War and Plague: Who Should Be Treated?

March 25, 2020 Updated: March 26, 2020


Governments everywhere are moving to a level of control over industry and civilian life normally seen only in wartime.

Iran and Israel agree on little else, but both see themselves as engaged in an all-out war against the virus.

The analogy to war is a common way to convey a sense of urgency, whether it be a war on waste or plastic straws, or poverty. In this case, however, there’s a wartime level of threat to life, a comparable interference in everyday lives, an expansion of state control over the economy, and, as British historian Robert Tombs puts it, “the need to create feelings of solidarity: the willingness to be public spirited and to bridle our natural egotism.”

Here I want to consider how the analogy to war, a “total war” that mobilizes the whole society, is being used or misused in conditions where health care systems are overwhelmed and forced to deny treatment to some who might benefit from it.

On a Wartime Footing

Comparisons to World War II and the “spirit of the Blitz” are common in Britain. It was a time when, in the national memory, Londoners withstood daily bombing with courage, determination, solidarity, and patriotism, and came to each other’s aid.

Government control extended beyond providing health care for those serving in the greatly expanded armed services. It was also a matter of how the state needed to organize industry to meet critical health care needs, to apportion and ration health care resources, not least but not only for those wounded in combat.

Both Prime Minister Boris Johnson and President Donald Trump are putting industry on something like a wartime footing. “In an unprecedented peacetime call to arms,” the Telegraph reports, Johnson “is asking manufacturers … to transform their current production lines to help produce ventilators as part of a ‘national effort’ to tackle the virus.”

In the United States, Trump invoked the Defense Production Act of 1950, first used during the Korean War, so he would be able to mobilize the private sector to manufacture goods needed in the fight against the pandemic.

The Dark Side of War Talk

For Irish writer John Waters, war talk is dangerous. From early on, as the disease engulfed northern Italy and swamped health care resources, physicians and policymakers spoke of the need to make hard choices in treating the sick, of “triaging in favor of younger, more ‘productive’ virus victims.”

It is the language of prudent policy analysis, of making inescapable choices, and the common good. But it sounds reasonable, Waters argues, only because it reflects and reinforces a wider throwaway culture criticized by John Paul II and subsequent popes, a culture of death in which the weak and vulnerable are increasingly excluded from the human community.

John Paul II argued 25 years ago that we are facing “a war of the powerful against the weak: a life which would require greater acceptance, love and care is considered useless.”

The culture, in short, is desensitizing us “by ‘training’ us to see illness as a kind of luxury, treatment as a concession, and the old as a separate category of the human. Because the old are increasingly hidden away from everyday society in purpose-built nursing homes, when we happen upon the old we are already beginning to look away from their frailty, and therefore their, and our own, humanity,” writes Waters.

The language of combat triage to exclude from care and treatment whole categories of people misunderstands and misapplies the process. Military triage prioritizes for treatment those most likely to be capable of returning to the battlefield. It’s a dynamic process in which a soldier’s priority can change rapidly according to his health status.

Military triage follows well-established protocols. It doesn’t prioritize sick soldiers on the basis of age. But age-based triage is what appears to be happening in Italy—as Waters demonstrates from many Italian sources. An Israeli doctor practicing in Parma, Italy, confirms Waters’s account. He reports from the front lines that the age for exclusion from critical care with ventilators is as low as 60.

Rationing Is Inevitable in Health Care

But are there not rational and just grounds for prioritizing measures like vaccination and testing of health care workers, who put themselves at higher risk and without whose work hospitals would collapse into centers of spreading infection?

Or for giving lower priority in the use of scarce equipment to those who are very frail and in rapidly declining health? Are these not indeed the kind of prudential choices that a plague, like a war, forces on our attention, however firm our commitment to doing no harm and to healing the sick?

Capacity for providing critical care beds with ventilators varies widely from country to country. No health care system can avoid the risk of being overwhelmed and unable to provide all the care they would if resources were unlimited. As in battle, not all the wounded can be saved, and choices have to be made. The current situation is not so different from combat triage as Waters suggests.

The important objection to Italy’s response is not that physicians had to choose whom to provide with the best available care. That is true in all health care systems. We have deluded ourselves into thinking that health care is an unquestioned right in the sense of an open-ended claim on the state.

Resources are limited, so the question remains, what better way might exist for allocating them? By treating age as the determining criterion, the Italian system laid itself open to the kind of criticism it has received. It excludes the most vulnerable, a whole category of the population, from the protection of the community.

The UK’s National Health Service (NHS) has long experience of providing a universal health care system within a constraining budget. It has always had to ration health care, albeit through long waits rather than copays, deductibles, and caps. It regards rationing—denying a potentially beneficial treatment to a patient on the grounds of scarcity—as inescapable. But the UK, like Italy, has a universal health care system. The two countries provide an instructive contrast.

Faced with even fewer critical care beds, relative to population, the NHS has developed official guidance for physicians on how to decide whether patients suffering from the COVID-19 disease should be admitted to critical care or not. It has done so without mentioning age. The new NHS guidance is a dynamic triage system that relies on a Clinical Frailty Scale (CFS) and “algorithm” or decision tree for choosing a treatment plan. It takes into account patient wishes, underlying pathologies, comorbidities, and severity of acute illness. All without mentioning age.

The UK’s triage approach isn’t immune from the cultural context that Waters describes, and doesn’t resolve other issues concerning the NHS and end-of-life care. But it is a more considered approach within a system that faces, just a week or two away, the kind of overwhelming strain on its resources that Italy has suffered.

Paul Adams is a professor emeritus of social work at the University of Hawaii and was a professor and associate dean of academic affairs at Case Western Reserve University. He is the co-author of “Social Justice Isn’t What You Think It Is” and has written extensively on social welfare policy and professional and virtue ethics.

Views expressed in this article are the opinions of the author and do not necessarily reflect the views of The Epoch Times.