(Cross-posted from this blog post.)
Spoilers ahead — listen to the episode beforehand if you don’t want to hear a rough summary first.
I quite liked the "Playing God" episode of RadioLab.
The topic is triage, the practice of assigning priority to different patients in emergency medicine. By extension, to triage means to ration scarce resources. The episode treats triage as a rare phenomenon– in fact, it suggests that medical triage protocols were not taken very seriously in the US until after Hurricane Katrina– but triage is not a rare phenomenon at all. We are engaging in triage with every decision we make.
The stories in “Playing God” are gripping, particularly the story of a New Orleans hospital thrown into hell in a matter of days after losing power during Hurricane Katrina. Sheri Fink from the New York Times discusses the events she reported in her book, Five Days at Memorial. The close-up details are difficult to stomach. After evacuating the intensive care unit, the hospital staff are forced to rank the remaining patients for evacuation; moving the patients is backbreaking labor without the elevators, and helicopters and boats are only coming sporadically to take them away. Sewage is backing up into the hospital and the extreme heat is causing some patients and pets to have seizures.
Meanwhile, on the news, the staff hears exaggerated reports of looting and lawlessness in the city. Believing they have no choice, some of the staff begin to think euthanizing the sickest patients (and those hardest to transport for evacuation) may be the merciful thing to do. It is alleged that some patients were euthanized, though no one involved was ever charged. Tragically, the possible killings took place on the same day that the rescue vehicles returned.
The crux of this story is that giving in to the logic of triage put the hospital staff on a slippery slope to “playing God”. The episode goes on to discuss ways of formalizing triage so people don’t have to rely on their own judgment at such a fraught time. (Utilitarian triage is discussed, and you can almost hear the speakers holding their noses.) Very often, concerns for the caregiver’s conscience take center stage, though no one acknowledges how selfish this is. Triage is portrayed very unsympathetically throughout, as if the people being forced to make the choice must be at fault somehow for having gotten in the situation.
But it was the last story that made me want to write this. Sheri Fink, the guest reporter, describes a woman she met in a American-run disaster-relief hospital in Haiti. Nathalie was a charming middle-aged woman whose life was spared because she went to the hospital for difficulty breathing. When the earthquake struck, her entire family was at their home, which collapsed and killed them all. Nathalie was putting on a brave face, just glad to be alive, and she radiated gratitude for the care she had received.
But there was a problem. Nathalie needed oxygen, and the hospital (indeed, the nation) did not have enough to go around. Because she was suffering heart failure, the triage nurses had decided she should receive no more oxygen and return to a local Haitian-run hospital, most likely to die. Fink mentions ruefully that the nurse who made the call had never met Nathalie, as if that makes any difference at all.
Fink rides in the ambulance with her to the new hospital, where she coughs and sputters and receives no oxygen to help. Fink’s heart breaks. But when Nathalie gets to the Haitian hospital, a clever doctor does what he can to drain the fluid from her lungs and manages to get her through the crisis without supplemental oxygen.
This story reinforces for Fink the fantasy that you never have to choose — that agreeing to choose is already going too far. Fink was so moved by Nathalie that she helped her to get a humanitarian visa to the US. It turned out Nathalie needed a heart transplant, and she died before she could get one. But, Fink says, she was a delight to everyone she met in those hospital; she even took up a collection for the other patients back in Haiti. So who were the doctors to say that she didn’t deserve every chance?
This is, of course, the wrong question. Of course Nathalie deserved every chance. No one should have to suffer heart failure in the first place. But did she deserve the oxygen more than all the other people who needed oxygen in that hospital? No. Did Nathalie’s time alive matter more than the greater amount of time the doctors could give other patients by employing the oxygen carefully? Absolutely not.
Nowhere in the episode were the beneficiaries of the triage discussed. There was no attempt to determine how many more people were saved because hospital staff took difficult, decisive action. There is no discussion of who should have died in that situation if not Nathalie — someone with many healthy years ahead of them? Two people who could have been saved with the same amount of oxygen? There is only denial that anyone had to die at all. There is no gratitude for the extra lives saved — only loss aversion. There is no acknowledgement that Fink would very likely not have wanted any other patient to die, either, had she met them, much less an acknowledgement that people matter whether you have personally met them or not.
Making better choices through conscious triage is no more “playing God” than blithely abdicating responsibility for the effects of our actions. Both choices are choices to let some live and others die. The only difference is that the person who embraces triage has a chance to use their brain to improve the outcome. The suffering of the person who doesn’t receive the scarce resource is no less because you, personally, haven’t witnessed it. When Fink saw Nathalie’s suffering, it should only have informed her as to the gravity of the situation — both for Nathalie and for those who did receive the oxygen.
