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Playing God

Sunday, August 21, 2016 - 09:00 PM

(Photo Credit: Twm/flickr)

When people are dying and you can only save some, how do you choose? Maybe you save the youngest. Or the sickest. Maybe you even just put all the names in a hat and pick at random. Would your answer change if a sick person was standing right in front of you?

In this episode, we follow New York Times reporter Sheri Fink as she searches for the answer. In a warzone, a hurricane, a church basement, and an earthquake, the question remains the same. What happens, what should happen, when humans are forced to play god?

Produced by Simon Adler and Annie McEwen. Reported by Sheri Fink. 

In the book that inspired this episode you can find more about what transpired at Memorial Hospital during Hurricane Katrina, Sheri Fink’s exhaustively reported Five Days at Memorial

You can find more about the work going on in Maryland at: www.nytimes.com/triage

Very special thanks to Lilly Sullivan. 

Special thanks also to: Pat Walters and Jim McCutcheon and Todd Menesses from WWL in New Orleans, the researchers for the allocation of scarce resources project in Maryland - Dr. Lee Daugherty Biddison from Johns Hopkins University School of Medicine, Howie Gwon from the Johns Hopkins Medicine Office of Emergency Management, Alan Regenberg of the Berman Institute of Bioethics and Dr. Eric Toner of the UPMC Center for Health Security.

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Sheri Fink

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Comments [70]

persis

Although the show is professional and thought-provoking, Fink's language and tone are value-laden.

Jan. 14 2017 02:55 PM
William Scheef Jr

I think my biggest point of contention and concern with this story and the practice of triage, isn't that they do it as I understand it's necessary, but it's how in this particular story it was done.

This woman was choking to death. They knew she would die without that oxygen. They should have put her to sleep. She'll die anyway, right? It was just luck that doc was able to extend her life, but it was still inhumane and tortourous, what was done to that woman and frankly any other patients they did that too.

No one should have had to suffer like that, that's inhumane, no matter how you slice it; rationing or no rationing, foreign or not foreign.

This type of inhumane behavior made me very upset and angry.

They could have put everyone who was going to legitimately die without O2 to sleep and killed them that way.

Dec. 27 2016 05:54 AM
stewarte from Massachusetts

Wow... I would absolutely hate being placed in the position of choosing triage plans. With no electricity, I'm not sure what I would have done in this situation; probably something much like this, the doctors were desperate. I am a male in highschool, this podcast took me on a bit of an emotional trip. I hate the idea of choosing that one life is more valuable than another. Every hour of life is just as valuable to one person as it is to another. I guess it comes down to how much of an effect one's life will have on people around them, as Jackie Robinson said, "A life is not important except in the impact it has on other lives." He obviously did not say this in regards to triage but I feel that it is very fitting.
In my Anatomy and Physiology class I was given the hypothetical situation of a severe outbreak of influenza and the hospitals were running out of respirators. In our groups we had to create a triage plan to decide who would get the respirators. We realized that we could never be the holder of one's fate, so our group decided that some form of a lottery should be used. Our group also saw that some lives obviously have more value than others. For example, a single mother of a two year old has a much more valuable life than someone who is on death row, so we decided to go with a rigged lottery system where your chances of being selected varied based on how valuable your life is. If you were a dependent or someone with a dependent and had a completely clean record you would be guaranteed to be picked in the lottery, almost 100% guaranteed a respirator were those who were not a dependent, did not have any dependents, and had a clean record. Things like being a smoker diminished your chances of being chosen. These things add up, taking away from your chances of being chosen, ultimately, the person with the worst chance of being selected being someone on death row. So, if two people walked into the hospital; one, a 60 year old man with no dependents; one, a person on death row, and there was only one respirator left in the hospital, the 60 year old would get 9999 names "put in the hat" so to say, and the person on death row would get one name "in the hat". This way, it was truly fate that decided who survived, but the person who has the more valuable life, according to Jackie Robinson's definition of a valuable life, is most likely to survive.
I understand that a triage plan like this would have been very difficult to carry out without electricity as in the scenario described in this podcast. I feel that a rigged lottery triage plan like this should be used when possible if it is ever necessary to choose who gets to live and who gets to die.(Sorry for not staying brief)

Nov. 21 2016 08:39 PM
charlesdan558@gmail.com from Romania

This was a meaningful, valuable podcast. My reflection was one that I have often with RadioLab, that the hosts are not only comfortable with ambiguity, but seem to lack respect for those who are trying to resolve the ambiguity. MP3 Juice apk download

Nov. 17 2016 07:36 AM
darlinga

this article is emotional and inspiring . In my anatomy and physiology class we had to make a triage plan before listening to this article . My groups triage plan was sort of close to yours. My group decided to help medical people and infants first . Then everyone else we put into a lottery execpt for the DNR patients.

Nov. 13 2016 02:18 PM

This is a very interesting and brings up a great point of how medical workers have to make hard decisions. Triage is a serious matter and there is no real way to decide these matters. In my high school Anatomy and Physiology we have listened to this in order to understand triage. In groups, we had to decide how we would make these triage decisions and it was hard. My group wanted to allow the most likely to survive and people who can productively contribute to society get medical attention first. This is broad but we believe that anyone over 3 years of age and under 80 years old who do not have mental disabilities and are medical workers would go first because they can contribute to society easier. Memorial Hospital did the opposite and started to save more I'll people first. The video did relate their decisions to a war where soldiers would save the less I'll and I agree with this. I feel like it is necessary to save the people that are more likely to survive in order to help society.

Nov. 10 2016 01:19 PM

This is my absolute most favorite episode. Phenomenal! I often reference this episode when I try to persuade people to listen to RadioLab, or podcasts, in general! Excellent work!

Nov. 02 2016 01:24 AM
Reid Winkelmann from Lincoln, Nebraska

First off, I loved the story (as I do nearly all the stories done here). My question is, if it is an impossibility to preform this level of triage, how does someone program autonomy. It is a fast growing field which I believe will be a in nearly every aspect of our lives sooner than later, but someone has to make those choices. It needs to be written in the code. Do we have a vote, appoint a committee, just let the developer handle it? I've struggled to come up with an answer, but would like to hear some intelligible responses.

