Medical rationing

Medical rationing is the allocation of scarce treatment, equipment, time, or access when not everyone who could benefit can receive it. It is therefore more than a clinical sorting exercise. The criteria used—medical urgency, likelihood of benefit, social circumstances, or some combination—encode judgments about what counts as fairness and whose interests a system is meant to serve. In ordinary care and in disaster, the arithmetic of scarcity cannot be separated from the moral authority to choose.

Scarcity and the history of selection

The book illustrates the problem through wartime penicillin, which the British military reserved for pilots and bomber crews, and through early kidney-dialysis committees in the United States. Before dialysis became widely available, some committees secretly considered age, gender, marital status, education, occupation, and perceived future potential. Their decisions did not simply identify who was sickest; they weighed an imagined contribution to the community. Public exposure of such practices prompted condemnation, including criticism of a Seattle clinic’s exclusion of people thought insufficiently useful or conventionally promising.

A story by Shana Alexander in LIFE magazine helped bring the dialysis decisions to wider attention. Lawmakers subsequently established a system under which Americans who needed dialysis would be entitled to receive it, typically with government support. That change shows one response to rationing: rather than accepting scarcity as fixed and asking only which individual should lose, a society can expand provision and establish an enforceable claim to care. The book contrasts this development with public hospitals in South Africa, where dialysis remained rationed because potential patients greatly outnumbered available treatment slots.

In South Africa, clinicians faced recurring decisions about whether criteria beyond medical need—such as employment, parental status, or a history of drug use—should influence access. The history of decisions favoring white patients raised a further question: how could a selection process be made more just after unequal outcomes had already shaped it? Doctors eventually sought patient input while developing a more standardized system. Advocates also pressed to expand dialysis programs for low-income patients and to prevent kidney disease. Accountability and public participation did not eliminate scarcity, but they made the process less insulated and connected individual allocation decisions to efforts to reduce the shortage itself.

Efficiency, need, and competing claims to fairness

Organ transplantation supplies another comparison. The United Network for Organ Sharing invited both medical professionals and members of the public to help design allocation policies. According to medical ethicist Robert M. Veatch, members of the public tended to favor patients in the direst need, even when they were less likely to survive or lived farther from an available organ. Health professionals more often favored directing organs to patients most likely to benefit medically. That emphasis on efficiency could leave the sickest patients without transplants and disadvantage people whose ethnic groups had higher need or lower donation rates, as well as kidney patients of lower socioeconomic status. Newer antirejection drugs mitigated one part of the disparity, but no allocation formula could secure universal agreement.

The comparison does not make justice and efficiency simple opposites. A system that maximizes the expected benefit from each scarce resource may save more lives by its chosen measure, while a system that gives greater weight to urgency may answer a different, also compelling, understanding of fairness. The book’s point is that the method cannot be judged apart from who devised it and whose experience counted. Including both clinicians and laypeople in organ-allocation decisions helped produce policies that combined concerns for justice and efficiency. Deciding who participates is itself part of deciding what a society values.

A related public debate concerned former Colorado governor Richard D. Lamm’s argument that expensive high-technology procedures could consume resources while prolonging a poor prognosis. Newspaper coverage distorted his remarks into a headline suggesting that older people were being told to die. Lamm later won a correction from The New York Times; the book distinguishes his argument about health-system spending from a claim that particular elderly or terminally ill people should surrender care. He also acknowledged that a sick person would naturally seek treatment and said that this was precisely why a health system needed to make decisions about the use of resources. The episode shows how abstract arguments about rationing can become accusations about the worth of individual lives—and how easily the distinction can disappear in public debate.

Disaster triage at Memorial Medical Center

During Hurricane Katrina, the allocation problem became immediate at Memorial Medical Center. The hospital faced the prospect of losing power while nearly two hundred patients needed evacuation. In a hastily organized command meeting, staff focused on moving patients dependent on life support or mechanical aids, including intensive-care patients, newborns, high-risk pregnant patients, and people receiving dialysis. The situation was shaped by the scarcity of transport: residents without cars struggled to leave New Orleans, ambulance dispatchers were overwhelmed, and some ambulances were caught in traffic or diverted to the Superdome. The patients’ need for rescue thus met a transportation system already constrained across the city.

