Elizabeth Lee Daugherty

Elizabeth Lee Daugherty is a critical-care physician whose experience with international scarcity and pandemic planning led her to question who should make life-and-death decisions when medical resources run short. In Maryland, she helped bring members of the public into discussions about triage before a decision-making framework had been set, making public deliberation part of preparedness rather than an afterthought.

Background and Professional Role

Daugherty, thirty-nine when she led a Maryland discussion in June 2013, had been thinking about scarce medical resources since college. A medical missionary trip to Bogotá with her father, who was also a physician, first drew her attention to the problem. Her later work as a doctor in impoverished regions deepened that interest, exposing her to resource dilemmas that were chronic rather than confined to a single emergency.

She became medical control chief for the Office of Emergency Management at Johns Hopkins Hospital, a 1,059-bed tertiary referral hospital and the central institution in the Johns Hopkins Medicine enterprise, valued in the account at $6.5 billion. In that role, she was asked to help design a pandemic plan. The work revealed a striking gap between the hospital system’s resources and the needs it might face: even a well-endowed institution could not expect its supplies to meet projected demand.

The Problem of Scarcity

Pandemic planning forced Daugherty to confront what a shortage could mean in practice. If intensive-care units had no capacity for every patient who needed them, some people might be turned away. A particularly stark possibility was removing one patient from a ventilator to make room for another who seemed more likely to recover. Daugherty struggled with whether a doctor could make that choice, and with the authority to decide whose prospects justified access to treatment.

The possible standards did not point to one self-evident answer. Priority might go to the sickest patients, whose lives depended on machines, or to those likeliest to survive their immediate illness. Decision-makers might consider longer-term prospects, age and the principle that people deserve the chance to live through every stage of life, or a patient’s practical contribution to the response, such as being a health professional needed during the emergency. Staff members beyond clinicians could also be considered. Alternatively, allocation might follow first-come-first-served rules or a lottery. Each approach reflected a different account of fairness, and each could impose a grave cost on patients excluded from care.

Daugherty was wary of leaving such judgments to health professionals alone. Clinicians often favor utilitarian efficiency when distributing scarce goods, but efficiency could not settle the moral question of whose life should be prioritized. The setting mattered as well: the neighborhood near Johns Hopkins Hospital was low-income and had little reason to trust medical institutions, given a history of ethically questionable research and discrimination. A plan devised without public participation risked deepening that distrust alongside the medical crisis it was intended to manage.

Building Public Deliberation

To address the problem, Daugherty and her colleagues sought a way to ask the hospital’s neighbors difficult, nuanced questions without assuming that residents would already be familiar with them. They also recognized that merely proposing limits on care could provoke anger. They turned to Carnegie Mellon University’s Program for Deliberative Democracy, whose approach drew on the work of philosophers Jürgen Habermas and John Rawls and on Jim Fishkin’s deliberative-polling method. That method gives citizens opportunities to learn about policy choices and consider them carefully, making it possible to examine how views change through informed discussion.

Maryland’s approach differed from a process in which experts write a proposal first and seek public comment afterward. Health professionals engaged a wide-ranging sample of residents in small-group discussions held across the state over two years, before developing a framework for decisions. Daugherty described Maryland as, so far as was known, the first state to begin this kind of public conversation at that stage of planning.

At a June 2013 session, she set out the emergency premise: a pandemic could overwhelm the system despite everyone’s efforts. She then put the competing triage principles before the volunteers and asked them to consider their values. The exercise echoed the choices faced at Memorial Medical Center as floodwaters rose and doctors decided which patients to evacuate first. Daugherty’s discussion did not make those choices easy; it made their underlying judgments available for public examination before an emergency forced them into practice.

Public Voice and Significance

The deliberations took place in very different communities, including Zion Baptist Church in a Baltimore neighborhood of boarded-up row houses and a wellness center in affluent Howard County. The contrast in settings underscored the breadth of the effort: the questions of allocation were not treated as belonging only to specialists or to one kind of community. Participants showed that ordinary citizens could gather, discuss difficult ethical ideas and learn from one another. Concepts some officials had assumed were the preserve of experts proved accessible to the people whose lives such rules could affect.

Daugherty’s contribution was therefore both practical and civic. She helped address a planning problem created by a foreseeable mismatch between demand and medical capacity, while insisting that professional expertise should not be the sole source of authority over allocation. Her work recast preparedness as more than the production of a technical protocol: it also required an open process in which people could consider competing principles before scarcity made the consequences immediate.