Oct. 28 2016 11:26 AM
Anne from San Francisco Bay Area

This was a meaningful, valuable podcast. My reflection was one that I have often with RadioLab, that the hosts are not only comfortable with ambiguity, but seem to lack respect for those who are trying to resolve the ambiguity. "That's terrible! How could they do this?" There is a smug satisfaction in this "conclusion" that doesn't work for me. I appreciate the hard look at difficult questions. Not all of us are here to actually solve problems. But it can sound pretty self-serving at times.

Oct. 27 2016 10:54 AM
Ivan from Russia

Thank you for breathtaking episode!

"Kill 'em all; let god sort 'em out!"

Oct. 11 2016 08:42 PM

" I would urge this international organization to work with an ethics committee to find a more ethical model of rationing that includes proper disclosure of medical treatment."

- from Amy from Northern California's comment

Thank you, Amy. Radiolab usually does an extremely good job, but I think here they dropped the ball by not discussing the glaring issue of disclosure.

Something about the doctor's comment that he saw another doctor say, "I'm going to give you something to make you feel better," during Katrina really bothered me, and by the time we hear, "She had no idea [that they had decided to deny her oxygen]," in Haiti, what it was became clear. The Katrina story left open a significant possibility that the doctor who gave the morphine was treating her patients like the pets they put down, not telling them of the situation, and the Haiti story made explicitly clear that they did not inform the patient.

Normally, doctors inform patients when they conclude there is nothing more they can do, right? There is nothing in these stories which comes anywhere close to justifying the skipping of disclosure. The patients are generally greatly debilitated and, more importantly, offer no threat of assault; and the rationale for letting go is believable enough in the emergency around them.

I find the most likely theory why Sheri intervened on behalf of the woman in Haiti to be that Sheri, without even necessarily consciously understanding why she was intervening, and despite social pressure to skip disclosure, was rightly unwilling to place herself so above the doomed woman as skipping disclosure required. So I say, good for her...

Oct. 11 2016 04:05 PM
Bill from Toronto

Good podcast on a very challenging topic however it stopped short of dealing with an essential element of the triage story.

My son is a paramedic and his life starts where the podcast ended - taking on "the God role that nobody fits". The added Catch 22 is that often people who are attracted to medical professions do so because of a heightened sense of compassion so, arguably, they are less well suited to making choices that are difficult, perhaps impossible, to rationalize. But, of course, it is their very compassion that makes them excellent at what they do.

We as a society, have asked these individuals to take on this impossible task, but the best they as individuals can hope for at the end of the day is to be able to look themselves in the mirror to see how much of their humanity they have lost in the process. Psychological trauma and PTSD is rampant among EMS and ER personnel for pretty obvious reasons.

At every traffic accident, or crisis, we see on the daily news, and many that do not make the news, there are EMS personnel there, in the field, facing almost unimaginably horrible situations. Sometimes in difficult physical conditions, they are dealing with the fundamental dilemmas presented in your podcast, in real time, with limited resources and sometimes losing patients, often while also trying to console family and friends.

Much is made of PTSD in the military but at least in a military context there is an end in sight for the individuals involved as the battle will end, and the tour of duty will be completed. For front-line medical staff there is no end; there will always be another major car accident, shooting, building collapse, suicide or tragic illness and death brought on by desperate living conditions. Over a career in the field, experiences and psychological damage unavoidably build up over time. Formalized triage is a fundamental tool we, in society need to help develop, support and give to front-line staff help spread responsibility for this "impossible piece of human business"

As an aside, I was disappointed that Sheri Fink choose to end her part of the segment recounting her extraordinary actions to rescue of Natalie. It made me think of an 8 year old who closes their eyes, covers their ears and hums la-la-la when faced with something they do not want to hear. Her self-indulgence, as a dilettante journalist, amounts to an insult to all of those compassionate front-line medical staff who do their best to save patients and reduce suffering but have to face hard realities every day.

Oct. 11 2016 02:39 PM
A Rae from Denver

Great episode! Although it struck me as odd that the statement made around 23:14 is practically identical to an interview (with a different woman) from a 'This American Life' episode from 2005...

Oct. 04 2016 12:27 AM
LM

I was unable to listen to the entire episode. As someone who went through Hurricane Katrina and continued to work throughout the storm it was too hard too listen.

I found myself in tears in a grocery store feeling as if I was right back in 2005.

I also wanted to correct a statement made during the piece. NPR was NOT the only source of information. I worked on air living at a radio station with my young son and my dog. So did some of my close friends at other radio stations in the city and in the area. A very small line. A throw away bit of information but not for those of us who were there.

Oct. 03 2016 10:12 AM
danielle from NOLA

it would, indeed, be wonderful if we could answer the issue of just distribution of scarce resources with a solution like "just don't have to ration." but that's really, really inadequate as a response. And I agree with Andrew's comment earlier that there is still rationing going on as we listen about Nathalie in Haiti. In Nathalie's case, she was allocated scarce resources because an influential individual found her compelling. Since this is fairly capricious, it isn't a solid strategy for the rationing that happened.

I am a doctor. I served in a drowned hospital in New Orleans during the hurricane. And, no, we did not hasten peoples' deaths. We didn't have the luxury of sentiments like "just don't have to ration." There weren't deliveries of things when we ran out of something. All things were finite in quantity except for heat, anxiety, muddy water and human needs. The patients had ongoing, evolving medical conditions during the days we waited for rescue. We ran low on things, and then we ran out of things. Decisions had to be made. And in opposition to the really unfortunate title of this episode, we were NOT "playing" god. We were not playing at anything. We were struggling every single second of every one of those indescribable days to do the right thing, to support our patients, to get everyone we could save through. Another luxury that we lacked: the ability to take compassion out of the equation. Removing compassion from the equation is just not a real thing that happens in a patient care environment. Instead, we had an abundance of moral distress, and we had to manage it so that it did not become the sole basis for decision making.

