Environmental Ethics
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Ernest Partridge, Ph.D

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Classical Guitar:
"The Other Profession





Ernest Partridge

May 26, 1980


This paper is derived from a response to T. R. Girill's Colloquium paper, "International Food Triage: A Conceptual Clarification," both presented at the Annual Meeting of the Pacific Division of the American Philosophical Association, San Francisco, March 29, 1980.  This version is an adaptation of the APA paper,  presented to the faculty of the Department of Agricultural Economics, Texas A & M University, May 26, 1980.


The focus of my analysis will be the concept of "International Food Triage" as presented by William and Paul Paddock in 1967. Both the concept of "Triage" and the Paddock's book are, of course, dated (as is immediately evident by the title of their book, Famine 1975!). And yet, the "triage" controversy is both close enough to us in time to invite adherents and to provoke discussion, and at the same time far enough removed in time to permit some critical perspective on the debate. I will pay particular attention to the Paddock's analogical method of argument and attempt to draw some lessons from it. We will also find that events that have taken place in the thirteen years since publication of their book will give special insight into the pitfalls of analogical reasoning of this type.

The concept of "triage" is concisely explicated by the Paddocks in the penultimate chapter of their book. A full page of their text will entirely suffice to introduce the concept and the use to which they put it. The Paddocks write:

"Triage" is a term used in military medicine. It is defined as the assigning of priority of treatment to the wounded brought to a battlefield hospital in a time of mass casualties and limited medical facilities. The wounded are divided on the basis of three classifications:

(1) Those so seriously wounded they cannot survive regardless of the treatment given them; call these the "can't-be-saved."

(2) Those who can survive without treatment regardless of the pain they may be suffering; call these the "walking wounded."

(3) Those who can be saved by immediate medical care.

The practice of triage is put into effect when the flow of wounded fills the tents of the battlefield hospitals and when it becomes impossible for the available medical staff to give even rudimentary care to all. Furthermore, the number allowed to be sorted into the third group for immediate treatment must be limited by the number of doctors available. The marginal cases must then also be selected out into the other two groups.

It is a terrible chore for the doctors to classify the helpless wounded in this fashion, but it is the only way to save the maximum number of lives. To spend time with the less seriously wounded or with the dying would mean that many of those who might have lived will die. It would be a misuse of the available medical help.

Call triage cold-blooded, but it is derived from the hard experience of medical humaneness during a crisis. In fact, if there is time before the battle starts, the medical staff prepares in advance the facilities to sort out these three groups.

President Johnson has proposed "that the United States lead the world in a war against hunger." On the battlefields of this forthcoming war the practice of triage will be vital because choices must be made as to which wounded countries will receive our food.

The leadership in Washington comprises the medical staff. The stricken ones in need of medical attention (American food aid) are the hungry nations. To provide maximum effective treatment the medical staff must divide them into the three classifications of triage:

As is immediately apparent, the concept of "international food triage" is based upon an analogy. Accordingly, we are led directly to the fundamental challenge faced by all analogy arguments: How similar are the cases (viz: battle casualties and nations). Or, to put it negatively, are the disanalogies between the exemplar case and the analogue sufficient to disallow strong inference from the exemplar to the analogue? I suspect that this is in fact the case when one attempts to draw strong inferences from medical triage to food relief. Furthermore, I suggest that while the concept of "medical triage" might serve to illustrate the dilemmas of international food assistance, further attempts to draw inferences from combat medicine to famine relief poses grave dangers of over-simplification and misconception of the moral requirements and practical responses that are appropriate to the international food emergency.

The gravest difficulties of the triage analogy reside at the very core -- with the concepts of "patient" and "survival" Let us consider these concepts in turn, as they variously apply to combat medicine and food assistance.

