On Triage

Utilitarianism emphasizes efficiency: Any action that fails to effectuate the maximum possible reduction in suffering is considered immoral. But isn't this standard for use of one's time and money too harsh? As long as one is making some sort of positive impact on the world, isn't that enough? Can't one live ethically without devoting all of one's energy and attention to helping others?

Example. Imagine a military doctor who comes across a battlefield laden with hundreds of injured soldiers in severe pain. The doctor calls for assistance, but the additional medical units will not arrive for thirty minutes. However, the doctor happens to have with him a bag of pain medicine that he can use to palliate the suffering around him. Would it be acceptable for him to treat five of the soldiers and then stop to read a comic book, arguing that he has produced some positive change in aggregated utility and he needn't spend all of his effort helping others? Similarly, would we countenance his decision to spend most of his limited supply of pain killer on the mildly injured patients nearest to him, even though many of those a bit farther away are in absolute agony? I believe that the answers ought to be "no." Rather, triage--giving greatest medical attention to those who can be helped most in the least amount of time--represents the ethical imperative under these circumstances.

Yet how are other situations any different? In choosing how to spend one's time, what to do with one's money, what to pursue in one's career, and how to devote one's life, we are making the same choice as the doctor wondering whether to treat suffering patients or read a comic book; the only difference is that the consequences of the latter option are not so immediate and tangible. Similarly, decisions as to which efforts to pursue and which actions to undertake are tantamount to the choice that the doctor faces regarding which patients to treat. Those who say, "I realize that this undertaking will not relieve as much suffering as possible, but at least I'm doing something," are in effectively the same position as the doctor who treats only those mildly injured patients nearest to him, because he is "at least doing something."

But isn't this focus on efficiency cold-hearted? Doesn't strict triage neglect the pain of those who don't get preferential treatment? As an illustration of this objection, I recall one scene from And the Band Played On--a film about the first years of medical encounter with HIV--in which one character scoffed at a legitimate concern about a large pecuniary expenditure, saying that it was insensitive to care about money when lives were at stake.

In the real world, though, we can't do everything. Resources are limited, and we inevitably face choices between helping one being or another. It is precisely the sympathy that we feel for those animals left homeless by a hurricane, for instance, that so fervently motivates us to devote our money and toward mores efficient way of ameliorating animal suffering, such as promoting humane slaughter methods. Triage is not an act of harshness; it represents the highest form of mercy and compassion.

There were two "Reigns of Terror," if we would but remember it and consider it; the one wrought murder in hot passion, the other in heartless cold blood; the one lasted mere months, the other had lasted a thousand years; the one inflicted death upon ten thousand persons, the other upon a hundred millions; but our shudders are all for the "horrors" of the minor Terror, the momentary Terror, so to speak; whereas, what is the horror of swift death by the axe, compared with lifelong death from hunger, cold, insult, cruelty, and heart-break? What is swift death by lightning compared with death by slow fire at the stake? A city cemetery could contain the coffins filled by that brief Terror which we have all been so diligently taught to shiver at and mourn over; but all France could hardly contain the coffins filled by that older and real Terror--that unspeakably bitter and awful Terror which none of us has been taught to see in its vastness or pity as it deserves.

--Hank Morgan, Chapter 13 of Mark Twain's A Connecticut Yankee in King Arthur's Court (1889)