This story kind of devolved into an example of acting to relieve one's own sense of moral distress. Healthcare professionals can sympathize with this. However, as a basis for an action to deal with any ethical dilemma, it is insufficient. Acting with the motivation to not have to feel moral distress, while very understandable, is not appropriate when we are talking about distributive justice in settings of scarcity. It's actually selfish--about oneself rather than about the people who are affected by the scarcity. Ironically, appropriate ethical action frequently causes moral distress. So you manage it rather than let it manage you.

I am not saying that the reporter shouldn't have intervened if she wanted to help Nathalie and alleviate her moral distress. That was perfectly right and good. She simply should have done so without relying on resources that she wasn't funding and that were delegated to a trained professional for stewardship. Lastly, I think a really honest portrayal of what happened with Nathalie should include the exact amount of money spent on her medical care in the US as well as a calculation of the number of oxygen concentrators, for example, that could have been bought and sent to Haiti with that amount of money.

Oct. 01 2016 11:26 AM
HS from MD

This episode is so great. The words "Don't leave me behind" stuck me still. Personally I feel no right and no position to decide who to live and who to die. I have no idea of what I will do if I were put to that position. It reminds me the story of three people killing the sick young one at the sea when they are running out of food and about to die. Humans beings are not perfect, giving this authority to us can be dangerous. We simply cannot judge a person by his/her gender, title, occupation, reputation, appearances, etc. As we have no idea of what this person has gone through and known his/her heart. Really good topic! Thank you!

Sep. 30 2016 02:25 PM
AndrewFischerLees from Los Angeles, CA

Every system of distribution is rationing. Every one. So saying "We shouldn't have to ration" is just plain nonsense. The author directed resources *away* from patients that she did not see *towards* patients that were before her eyes. So, it's just rationing on the basis of who the American reporter comes into contact with. She is shirking the counterfactual of the patient that did not get life-sustaining treatment because that treatment was being used by a patient with a worse prognosis, but who was lucky enough to have met the American reporter.

Sorry to be harsh. The rules are there for a reason. When you break them to give something to the patient in front of you, you are TAKING something away from the patient not in front of you.

No mention of John Rawl's veil of ignorance? Missed opportunity...

Sep. 20 2016 09:35 PM
Anne

To the folks at Radio Lab, and all the people involved in this story, you have out done yourself in excellence. These are the conversations we must have to ensure we have a future worth living for all.

Sep. 12 2016 12:05 PM
Barbara Hall from Vancouver, WA

Thank you so much for this piece, it was fantastic and so well done. As an incurable devil's advocate, I want to say that as a person who has made end of life decisions for both parents and refused life preserving care for them, I know there is a way to be both compassionate and utilitarian. Perhaps those are the people who could be recruited and turned to to advise on policies like these--people who have been faced with these difficult decisions before, particularly with those they loved and for whom those decisions are not as abstract.

Sep. 09 2016 11:16 PM
Alene

Thank you
What an incredible piece
I feel moved just to say thank you
so thank you
My thoughts are wandering to the anti-vaccination movement. These events that you are describing would require really impossible decisions. Comparatively, the decision to require all kindergartners to be vaccinated carries minuscule risks. I wonder if part of the issue is that our culture has lost their sense of relative risk. I'm thinking not only of wartime experiences but simply living in an age prior to vaccinations required a tolerance of uncertainty and risk that most first world citizens don't face these days. That may be interesting fodder for another piece.
Again thank you

Sep. 08 2016 02:48 PM

"most people believe our lives are worth about as much as a cocker spaniel."

Actually, I believe my dog's life is worth quite a bit more than most people's and someday there will hopefully be a time where we don't judge the worth of a life as less because it's different from ours.

Sep. 07 2016 06:21 PM
Debbie Maher from SD

Wow, a thought provoking story! What I got out of this is how the Libertarian philosophy is best .. the individual can make the best decisions not central planning. No rules or laws will work for "future disasters". Let the people involved decide. Every situation is unique, every individual is unique. No decisions will be perfect, but central planning would be a top down monstrosity that takes away common sense and reason. Same applies to education, each child learns differently and has special needs. A top down education system like Common Core will not work and is unfair to children.

Sep. 07 2016 12:05 PM
Archie Buchanan from Portland OR

I listened to this episode and it brought back painful memories.

I have been through devastating floods while working as a maintenance supervisor at a nursing home in Tillamook County, OR. I can relate to the difficulties of keeping a healthcare facility operating without services. In the flood of 1996 the town of Wheeler was completely cut off - no power, no drinking water, no fuel. I was the guy maintaining the generator at the nursing home. I was the guy driving through 2-3 feet of floodwater to get diesel fuel from local farmers to keep the generator going. I was the guy fording the flood to get staff to and from the facility. Couldn't have done it without my big old truck. When potable water failed I found a way to keep us going until National Guard arrived in town by boat and set up a desalinization plant, and then I transported water to the facility.

Every month throughout my career in nursing homes I provided fire training and evacuation training. Evacuation training was the hardest. It involves triage. Teaching care-giving, loving staff to prioritize evacuation among a dependent population was always difficult. They needed to learn to start with the ambulatory first; do not take time to put people into wheelchairs in a fast moving fire, use the sheet-drag method; do not move people in their beds, it can jam up the hall and cause loss of life; learn that the person who weighs in excess of 500 pounds just needed to be left to last and that is not easy for them to accept.

Sep. 04 2016 03:35 PM
Deb from Washington DC

Christians who would like to broaden the scope of discussion might find al Mohler's , president of Southern Seminary, comments about he topic interesting. http://www.albertmohler.com/2016/08/30/briefing-08-30-16/?segment=2.m

Sep. 04 2016 03:14 PM
Kurt Lewis Helf

Wonderful, compelling episode. The title, however, is *awful*. Why in the name of Hell wasn't it titled "Triage"? Evoking a mythological entity in both the title and the closing remarks really tainted an otherwise great episode. Who, exactly, is this "God"? Further, Robert Krulwich's final comments miss the point entirely. These acts were *wholly* human and to call them inhuman robs the people who committed them of their compassion and horror. Why not use the name "Vishnu", "Zeus", or "Cthulhu"?

Sep. 03 2016 10:16 AM
Amy from Northern California

There are so many comments for this show, I am not sure if anyone has mentioned this yet.