Memorial’s doctors established an exception to the initial principle of moving the sickest and most machine-dependent patients first: patients with Do-not-resuscitate orders would be evacuated last. The distinction matters because a Do-not-resuscitate order concerned whether a patient whose heartbeat or breathing had stopped should be revived; it was not, by itself, an instruction to withhold rescue or other treatment. The book explains that these orders were ordinarily signed with the informed consent of the patient or a health-care proxy, while Louisiana’s living-will law addressed a different question: whether life-sustaining procedures could be withheld or withdrawn for someone with a terminal and irreversible condition. At Memorial, however, medical chairman Richard Deichmann later said he believed the law required Do-not-resuscitate patients to have a certified terminal or irreversible condition and thought they had the least to lose if disaster struck.

The consequences of that policy were not merely theoretical. A patient’s daughter had agreed to a Do-not-resuscitate order in anticipation of cardiac arrest, reasoning that resuscitation would not make sense for her ninety-three-year-old mother. When the daughter learned that the order was affecting her mother’s evacuation, she explained that she had not understood it to mean that her mother would be left without rescue and asked to cancel it. The patient was then moved toward evacuation. Another daughter, Angela McManus, tried to rescind the order for her mother, Wilda, after hearing that Do-not-resuscitate patients would be deferred, but staff told her that no doctor was available to do so. These episodes expose a basic failure of communication and consent: a narrowly defined medical instruction had acquired a new, consequential meaning in an emergency without patients and families being adequately informed.

Who decides, and who can challenge the decision

At Memorial, medical professionals alone determined how patients would be categorized for evacuation, and no system was established to explain those decisions to the people most affected. In some instances, staff were instructed not to tell family members that a patient’s Do-not-resuscitate status explained the delay. The problem was not only which patients received priority; it was also who had access to the rule, who could understand its consequences, and who had the power to alter it. A category intended to guide resuscitation became, in practice, a barrier to timely rescue, while families’ ability to respond depended on whether they were told what the category meant in that setting.

The book places this episode beside Jannie Burgess’s history. Burgess had worked for thirty-five years as a nurse in New Orleans hospitals and nursing homes, yet, because of racial segregation, she could care for patients at many private hospitals without being eligible to receive care there herself. Southern Baptist Hospital, later Memorial Medical Center, was among the last Southern hospitals to integrate; it refused federal hospital programs in the mid-1960s rather than accept their nondiscrimination requirements. During the Katrina evacuation, Burgess was among the intensive-care patients with a Do-not-resuscitate order who were assigned last priority. The account does not establish that race caused the triage decision. Its juxtaposition instead makes visible how a formally clinical category operates within a longer history of unequal access and raises the stakes of treating any supposedly neutral rule as self-justifying.

Accountability beyond the bedside

The book’s comparisons point toward procedural safeguards as well as better medical criteria. At the time of Katrina, at least nine recognized systems existed for triaging mass-casualty patients in the United States, yet little research had established whether commonly used systems achieved their aims or might worsen overall survival. Many systems directed medical personnel to attend first to the most severely injured, while allowing people with less serious injuries to wait. That established disaster principle does not, by itself, answer how to allocate evacuation transport, how to treat patients whose status is misunderstood, or how to communicate changing priorities during a prolonged emergency.

Later planning efforts addressed allocation more explicitly. New York State developed a protocol for rationing ventilators during a severe influenza pandemic, and state health departments wrestled with how to set rationing standards. A 2009 public-engagement exercise in Seattle and King County and the extensive crisis-care work discussed by the Institute of Medicine belong to the same broader effort: to decide principles before a crisis, make those principles open to scrutiny, and involve the public in decisions that affect life and death. The book’s central concern is not that any procedure can remove tragic choices. It is that scarcity does not absolve institutions of the duty to explain criteria, test their consequences, include affected people, and distinguish a patient’s refusal of resuscitation from a decision to stop trying to save that patient.