I understand that it’s hard, that we will always instinctively care more for the people we see than those we don’t. There’s no shame in Fink’s deep feelings for Nathalie. They are a key component of compassion. But there should be great shame in letting more people suffer and die than you need to because you can’t look past your own feelings. This is the kind of narrow empathy that Paul Bloom is against.
There are millions of people around the world dying of entirely preventable causes. Why should it make any difference that they aren’t in front of us? You know they are there. They know the suffering they feel. Poverty is a major culprit, as are neglected tropical diseases that could be cured for pennies per person per year. Money that you won’t even miss could be saving lives right now if you put it to that purpose instead of, say, home improvement or collecting action figures. Every decision we make bears on the lives of the myriad others we might be able to help.
We are always in triage. I fervently hope that one day we will be able to save everyone. In the meantime, it is irresponsible to pretend that we aren’t making life and death decisions with the allocation of our resources. Pretending there is no choice only makes our decisions worse.
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I just wanted to say that this essay was really important for me getting into EA a few years ago, it really resonated with me emotionally in a way that little else did. So wanted to thank you for writing this.
I know this is not how EA is defined for most people, but I often think of EA as recognizing that we are always doing triage.
Aww, these comments mean everything to me! Thanks for taking to the time to write it <3
I heard this episode of RadioLab and I don't think it reinforced any fantasies about traige: I think it was pointing out that triage itself relies on the fantasy that life is a zero-sum game. The reality was that when a weaker person was given an advocate, it turned out the worst outcome of triage was avoided without any harm to anyone else. Nathalie's experimental treatment did not take anything away from anyone; had the doctor not spent time on her, he might have taken a smoke break or a nap, or spent his time with a patient who didn't end up needing immediate treatment, or who didn't end up surviving the day for some other reason.
The fact that the doctor was pushed to think beyond the simplistic concept of triage could even be a net benefit--the next time he sees a patient with Nathalie's symptoms, he now knows how to treat them without using limited oxygen that could be used for other patients, meaning he can now save more lives with the same amount of resources and can teach other doctors to do the same. This is the strongest critique of the concept of triage: while it's a necessary last resort, offering it as an option too soon can limit creative problem-solving that could be beneficial for future crises over the longer-term. A lot of medical best practices are developed in resource-rich and lawsuit-prone environments, and medicine is therefore quite risk-averse and wasteful. In a true emergency, there are probably many solutions a smart doctor could try before giving up on patients altogether in the name of triage. The whole point of technological progress is that we don't live in the dark ages anymore, and innovation means that life and health are no longer automatically a zero-sum game.
But there are scarce resources and at some point hard decisions really do have to be made. The condemnation of triage is not fair because it dodges the brute reality that you can't always find a magic third solution that's positive sum. We have to work on all aspects of problem-- creating more options, creating more supply, and how to prioritize when there isn't enough for everyone.
We are making decisions every single day, however a lot less frequently than every second.*
An additional consideration for the benefits of Triage is to address decision fatigue. Triage is a methodology and can be considered a logical, sequential system of prioritization to prevent the overwhelm of making a decision on a decision. Triage is a way of weighing options quickly and consistently. I believe most of us here have the privilege of making gradual decisions, especially in everyday life.
Triage is to maintain calm in chaotic and emotional environments of immediate and obvious human suffering. Many of us, especially Earn to Give, are often shielded from those environments. The media we have access to understand tropical diseases or other high-impact, low-cost is not necessarily personal or visceral. Every choice we make takes considerable energy, from breakfast to whether to acknowledge a human we see in clear distress with a cardboard sign requesting assistance.
I get frustrated when I see charity organizations pushing images of suffering as it often portrays an image of inferiority of recipient below the giver rather than equal. I believe the reality of the living conditions of our fellow man needs to be transparent, but presented in a context where people have space to understand the systems that create these disparities in the first place. Poor people deserve privacy in their lives as much as those with an semblance of wealth. However, whether an intimate knowledge of someones life conditions is necessary to provide effective support is a discussion for another space.
For triage to be conducted in the context of Effective Altruism, there need to be explicit and accessible guidelines and best practices to of how to process the information about various sources on how to prioritize recipients of abundance. I am at the beginning of this journey, so I ask for your understanding as I continue to learn through the resources provided and contribute my reflections along the way.