We actually do have a system for rationing limited medical resources in this country that has worked for many years. My brother lost his life last year and he was an organ donor. The people that received his organs were probably the best candidates to survive after the transplant and also had been on a list. I did not hear any of the guests refer to this as perhaps a model of care to use for emergency rationing.

As a nurse myself, I was deeply disturbed by the manner in which the international emergency medical crews handled the rationing of oxygen. The Haitian woman had been not been informed of the dire situation. To surprise her and suddenly withdraw her oxygen was dishonest and sneaky. It assumes that people cannot understand that the medical resources that are keeping them alive are running out. It also does not allow for self-determination. I am not a bioethicist, but I do know from caring for people on a daily basis that most want to be prepared and have time to find their own resources and/or be able to say their goodbyes. I would urge this international organization to work with an ethics committee to find a more ethical model of rationing that includes proper disclosure of medical treatment.

Sep. 03 2016 10:12 AM
Andris from Riga, Latvia

Thank you for this episode and pardon my english. (my third language)

I had a long drive ahead of me during nighttime and podcasts often keep me awake. But this one not only kept me awake but made my pulse jump - so the journey was safer. The peak for me was death of overweight man in hospital.

The question of the guidelines is indeed very complex. But I recommend to start with ones world view of things. That is to ask - what human is? If you are a naturalist, then you would think that we are only matter and energy and our feelings are not genuine, therefore it is quite easy to set up guidelines for extreme situations. Does not really matter what they would be - at the end of the day humans are only cells with no soul and higher worth. So you can aim for maximum years or maximum color or gender. One will not be better or worse than other.

But I am not a naturalist. So my world view tells me that humans have soul and have great worth. And pastor is not more worthy than criminal and child is not more worthy than a person on last months. I personally believe that our worth is the thing that will not allow us to set the guidlienes that we can actually fallow.

We saw the slippery slope in action. And that shows natural human nature and pure evil that is in us.

What would I do. I actually think that it is impossible to create satisfactory guidelines for such situations. So we have to try to seperate rational/subjective worth of a person from objective worth, I think a good direction would be to save maximum years and competence - that would mean saving children and ones that can care for them and for others. It would not mean that they are more worthy than elderly people in a sense of objective worth of a person. It just means that that is our ubjective choice.

I also thing that existance of such dillemma alone pushes us to seriously question naturalism and atheism. Why would we care if we are only atoms and neirons and grawe is the ultimate end?

Sep. 03 2016 03:09 AM
Elisa from

Thank you for presenting this subject. Organ donation is mentioned in one of the comments and I can see why: who gets a very limited resource, be it a heart or oxygen? Indeed, how is the recipient list prioritized? Could this be applied to emergency scenarios? This could give food for thought in another episode.

Sep. 02 2016 05:48 AM
Derek

The music at 5:40 is fantastic - great for hiking.

Sep. 01 2016 03:50 PM
Nicole Rondello

I think the final summation was just BRILLIANT!!!

"...I think what you have hit upon here is an impossible piece of human business....an inhuman act which humans are tring
to do but the fact of their humanity makes it impossible. So what we got here, what we have here is a real deep problem. We have a God role, and no one [no human] fits it."

Sep. 01 2016 12:27 PM
Dama from ct

It enrages me that a hospital administrator can make the decision to withhold treatment and ultimately choose life or death but we are not allowed in most states to make the decision for ourselves

Sep. 01 2016 08:06 AM
Mike Rizzo from Washington, DC

Public conversation on triage is essential to make it clear that in some extreme emergencies there aren't infinite resources, and all persons cannot be fully served. Limitations exist. That is reality. No doctor wants to deny treatment.

Without infinite medical resources, systems are essential to provide the maximum benefit to the maximum number of persons. That is, at some point, decisions must be made. Decisions are unavoidable.

Arm-chair moralists can kick the can and persist in the delusion that everyone can be saved--they can resist systematizing--but in the field a doctor has to make difficult decisions because that's what doctors have to do, and are trained to do.

Systematizing is the only democratic and rationale solution. Anti-systematizers are promoting favoritism by other names. Doctors need systems in emergency situations. Not creating systems makes doctoring harder, and ultimately degrades treatment.

There's nothing easy about this answer, but it is the only responsible one. If the questions raised by the episode were easy, it would be interesting, but not necessary. Thank you, Radiolab.

Sep. 01 2016 01:12 AM
AlwaysResuscitate

....These doctors should have been charged with manslaughter. The reason we charge people with these things is to send a message, and a message should have been sent. They took the lives of people whose lives should not have been taken. We ought to offer them no sympathy for what they did, because they had no sympathy for the people whose lives were in their care. You can never, ever take the life of another person, no matter what rationale you believe you have for it. You cannot believe that you're doing it to 'end their suffering' because you're not in another person's mind. The fact that they saw the person's life as worth less than their own because they were disabled or 'going to die anyway' doesn't matter. That person's life is not worth less because they're 350 pounds and sweating; or if they’re black and poor and old. That's ableism or racism or agism at its finest, no matter if you tell yourself you’re doing it out of kindness. If the listeners of this podcast or the viewers of the tv show they went on offer them sympathy, then we too are acting with bias. If I was in that hospital on that day, I'd have chosen to stay alive as long as it took for a helicopter or the military to rescue me. I'd rather die in the hospital than have a "kind" doctor end my life. And if they’d tried, even if I were bed bound and unable to move, I’d have fought back, I’d have written a letter saying I did not give my consent, I’d have tried to injure the doctor, to do whatever I could to show that this was murder. But were the patients asked? No. They were just given morphine.

When you make this comparison in your podcast, you overlook that the decision, and the rumors that "wouldn't it be kinder to end the patients' suffering" started being thrown about as related to euthanizing pets. That shows how slippery the slope is. Disabled peoples lives are related to pets, and the slippery slope started with pets and progressed to people whose lives are typically looked at as so unenviable most people believe our lives are worth about as much as a cocker spaniel. But I bet you that no doctor would choose to 'end his or her life’ no matter how long they were trapped in that overheated hospital. If a doctor offered me morphine to ‘end my suffering’, my next words would be, ‘You first.’

