“To Triage or Not to Triage?” That is NOT the Question

Part 1

The Radiolab podcast from WNYC Studios is as close to appointment listening as we have in 2016. One of the show’s recent episodes, entitled “Playing God,” takes up a topic directly in the A2J Lab’s wheelhouse: triage. In a stark bit of commentary, the host characterizes the practice not as deciding how to allocate scarce resources; rather he described it as an “inhuman act which humans are trying to do.”

thischoices2doorsErika and I have written a couple of blog posts about triage, and our conclusions reveal the practice to be all too human. We have covered lessons from analogous medical decision-making; choices that legal practitioners face everyday; and how and why we should test those advocates’ decisions. Legal service providers are experimenting with different types of triage and intake systems across the country, often by implementing new technologies to streamline service and increase capacity. How we triage within the legal field should be discussed and should be tested. Resources, scarce as they almost always are, should be apportioned after determining what methods work best and in which contexts.

So what do we need to keep in mind when arriving at these decision points? In our opinion, triage is not really about “playing god.” It’s just about facing constraints and operating within them. (Any deity would presumably be free of such restrictions!) First, one should be attentive to the values reflected by triage-based decisions. Second, the provider should be wary of the dangerous desire to avoid the decision, or refuse to accept its necessity. And third, one should be attentive to the variety of legitimate, feasible options and demonstrate that triage needs to be deliberately planned out and implemented. This blog post will touch upon the first point, but stay tuned for blog posts next week that take on the second and third.

The Radiolab episode dives into several stories regarding medical triage in disaster scenes that reporter Sheri Fink either experienced firsthand or on which she conducted extensive research, The settings include a hospital in the days following Hurricane Katrina, post -earthquake Haiti in 2010, and an attempt in by Johns Hopkins doctors to include the community in triage policy debates within their Baltimore hospital. An intriguing part of conversations on triage, especially evident in the Baltimore story, is how the process is framed. On one hand, it can be a positive discussion to have; it raises questions about doing the most good and helping, if not saving, the lives of the most people. Despite these positive lenses, openly discussing how best to triage can be difficult and intensely emotional, especially during a crisis.

The discussion then might flip to asking: which persons will we not be able to save or, even more heart-rending, which are we actively choosing not to save? This sort of thinking becomes particularly salient when Fink describes her interaction with a patient in Haiti after the earthquake. The patient already had a chronic condition. In triage terms, any effort to help her would mean expending desperately scarce resources on saving her life. The podcast hosts  consider the same question that Fink and others thought at the time: just why would it be so bad to save the human being in front of them? Of course, such effort would be noble. But it would also be a function of the immediacy effect. Just because one instance of a problem is staring a decision-maker in the face doesn’t mean it should receive attention first. Resource-constrained service providers can’t forget about the people with whom they don’t immediately interact. They are equally as human as the ones in front of them and might be more in need, medically speaking, of precious resources.

According to Paul R. Tremblay, Clinical Professor at Boston College Law School, the rationing of legal services is not a new crisis, and “legal services for the poor will always be rationed.” Rebecca Sharpless, Clinical Professor at the University of Miami School of Law, considers triage “[a] central—if not the central—challenge for social justice lawyers.” There’s clearly a lot more that can be said about triage, the questions that arise from this RadioLab podcast, and how triage is done in the legal profession, so stay tuned for follow-up posts next week!

 

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