In the case of medical triage, we clearly know what a "patient" is. It is an individual human being -- a biological organism. But what is the "patient" in the case of international food triage? The Paddocks identify "hungry nations" as the "casualties" (p. 207), But what, in fact, is a "nation?" Is it a territory? Is it a culture? Cultures persist through centuries, as if independent of the bearers thereof. One does not "feed" cultures. Is the "patient-Nation" a government, then? Hardly. The "survival" of Idi Amin's government was a disaster and its downfall a triumph. Perhaps the best we can do is to identify a "nation" as the population residing within a territory administered by one or another government. (Thus the "nation" may endure, though governments come and go). But this definition scarcely solves the problem of identifying the "patient," for "nations," so defined, may not be in need of aid though some inhabitants thereof may be in desperate straits. Perhaps some victims of famine maybe better identified as members of an ethnic group within a national boundary (e.g., the Ibo of Nigeria), or an identifiable group among various countries (e.g., the Kurds or the Armenians) or even an identifiable population without a state (e.g. the Palestinians today or, ironically, the Israelis before 1948). How are such groups to be "targeted" for relief? How can these "patients" be "treated" except through national entities? But "the nation" doesn't need aid, the distinct groups within or among nations need aid. (This distinction is tragically exemplified today in Cambodia).

Consider still another problem residing in the concept of "the nation" as a "triage patient." Battle casualties are, of course, biologically discrete, individual human beings. The treatment of one human patient does not directly affect another. Physical boundaries between such patients are separate and impermeable. In contrast, the boundaries between nations are not impermeable, and the "patient-nations" can not be treated as discrete entities. The Paddocks give a vivid, if inadvertent, illustration of the point. In 1967 they proposed that Pakistan might qualify to receive aid (triage group C) but that India was beyond help (triage group A). Consider the implications of this pronouncement, as the Paddocks apparently did not. Are we to suppose that the Indians, one the opposite side of their thousand-mile common border (and with their primitive, dirty nuclear bomb), will quietly resign themselves to their dreadful fate, while American freighters unload their grain on the docks of Karachi, some 150 miles away? Not with the simplicity and finality of the unfortunate battle casualty assigned to group A by the triage officer.

Consider another problem, tied to the concept of "the nation as patient." In the triage scheme, the separation of "casualties must be made early and, as just noted, the decision can not be open for appeal. The crush of the emergency does not allow for second guessing. This necessary finality is applied by the Paddocks as they describe the "hopeless case among nations:

(These are) nations in which the population growth trend has already passed the agricultural potential. This combined with inadequate leadership and other divisive factors make catastrophic disasters inevitable. These nations form the "can-be-saved" group. To send food to them is to throw sand in the ocean. (207)

But what is it that "makes(s) catastrophic disasters inevitable"? First, say the Paddocks, a "population growth trend ... (passing) the agricultural potential." But this sounds like a careless extension of "carrying capacity" from ecology to international political economy. As several commentators have noted, a nation's "carrying capacity" can be significantly expanded through the development and exportation of domestic natural resources (e.g. Libya) or the training and utilization of human resources (e.g., the Netherlands and Japan). (I will grant, however, that the "carrying capacity" concept has application to human population on the world-wide level).

But when we turn to the other factors alleged to "make disaster inevitable," the Paddock's case is even worse. These other factors, we will recall, are "inadequate leadership and other factors." (Note the vagueness here). Inevitable Disaster? Only if the continuation of "inadequate leadership and other divisive factors" is "inevitable." But this I submit, is never the case with nations. To illustrate this point, one can do no better than to note the changes, for better or for worse, since the publication of the Paddock's book in 1967. Let the Paddocks speak their own refutation:

  • (In Egypt) Nasser consistently, year after year, does all in his power to abort American policies in the Middle East, The Congo and elsewhere through deliberate acts of subversive plots, alleged attempted assassinations of neighboring leaders friendly to the United State and open, active support of anti-American regimes throughout the area.

  • (In Pakistan): "Officials who were fearful, suspicious, or jealous of (Norman Borlaug and colleagues) ... have been converted or transferred. Other roadblocks will continue to be laid down by minor bureaucrats and local scientists, but the overall progress is assured.

  • The Philippines is Asia's freest democracy ... The present administration of Ferdinand Marcos is far above the caliber of its predecessor ..."