(Part 2 of 2)

Aug. 30 2016 05:53 PM
AlwaysResuscitate

As a chronically disabled person who goes into the hospital regularly, this podcast angered me greatly. You spend a great deal of time sympathizing and attempting to think about how difficult it was for *doctors* to be in this position in the hospital in New Orleans, but very little time examining how utterly powerless it would be to be in the position of a person who is chronically disabled. I am chronically disabled and have conditions that are not terminal, but could have been *perceived* terminal at times, until the underlying factor that was found to be causing my decline was figured out and solved. I've undergone chemotherapy to deal with lupus complications, not cancer. I've been hospitalized because I was severely malnourished. My condition goes up and down regularly. I was for a time in a motorized wheelchair, I have had MRSA and a severe lupus flare at the same time. I've since recovered and live a somewhat normal life for a 36 year old. I no longer use the wheelchair even. But it can change again, depending on what complications I get along with my lupus. If I were to be hospitalized in a hospital that is undergoing a catastrophe at the same time I have severe complications which are not figured out or diagnosed at the same time, I could potentially see myself in the same position as these patients.

So if I were in New Orleans in 2005, to know that my life could be terminated in the space of 5 days due to the fact that doctors panicked in a catastrophe and decided instead of letting me wait for a helicopter, they’d rather “end my suffering” because it’s a kinder thing to do to me, supposedly (and let's face it, this was not about medical ethics, this was the fact that doctors panicked!) That means that I am never, ever, going to get a DNR. Why? A DNR might be a logical response and decision, but I realize that I cannot place my life in the hands of people who act illogically in tragedy, and I know perfectly well that doctors are human beings who respond like any other human beings, regardless of how they are trained in medical school. This is how doctors play God. It’s also how doctors discriminate, and let’s use the correct word, this is about *discrimination,* not triage. The decisions the doctors made on that day were due to panic and discrimination. They were not being kind, they were discriminating, most likely due to race, class, weight, (notice that one of the doctors deliberately mentioned one of the patients’ weight in a statement, as if that negated the worth of the patient or his or her quality of life.)

Part 1 of 2

Aug. 30 2016 05:52 PM
Ed Muir from Bowie, Maryland

Wow, what a powerful and important story! During my training as a Navy Hospital Corpsman we reviewed the rules of triage. The priorities are a bit different; those who can be treated & returned to battle must be first; those who require the most resources are last. Yet human subjectivity comes into play in that middle area. I am glad I was never put in that situation. We were also taught how to administer a lethal dose of morphine if supplies allowed. I will read the book for sure. I think this is the best Radiolab program I have heard. Thank you for such strong work. I look forward to each program.

Aug. 30 2016 02:32 PM
Paula from Pittsburgh

I was fascinated by this story, and saddened that we have to plan for such devastating times. I think the reporting did a great job of showing theory vs. practice. To put it simply, it's a lot to ask of people in caring professions -- who are trained to help their patients -- to stand by while somebody suffers and dies due to lack of resources. This is all the more complex when the resources still exist but are dwindling, and that person is not at the top of the recipient list.

That said, I feel there was an angle/approach that was not covered and I'm very curious about it. It seems like a combination of transparency and palliative care could've reduced the suffering of both the patients in need and witnesses to their suffering. Why hadn't anybody explained to the patient in Haiti that she would soon not have oxygen? It seemed like she was unaware of where she fell on the triage list. Had she known, maybe she could've come to terms with it in some kind of mental/spiritual way and also had a chance to make requests in regards to her physical comfort, e.g. being sedated so she would be unconscious when she began to suffocate (I'm not sure if that's a real possibility to begin with let alone whether sufficient sedatives would be available in a desperate situation, but it seems like there is some area yet to be explored ... a sort of hierarchy of treatments when the most effective one is unavailable).

There may be ethical concerns about asking patients to make life/death decisions while under duress, but not even sharing the truth with them raises concerns as well -- and it seems patronizing and a bit cruel.

I don't mean to disparage any of the doctors who have been through these tragedies, I only mean to suggest that as the medical world continues to grapple with a protocol that provides fairness and dignity in chaotic times, it should strive to provide honest and choice if/when possible.

Aug. 30 2016 12:26 AM
JVS from Milwaukee


Would another option for identifying those to withdraw treatment be to ask for volunteers where governments or organizations offer financial rewards to loved ones of the volunteers. I think some would accept such an offer as it does offer a meaningful impact the volunteer could make for which they otherwise might perish anyway and not have the impact.

Aug. 27 2016 04:31 PM
The Clock from NJ

Sheri, your comment indicates that the decision to remove O2 from those two patients wasn't driven by the immediate lack of O2 after all, and that there was still O2 remaining. That would've been interesting had it made it into the radio show.

Aug. 27 2016 01:26 PM

It's hard enough to triage people who are right in front of you. It's even harder to have to factor in people who are NOT right in front of you, but may well be coming soon in need of your help and limited resources. How does a compassionate person say no to someone right in front of you (especially if that person is friendly and kind a "good person") because someone else is probably going to walk in through the door in a few minutes with equal or greater need? Without some kind of protocols other than compassion we default to "first come, first served" or to helping the people that we consider to be "deserving" of saving.

This was a really interesting podcast.

Oh, and Radiolab comments are one of the few kinds of comments I like to read!

Aug. 27 2016 10:28 AM
Richard Moore from Salt Lake City

Guidelines are useful tools. They shouldn't be rules. I'm partial to the idea that you should just take care of whoever's in front of you, and not waste thoughts on trying to make fair what simply is not. I just knew those helicopter were going to show up right after someone in authority, speculating about a future they shouldn't have been pretending to know, started taking those patients fate into their own hands. I have nothing against prioritizing, but you can't make such situations fair.