Thanks for sharing this, Holly!
To anyone who liked the essay, I also recommend Julia Wise's "No One is a Statistic", which makes a similar argument.
Thanks for posting this here. I think it makes an important point as to why EA is important.
Btw, you might want to consider spacing out posting your old blog posts here just a little more :) I'm glad to see more good content here, but it feels a little spammy to me at the moment.
Thanks :) Haha, yeah, when I hit the 5 post limit I realized maybe I shouldn't be treating this like an archive... It honestly didn't occur to me that the posts would spam people if I just got 'em up as quickly as possible! Still figuring out how the forum works, haha.
Haha sounds good! I'm looking forward to it. Do you plan on posting the discussion on your FB wall about long-termism a while back? I think that would be valuable to have here.
I used to be more utilitarian about this but eventually I started to believe it is quite important to be 'extra' nice to the people closest to us as it brings the benefit of cooperation which has in turn allowed us to be so effective as humans at all.
Sounds utilitarian 😉
This post (and also chapter 2 of Doing Good Better, but especially this post) added "we're in triage" to my mental toolbox of ways to frame aspects of situations. Internalizing this tool is an excellent psychological way to overcome forces like status quo bias (when triage is correct), and sometimes an excellent way to get people to understand why we sometimes really ought to prioritize doing good over making our hands feel clean.
I would guess that this post would be even better if it was more independent of the podcast episode.
I would guess that this post would be even better if it was more independent of the podcast episode.
I wish I had known it would be such a hit!
This strikes right at the heart of trolleyology for me. And in some cases, seems like a scarcity problem rather than a moral problem.
Yes, triage flows directly from scarcity. But once you're in a triage situation, you can't answer it by saying "this is caused by scarcity" (basically "we shouldn't be in this situation")-- you have to choose something to avoid losing everything. It becomes a moral problem when you won't step in and save more people because you don't want to get your hands dirty.
Holly, I absolutely adore this essay, this has to be my favourite EA text ever right after On Caring! Thank you so much for writing this. I came back to it a couple of times over those 2 years and I've sent it to someone quite recently.
I'd rather you space out your older essays too, so that people may be more likely to read them!
Thank you :)
Hi! thank you for this essay. I fully agree with the idea of triage and that we are all responsible for the choices we make, and don't make. Consciously and unconsciously.
I felt quite a strong shaming tone at the end of the article which I don't believe is necessary to home in your point.
I do appreciate the underlying message and the necessity to say it clearly.
Thanks
Can we say everyone likes Natalie, so saving her can help raise money to save other patients, is that an utilitarian way to say?
That's not an information the doctors have at hand when they're trying to figure out who should receive oxygen.
(Also, it doesn't matter what's the utilitarian way to say, what matters is saying correct things - and utilitarianism happens to sometimes help with that.)
The most common critique of effective altruism that I encounter is the following: it’s not fair to choose. Many people see a fundamental unfairness in prioritizing the needs of some over the needs of others. Such critics ask: who are we to decide whose need is most urgent? I hear this critique from some on the left who prefer mutual aid or a giving-when-asked approach; from some who prefer to give locally; and from some who are simply uneasy about the idea of choosing.
To this, I inevitably reply that we are always choosing. When we give money only to those who ask as we walk down the street, we are choosing to prioritize their needs over the needs of those whose calls for help cannot or will not reach us. The choice not to choose is really a choice to leave the decision to external factors.
Resources are limited. We must choose. The question is how, and this is the role of effective altruism.
This post articulates an essential component of effective altruism in an elegant way. It provides a simple metaphor that is helpful both for adherents of the movement to reflect on what effective altruism involves and to communicate with the public about the ideas that undergird the movement. This simple, powerful metaphor renders this post deserving of lasting attention.
The post itself could be stronger; I think there’s a reasonable argument that the post would be equally strong or stronger without the central example. An abbreviated version of the piece, consisting of the first full paragraph in conjunction with the final four, could serve as a brief overview of this sharp idea. However, that’s something of a quibble: the piece is well-written, and explores a brilliant idea. I'm grateful that I had the chance to read it, and I would highly recommend that others give it a read.
I think the concrete story actually makes the article more powerful. Communication in this space is sometimes too full of abstractions and lacking in concrete examples, which would make it more powerful for most people. And this is coming from someone who loves and studies abstract nonsense (maths).
This is such a great summary and restatement! You suggest a shorter version of the piece and I think a longer version of this comment might do that job perfectly.