In sum, it will not do to treat "national leadership" as a constant upon which an early but irrevocable decision is to be made concerning food assistance. If we are uncritically beguiled by the battlefield analogy, and regard nations as "patients," we may likewise assume that, as "patients," nations are passive receivers of aid. But it is far more appropriate to monitor and react to the responses of recipient nation-states to food aid. For the sake of these states, the leaders therein should respond to assistance with positive programs leading toward population stability and economic self-sufficiency. To this end, it may even be necessary to say, in effect, "If you wish to believe that God brings you your children, that's your business. But you must take your pick: leave it to God to regulate your population, or let us help you feed your population while you do God's and control births. But you can't have it both ways.

In short: In the battlefield, the triage officer must make crucial and final diagnoses and prognoses, after which the patient is "sorted," with little chance for "appeal" or a "second opinion." On the other hand, food assistance decisions must constantly be monitored -- open to review and reconsideration. A nation's failure to implement population control may indicate a need for "resorting." Conversely, the overthrow of a reactionary theocracy may open possibilities for effective family planning policies. And so, if it is not the case that "inadequate leadership and other factors make disaster inevitable" and, I would add, "irredeemable," then there are, in principle, no nations in the Paddock's "can't be saved" category. It is a null class.

If there are difficulties to be found in the attempt to apply the concept of "patient" to both casualties and nations, the problems are even more severe as one attempts to apply the concept of "survival" to both cases. Indeed, I submit that the differences are sufficient to tear the analogy asunder.

At the field hospital the meaning of "survive" is clear enough: it means, simply, not dying in the immediate future as a result of one's wounds. But what does it mean for a "nation" to "survive." Does it mean that the government or the political system is preserved, or that the same land area continues to be administered by a single political administration (of whatever kind)? Surely not, since by this definition many "developed" nations fail to "survive." Furthermore, as noted earlier, "Failure to Survive" in the political sense can be regarded as a moral gain (cf. the case of Uganda).

"Survival" can not mean that no member whatever of a country's population dies as a result of lack of food, for if that is the test, no country on earth is "surviving." But neither can "failure to survive" mean that every member of a country will perish from malnutrition, for that would describe an empty set. All nations fall within these extremes. Furthermore, and more significantly, we have described here two extremes, the difference between which admit only of degrees -- a continuum between the extremes. This gradation of differences is compounded when we add to this analysis, as we must, the obvious consideration that malnutrition and undernourishment, in each individual case, admits to degrees. And yet we are asked to treat these complexes of continua as analogues to the stark dichotomy of life and death in the case of the battle casualty.

What, then, are we to make of all this? The triage analogy is illustrative of the desperate moral crisis that must now be faced by those nations possessing food surpluses -- most significantly, of course, the United States. It is all too clear that there will soon be, if there are not already, far more human beings in need of food aid than there is food available for distribution. With need far in excess of resources for relief, some criteria of "sorting" among potential recipients is necessary. Thus is the hungry Earth like a battle hospital. Beyond this, the triage analogy is not helpful, and a determination to draw moral inferences there from is likely only to confound us. The recipients of the aid (the nations) are not the "patients" -- those for whom the aid is not "national survival." Instead, the objective, in part, is the optimum survival of individual human beings, in a manner that is, first of all, not productive of future victims of famine, and secondly, conducive to eventual health, self-sufficiency and well-being. Such, I say, is the objective "in part" of international food aid. The other "parts" of the objective, namely the enhancement of international political stability and peace, the extension of the rule of law, the preservation and restoration of ecological integrity, etc., are all, of course, morally significant. And all these additional considerations further display the disanalogy between medical triage and international food assistance.

We will ignore these disanalogies at the peril of causing severe injustice and injury to the intended beneficiaries of our unavailing good intentions.



Dr. Ernest Partridge is a consultant, writer and lecturer in the field of Environmental Ethics and Public Policy. He has taught Philosophy at the University of California, and in Utah, Colorado and Wisconsin. He publishes the website, "The Online Gadfly" (www.igc.org/gadfly) and co-edits the progressive website, "The Crisis Papers" (www.crisispapers.org).  Dr. Partridge can be contacted at: gadfly@igc.org .