Aug. 26 2016 03:14 PM
Sheri Fink from New York City

This is Sheri, the reporter on the episode. Thanks for listening and for all of your insightful comments. Here are a couple of answers to some of your questions. As for the person who asked about "following the oxygen," the answer is yes. Unfortunately not everything could fit in the episode, but what struck me was that the oxygen concentrator Nathalie was using in the field hospital sat unused for days after she was transferred out. Incidentally, there was also more oxygen in the New Orleans hospital, after nurse Gina was told by a doctor that there wasn't any for her patient and she had to "let him go". These are good reminders that triage is all about reassessing resources and needs. Also, I want to reassure Anna that Nathalie LeBrun gave consent to be recorded for radio prior to the episode in the Humvee ambulance when she became hypoxic, and we had one or two interviews in the days after she stabilized. She knew this would be part of a story that Americans would hear, and she was that kind of a generous person, who, I believe, wanted to share her experiences out of a desire to help others. It's great that more people now know about her, have heard her voice, and hopefully are inspired by the example of humanity she set in her short years.

Aug. 26 2016 11:53 AM
Dana from Lindstrom, MN

Thank you for Radiolab. I could not help but wonder about the perspective of ill people. I liked that the folks in Maryland got together to think this through, and, while the perspectives of citizens, future ill people, ethicists, researchers, and medical personnel are salient, I could not help but wonder what perspective those on the receiving end of triage might add. I remembered being surprised by an article that I read about dying people. When shown the costs and benefits of treatment, they made different, and less expensive, choices than not as well informed. The perspective of the ill might help inform the dilemma which you articulated well.

Aug. 25 2016 10:45 PM

what a wonderful episode. It had me hooked from the beginning!

Interesting how the Haitian woman died at the end; in a way, it validates the doctors decisions on who to save.

I disagree with the first comment written by Anna about hearing the Haitian woman's words of distress as taking away from the piece, even sensationalizing it. It did not feel this way at all to my listening ear; quite the opposite, in fact: I felt it added impact- it helped put the listener in the medic van with the patient and the journalist. It also helped me feel some of the emotions the journalist must be experiencing and provided important context into why she made the decision to intervene (exploring the ethics surrounding journalist intervention can be an entire Radiolab episode in itself).

In addition, I love Dennis' idea of following the oxygen. That also would have been super interesting.

Aug. 25 2016 10:34 PM
Anna

I found the recording between 55:10 and 56:00 of the Haitian woman suffocating distressful and exploitative.
Distressful because it's the worst thing in the world to see someone dying from suffocation and seeing them be refused oxygen. She didn't think the asthma medication was oxygen, she was begging for oxygen because she knew she needed it. Believe me, I've seen this before.
Unethical and exploitative because she wasn't in a situation to understand what was happening to her, and to properly give consent (whether in the moment because of hypoxia induced confusion, or once recovering or in the US because you can't refuse someone who you perceive as having saved you).
It didn't add to the story, or inform the audience. It was a sensational tidbit, a voyeuristic glance into depths of human suffering that you cannot properly understand through a 50 second clip (you have to be there and look into their eyes to understand). Add to that the triggering aspect of the recording, that is sown into the conversation in a very Radiolab-esque way that springs upon the unprepared and engaged listener in an unsuspecting way.
I have true respect for the team responsible for Radiolab as well as the reporter for this story. I hope I've explained my criticism of the editing of this audio bit in a coherent and comprehensible way.

Aug. 25 2016 08:24 AM
Phil R from Denver

Now imagine that there were armed police officers in the hospital to enforce the protocol. Would they be empowered to arrest those docs and nurses who chose to act compassionately toward some patients? Would they be authorized to taste, even shoot those who failed to adhered to the rules? How does the utilitarian calculation change if enforcing the protocols removes helping professionals from the scene causing even more suffering downstream?

The vision of police shooting civilians on a New Orleans bridge for 'failing to follow protocols in a crisis' comes to mind. We must exercise great caution in not only writing the rules but also in planning for their enforcement.

Aug. 25 2016 01:24 AM
Melanie Schwartz from Denver, CO

This was a phenomenal show. I think it is important to point out that most people like Sheri and others who choose to go into the medical field are very compassionate people. Which is why this is such a gut wrenching dilemma for them, not to mention the masses. "First do no harm" the question is; What is harm and what is compassion for a dying soul? If the patient will suffer is it better to let them go as the brave souls in that New Orleans hospital had to decide under duress? Powerful food for thought.

Aug. 24 2016 05:25 PM
Bobby Gladd from Bay Area

Excellent. Is there a transcript? I came to this by way have having read and reviewed Ann Neumann's compelling book on my KHIT.org blog. She cited this (and Sheri Fink's ProPublica article and subsequent book) on Facebook. I will likely embed/post this on my blog in a forthcoming post.

Aug. 24 2016 02:39 PM

Thank you Radiolab. This was an intense, thought-provoking episode. I had tears in my eyes for much of it. I think Robert's conclusion is correct, that we can't take compassion and our humanity out of the equation. Even if we have objective protocols, each situation will confront us with different people and elements to consider and I don't think we can say what we would do until it would happen to us. With that said, I think guidelines and training in what to consider for how to allocate scarce resources are important.

Aug. 24 2016 01:23 PM
Wendy from Minnesota

Wow, that was a powerful episode,a very interesting and thought provoking topic. If I were a teacher, this would definitely be a worthwhile episode to share with students to get them thinking about, among other things, compassion, reality, and critical thinking in stressful situations. Thank you for producing such a great piece.

Aug. 24 2016 12:24 PM
Parm from New York

Sometimes it is not that easy to determine what is more important - the difficulty of carrying a guilt all your life or the satisfaction derived from extending a precious life. Since humans are susceptible to collateral damage/emotional turbulence, I wonder whether we will abandon this critical decision to machines in future.

Aug. 24 2016 11:07 AM
Dennis from Perth, Australia

A wonderful episode - but I wish Sheri had followed the oxygen, instead of the patient, at the end! I get that individual stories are powerful (and extremely important), but they're also what we hear everyday. Seeing -why- we have to choose to conserve those resources (namely, seeing how many lives that oxygen saved), would have been the real story, I think.

Aug. 24 2016 09:09 AM
Dawn from Norfolk VA

While listening to the podcast halfway through it dawned on me what could have avoided the whole power loss thing which was the reason for so many deaths.

Solar panels on the rooftops of every hospital.

Problem solved.

