of such tragedy we are often forced to make difficult and painful decisions. These decisions then tell stories about our character and who we perceive ourselves to be, both in the process by which they are made and through the way we react to them afterwards.
One of the painful practices often necessitated by disastrous events is the need to engage in what has been termed “absolute triage,” i.e. the “decision to treat some injured persons first, based on an assessment of their likelihood of survival, with the knowledge that delaying or denying treatment to others will likely result in their deaths.” Events have only recently raised this issue to the fore of societal consciousness, yet it is a decision the reality of which military doctors and chaplains have been forced to deal with for generations. As is so often the case, the horrors of war mirror in a heightened and condensed way the common reality of life in a fallen world.
From a strictly utilitarian (the maximization of happiness and reduction of suffering for the most people) point of view the choice to engage in absolute triage makes perfect sense. Whether in a civilian or military setting, the utilitarian recognizes that limited resources and capabilities necessitate their most effective use. In this case the decision to treat those patients with a higher likelihood of survival first, means that at least some of the injured will live, while operating from another framework or from the reverse, i.e. treating the worst patients first whether they are likely to survive or not, could result in the deaths of many more.
A robust utilitarian viewpoint might necessitate going even further however, beyond the immediate question of which patients have the highest likelihood of survival to the question of who or what their patients are. The famous example of this is the question of whether one would choose to save the President of the United States or a janitor in a given situation. The obvious answer from the utilitarian viewpoint would be that one would first treat those patients with the highest likelihood of survival and order their treatment based upon any knowledge one might have of their possible contributions to the good of society. The danger here of course, is that any notion of worth is much more subjective than an evaluation of survivability.
In contrast to the utilitarian viewpoint, a Christian understanding would also support the implementation of absolute triage when necessary, but would do so for different reasons. The Christian shares with the utilitarian the concern that the best possible use is made of all available resources. Like the utilitarian, the Christian is initially concerned with saving the most people possible, and allocating resources accordingly. Yet where the utilitarian view is almost exclusively anthropocentric, the Christian perspective is shaped by an understanding of who God is as well as by a distinctively Christian anthropology that informs our understanding of who we are.
This Christian anthropology is one that is primarily theocentric, being based upon the premise that humanity is created in the image and likeness of God and therefore derives worth from this principle, this unique relationship with God. Because of this affirmation about the nature of humanity and our God, a Christian is bound to make choices in view of what would offer the most people the chance of survival. And yet, this affirmative task of saving as many patients as possible is balanced within the Christian consciousness by the recognition that those who will die are also images of God. There is no sense in which a Christian would be able to disown the fact that their decisions may have resulted in deaths, most of which would perhaps have happened anyway, but which would have been more bearable had action been taken. And yet, the recognition that there are situations in which everyone cannot be saved is important. In this sense then, a Christian perspective is able to maintain a sense of the tragic that may be unavailable within a utilitarian framework.
The decision of the Christian to engage in absolute triage is based upon an affirmation of common human identity as created in the image of God; this leaves little room for any distinctions beyond survivability. Again, it is important to note the element of tragedy in this, a sense of which is an important aspect of any Christian response to disaster. Any disaster that takes the lives of human beings is tragic on multiple levels: it is tragic because it cuts short the life of a human being created in the image and likeness of God, it creates pain among those friends and family members who are left behind and in a broader sense, is tragic because it stands as a testimony to a fact of our existence that is not part of God’s will for us, death having entered the world by sin. This understanding is under-girded by the understanding that our world is imperfect and fallen and that nature too groans for redemption, as Paul says in Romans.
Such recognition of the fallen nature of the world is the only means by which Christians might be able to move forward through extreme tragedies and hardships. In such a world, Christians must reject the desire to explain all decisions away as positive and unblemished goods. There must be recognition of the scriptural mandate we are under to care for the afflicted. Christ healed the sick, cast out demons and raised the dead. These miracles stand as both testimony and mandate that we, followers of Christ, do all within our power to give comfort and aid to the afflicted and to heal the sick. This is part of what it means to be imitators of Christ. The call to minister to the afflicted is one that the Christian cannot avoid, with all its attendant risk and pain.
Because of Christ’s ministry here on earth, and the commandments he left with us, we are called to minister to our brothers and sisters, to convey the love of God. At the same time Christ’s example, his death on the cross, should illustrate that there are some situations out of which we cannot expect to come unscathed or unstained. And yet if Christ was willing to bear the sins of the whole world upon himself, then his followers should be willing to bear the possibility of guilt in a situation wherein painful decisions are called for. Indeed, there is a necessary humility to be found in making such difficult decisions. This humility comes from the recognition that, as Rowan Williams points out in his book Lost Icons, every choice I make will somehow limit someone else—the idea that I am a free agent and can make choices without consequence, without necessarily restricting the choices of another, is a myth.
When taken in this context, when we have accepted that our mundane decisions can have consequences, it becomes somewhat easier to accept our human frailty and our culpability and recognize that momentous and difficult decisions are not aberrant in their tendency to affect others, only dramatic in their consequences. This is an important realization because decisions are necessary in all aspects of our lives, including these tragic circumstances. We have to be willing to accept responsibility, to recognize the nature of the world in which we live and step up to the task of making the painful choices we’re called to. Such is the lesson of Dietrich Bonhoeffer’s decision to participate in the plot to assassinate Hitler. Bonhoeffer never attempted to explain away his actions—or the actions of any of his compatriots—as a positive good; rather, he demonstrated that there are choices that present us with degrees of evil, and sometimes refusing to recognize the harshness of the truth and choose anyway is the greater evil or sin.
Bonhoeffer’s situation is not all that different from the situation that faces those Christians who find themselves faced with the hard choices of who to treat or not treat. There is no denying the fact that such choices are often tantamount to determining who lives and who dies. In the situations where such decisions are necessary however, it is more likely that such choices determine who lives, since not choosing would mean that most or all would die. It would be a grave sin to allow many to die for an inability to muster the moral courage necessary to make a choice, and live with the consequences. For some, the refusal to make these decisions could be the result of fear—fear of guilt, fear of reflecting upon whether they chose the right people for treatment. For others the motivation could be pride, the refusal to let go of the belief that we can control every aspect of our lives, that somehow we can make a limited supply of medicine or supplies stretch, or we can keep our patients alive as they wait in line for treatment, without the need for difficult decisions. In reflecting upon these situations it is important that we keep our own human frailty in the forefront of our minds, that we never take upon ourselves the role of savior and in so doing fail miserably. Indeed, our Lord himself did not heal all who were sick, nor did he raise all who died from the grave like Lazarus. He suffered the death of John the Baptist and in the end did nothing within his power to stop his own torture and crucifixion. Jesus came to inaugurate the Kingdom, to announce the reconciliation of God to humanity and to open the path to everlasting life in the midst of the fallen and cruel world.
And it is in the time between the inauguration of the Kingdom and the final establishment of God’s rule that we live. In the time between Christ’s first and second advents, we are called to recognize the still-wounded state of the world and be prepared to make decisions that we would otherwise reject. Because of this, there are times when we must bear the blows of the world, but in doing so, we are called to witness to hope—the hope of miracles and forgiveness in our day, and the hope of everlasting life in the future, where we look forward with anticipation to the coming of Christ and the restoration of all things.