Aug. 23 2016 03:55 PM
4th year medical student from Boston, MA

Thank you for this. Lots of things to consider that don't just come up in disaster situations but actually in day to day practice

Aug. 23 2016 03:51 PM
Marlus Pasinato from Curitiba, Brazil

Wonderful show. It brought tears to my eyes. Congratulations!

Aug. 23 2016 03:44 PM
Nick from Colorado

Probably your best podcast so far... this is near and dear to myself. Having worked as a medic in Iraq, third world countries, and many years in the US, these types of decisions are so often ignored, misunderstood, and avoided at all costs. These are the hard issues that have to be addressed before disasters happen.

Aug. 23 2016 03:03 PM
Justin from Louisiana

This episode touched on many issues I deal with on a daily basis: The juxtaposition between how civilians approach these tough questions compared to professionals, the views they have on death and dying, and the views on placing a value on human life.

Consider this: As an ICU nurse for many years, I have found that most of what I am paid to do is treating people's loved ones inhumanely (essentially a form of torture), at family request. We keep people alive who are (mostly) elderly with multiple chronic comorbitities that have no hope of ultimately surviving or no hope for any meaningful improvement in quality of life, all because the family (who has no experience in death and dying) has hope and "compassion" for their loved one and wants them to get better. It's hard to fault them for this, but it is costly and inhumane. As someone who works in the medical field but is also a human being that lives in the real world, I understand how what happened in New Orleans and Haiti sounds cold, heartless. But I live in another reality where people with experience dealing with critically ill patients can know with an uncanny degree of certainty what is in store for those patients, be it a good chance to return to previous quality of life, a life in a nursing home or assisted living, a life in a nursing home with frequent readmission and suffering for months, culminating to death; a patient who ultimately will not ever make it out of the hospital, or a patient who has less than 24 hours to live. We can accurately predict these things based on our knowledge and experience, but it is near impossible to convey these things to the civilian population who is filled with hope and the belief that miracles do happen. It is unfortunate that in my line of work, what would truly be miraculous is someone who can live forever. That's a miracle that I'm confident has not and never will happen.

Given the above, as objectionable as it sounds, I often wonder if we should be involving civilians in this decision making process, especially when it comes at such great expense. I believe there was a previous episode of Radiolab where it discussed the exorbitant price of a particular cancer drug. In it, someone mentioned that saying "you can't put a value on human life" is easy to say when you aren't paying for it. But the fact is, someone is paying for it. Money is one of these resources, and money is limited.

Aug. 23 2016 01:58 PM
Marko from Serbia

First of all - I love the show - i know every episode by heart but I had problem with this one. Guys - the first sentence told by Jad is false - or is something that is populated by the same newspapers that Sheri Fink is working for.

Serbs were not attacking anybody in their part of the state - that was used as a reason by the USA government to make it legal to do what they were doing.

For the less informed please see the movie in the link below:

https://www.youtube.com/watch?v=waEYQ46gH08

Please double check the facts before saying something like that - you're a science show.

Best,
Marko

Aug. 23 2016 01:09 PM
LA

To people that think we must never abandon our compassion or that these sorts of protocols can't/shouldn't exist, please reconsider. These types of protocols are being created and debated because of our compassion, not in spite of it.
The idea is to maximize the good/minimize the bad. It gives us guidelines so we don't have to make emotion-based judgement calls in a terrible situation.

Take for instance the journalist/doctor in Haiti. She knew the protocol but was overwhelmed by the gruesome reality of a person dying right before her eyes. So she acted in a way to alleviate the patient's and her own anguish. What if there were two people in need of oxygen on that bus? Or three? How then would she decide who got the oxygen or not? Also, while she does see this one person temporarily saved, what she doesn't see is the hundreds or possibly thousands of people who may be in greater need of said oxygen that they now cannot receive.

When she was asked about it a little later in the episode, she tried to justify it with all sorts of emotional considerations such as: she was a good person, she tried to help others till the very end, etc.. I understand why someone would do this after the fact, but in a emergency situation no one could know the merits of someones life or what they would do afterwards.

Good episode though. Tragic and thought provoking stories.

Aug. 23 2016 03:01 AM
Tara from Boston

I think it's also important to consider how many people are financially or emotionally dependent on the person in question. This is of course impossible to determine- but for example, if the person is 65 and raising his or her grandchildren and they would be put into foster care with the loss of that person. Just something to consider.

Aug. 22 2016 10:40 PM
Lauren from Albany, NY

Interesting show but when they posed the idea of making decisions when there are limited life saving resources I automatically thought about organ donation. They have a method to prioritize those on an organ donor wait list and I wonder if some of this reasoning may apply to a protocol in emergency scenarios.

Aug. 22 2016 09:54 PM
Julia Kraus

Damn.

Aug. 22 2016 05:06 PM
Paul from Paso Robles

So much to comment upon..

First, two of the people in the Maryland focus group said some disturbing things: (39:55 mark) A woman would make the decision to let live a young pastor and let die a reprehensible criminal. Who's to say that the your paster isn't secretly molesting children and the alcoholic turns his life around and becomes a force of compassion, helping others? Also (42:06 mark) the man is SOOO insecure and selfish he chooses his father over everyone else? I don't say these things with any negativity towards those two people, I'm just pointing out how making decisions, particularly life and death decisions, requires questioning everything and looking to see what is behind each answer that comes up.

It's impossible to set a protocol to decide these things ahead of the time of calamity. But what is possible is to cultivate ways of digging deeply into how we think and act. When our inner world makes contact with our environment we go through a very definable process which ultimately directs the outcome in both our consciousness and our actions. By paying close attention to this process we can see how our perceptions, cognitions and inclinations shape our thinking, opinions and actions. With this understanding we can actually make much better decisions on a daily basis and be equipped for the tough times.

Aug. 22 2016 04:51 PM
Aunt Jane from Kentucky

Listening to your podcast made me realize that there is a reason we can not divorce ourselves from our feelings when it comes to applying disaster protocols in an individual situation. It is our humanity, our identification with others of our species. Those without this "problem" are called psychopathic. All life is valuable so we need to try to save all rather than decide who lives and who dies if we want to be able to live with ourselves.

Aug. 22 2016 02:58 PM
Rich

Very interesting to compare this episode to the Buried Bodies one a few podcasts ago. In that episode, the lawyers faced a moral dilemma where they could either hold tight to a strict utilitarian protocol (not disclose any information to incriminate their client) or let a small piece of information slip that could put panicked parents' minds at ease. In the last part of this episode there is a moral dilemma almost identical in nature, where the strict utilitarian protocol said "don't give this woman oxygen" even though she was suffering. I think it's interesting that the lawyers chose to stick to protocol, unpleasant as it may be, while the doctors chose to break it and save the woman. Apparently in this woman's case it worked out.

Personally I feel that while the protocol provides a good fallback so that everyone gets a fair shot under the rules, in the end this is a human decision that we're making. It should be made by humans, in the heat of the moment, because that's where our humanity shines. Whether or not it is the logically correct decision as decided by utilitarianism, the capability to process information and make that decision based on both knowledge and empathy is what sets us apart from machines. That's why I'm okay with both outcomes despite them coming to opposite conclusions. We can try to make these choices easier with protocols but in the end, it should never really be an easy decision to make, and it should be made on an individual level by humans.

Aug. 22 2016 02:21 PM
Amy Hollis from Baltimore

Part of the answer in the final chapter is to have a Plan B for people, rather than simply deciding that since they can't have the easiest solution so they can't have anything. Before the woman's departure, someone decided it was oxygen or nothing. While the woman did get a small bit of oxygen when they stopped, her new doctor tried multiple non-ideal treatments to get her some relief. Had those measures been taken before her transport, would her trip have been easier? Not sure, frankly, but those mid-level options need to be on the table. I think we can make hard decisions without becoming automatons.

Aug. 22 2016 01:37 PM
Matt from California

Great episode. The final statement was the best -- we are undeniably bad at playing god(s). Yet, we do this every day. The irony is that the setting of this story takes place at a hospital, which is the epitome of our modern god games. Hospitals are created to give us some measure of control over who lives and who dies. If we lived by the hand of god(s) (metaphorically speaking), then most of the people within hospitals would have perished long before the disaster struck.

It seemed as though the "townhall meeting" to discuss ethics completely missed the obvious lesson to learn from these situations -- the gods are already deciding who lives and who dies within the scope of the natural disaster, pandemic, etc. These events are random and have no moral compass about them -- much like the lottery that was proposed. Our problems lie in that we simply don't like the gods' decisions and are under the impression that we can do things better. The entire discussion is very reminiscent of Daniel Quinn's book ISHMAEL in his story about the gods' quarreling about who will live and who will die on the earth.

Of course, the scope of the story only discusses how we play god(s) with other human lives. But this is also a reflection of how we play god(s) gods with other lives on this planet -- even those lives on whom we depend for our own life (every other living thing on this earth). Indeed, we humans are terrible gods.

Aug. 22 2016 01:34 PM
Tara from Boston

I think we all agree that on an unconscious and also a conscious level Doctors are perceived as the closest thing to Gods that we have- this is because they can bring life into the world, save life and take life away. The reason I bring this up is because yes, they DO have a responsibility to the greater good as is being discussed- but not in the way that it is being thought of here. We look to many doctors as a culture- I would argue- for our moral codes of conduct towards humanity and each other. The fact that they killed those people in the hospital is sending a terrible ethical message to the public. Yes, they do have a responsibility to the greater good and that is to role model COMPASSION. As a culture- during a large scale catastrophe or pandemic- who do you think will have to jump in and react ethically? ALL OF US. If the doctors are not role modeling compassion- neither will any of us act compassionately towards each other when the shit hits the fan. I am in complete agreement with the compassionate Doctor who told this story. It is her ethical and humanitarian response that will propel us towards a more ethical society- compassion is never, ever a liability.

Aug. 22 2016 12:43 PM
Jesse Murphy from West Palm Beach

I think this was such an important issue to explore.

My own navigation through the issue came as I was reading Grapes Of Wrath driving through the Banana Plantations of Guatemala looking of mounds of rotting fruit as hungry people live nearby.

Sent to the depths of despair, contemplating how vain "doing good" is, when the scale of bad is so vast, I concluded that perhaps the best we could do is keep our head down, and nose clean, get through life hurting as few people as possible.

When sharing this with a friend, he reminded me that this was perhaps the single most important moral change Jesus made when he was on earth. When the prevailing more code was to "do no harm" and variations thereof in the major religious and moral teachings of the time, Jesus was asked, what's the greatest commandment, and he said "love God with all your heart mind and soul, and love your neighbor as yourself." With that, Jesus flipped the moral world on it's head--180 degrees from passively "doing no harm" to actively loving your "neighbor" as yourself is the whole difference. And maybe the most perfect way to answer the question, whether it comes down to a triage situation, or helping the homeless on the street, or carrying the groceries for the elderly, our instructions are the same "if you were in their shoes, do as you would want done to you". It's simple, and profoundly unique for every person, in every situation.

I think this is so important, because what might matter more than which person dies first or last, is what kind of humanity those who live will carry on.

I think in the situation presented in Haiti, perhaps both the Dr. and the journalist did the right thing. The Dr. according to the knowledge they had in trying to do the greatest good for the greatest number of people, and the journalist, for the woman right before her.

I think it's important that we all struggle with this and not abdicate it to an equation or computer or we could risk losing our humanity in the pursuit of saving it.

Aug. 22 2016 11:05 AM
Daniel Stull

This was a rather intense Radiolab. Much respect and thanks for putting out such great content.

Aug. 22 2016 09:32 AM
DRP from London

I am a very sorry to this wonderful, talented and compassionate doctor for what I am going to say but her compassion is precisely the problem the protocol is trying to solve. Compassion is sometimes a liability and as they said, she's clearly avoiding trying to make the decision not to loose her humanity. That is understandable but in that situation, we need rules which, are the most human and just tool we have. That is why we have laws, they work better than human compassion.

The more feelings are involved, the greater the chance for injustice. We were there before... we need rules set up and , probably unpleasing, people to implement them. That's why justice is blindfolded.

Aug. 22 2016 08:08 AM

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