“A duty to die”

“A duty to die” is the phrase Richard Lamm used to argue that people kept alive by costly medical technology might owe it to society to step aside. The book presents it as a flashpoint in debates over resource allocation, not as a rule adopted at Memorial Medical Center. Its force comes from the question it leaves unsettled: when survival is difficult and help is scarce, who gets to distinguish a limit on treatment from a judgment that a life is not worth saving?

The phrase and its controversy

Before Lamm’s intervention, Horace Baltz had already encountered colleagues who spoke dismissively about the resources devoted to LifeCare Hospitals’ typically elderly and infirm patients. Over coffee, one colleague complained that too much was spent on patients he called “turkeys” and argued that they should be let go. Baltz answered, “You have no right to decide who lives and who dies.” Their disagreement exposed two competing understandings of medicine: care as an obligation to the individual patient, and care as a finite resource that might be redirected elsewhere.

In 1984, as medical costs and budget deficits drew increasing attention, Colorado governor Richard Lamm criticized expensive, high-technology treatment that could keep some people alive almost indefinitely regardless of age or prognosis. At a meeting of the Colorado Health Lawyers Association, he cited a critique of antiaging research by University of Chicago bioethicist Leon R. Kass and declared, “We’ve got a duty to die,” so that others could build a reasonable life. A Denver Post reporter’s account carried the statement nationwide and provoked a public furor.

The argument had gained urgency as crash carts and intensive-care medicine extended the capacity to sustain life, while Medicare covered new technologies regardless of cost. But the book sets economic calculation against powerful objections: limiting life-saving care runs against the impulse to rescue a person in extremis and against the continuing search for treatments that might prolong life. The proposal also collided with American memories of eugenics and Nazi medicine, whose language of “lives not worth living” had shown how claims about the welfare of the larger society could be turned against particular people.

A crisis of triage and authority

At Memorial, the question of who should receive protection became immediate and practical. When Susan Mulderick announced that floodwaters were approaching, Karen Wynn recalled that the command room’s atmosphere shifted from a hospital emergency to something like a military operation. The objective was to act before power failed. Nearly two hundred patients needed to be moved, including intensive-care patients dependent on life support, newborns, high-risk pregnant patients, dialysis patients, and bone-marrow transplant patients vulnerable to infection. Mulderick sought more help from Acadian and contacted her former husband about helicopter transport, only to learn that his company was already committed to evacuating Tulane Hospital.

The doctors’ evacuation plan contained a consequential exception to the general proposal to move the sickest patients first: patients with Do Not Resuscitate orders would be evacuated last. Four such patients were in the ICU, including Jannie Burgess, a Black nurse who had once cared for patients at hospitals where she herself could not receive care. A DNR order meant that a patient whose heart or breathing stopped should not be resuscitated; it was not the same as a living will requesting that life-sustaining treatment be withheld or withdrawn. Yet Richard Deichmann later said he believed DNR patients had to have a certified terminal or irreversible condition and thought they had the least to lose if disaster struck. The difference between the order’s actual scope and that understanding matters: a designation about resuscitation became a basis for assigning evacuation priority.

Other moments at the hospital showed how authority and judgment could be contested under pressure. On the helipad, a doctor argued with a Coast Guard pilot about how many patients his helicopter could carry; the pilot left to rescue people elsewhere. An Air Force captain then took charge of the flight line, clearing doctors and patients from the pad so pilots could land. When a later helicopter was directed to a hospital west of Baton Rouge rather than the destination that had agreed to receive Memorial’s newborns, the neonatal nursing director refused to release them unless the pilot secured approval to fly to Baton Rouge. The flight plan was changed, and the babies arrived safely. These scenes do not show staff invoking Lamm’s phrase; they show the related, concrete dispute over whether emergency decisions should be governed by generalized judgments or by the needs and risks of particular patients.

Comfort, treatment, and the meaning of letting go

The phrase also shadows disputes over medication, though the book distinguishes comfort care from an intention to hasten death. In an interview, Mulderick said that the idea of medicating patients on Thursday had come from her and described her aim as comfort. She offered Ativan as an example of a drug that could relax patients. But prescriptions seized from the pharmacy showed that Pou and other doctors had already been prescribing Ativan and other ordinary comfort medications during the disaster. That evidence made it difficult to explain the proposal as a new need for someone to tell Pou what drugs were available. The disagreement was not simply about whether medication might ease suffering; it concerned purpose, prior practice, and whether foreseeable harm was being treated as an intended outcome.

John Thiele’s later critical illness sharpened the importance of prognosis in these debates. After a month in a half-conscious state, he said he remained confident in what he had done at Memorial and distinguished his own condition from those of patients he had helped inject. He had developed many signs associated with poor survival, but believed every problem he faced could potentially be reversed. He said he would have given a family a grim account of such a patient’s chances, yet would still have continued treatment because recovery remained possible. The distinction he drew—between an unlikely recovery and an irreversible condition—shows how judgments about prognosis can determine whether continued treatment is understood as warranted care or futile expenditure.

The human aftermath

The book’s later scenes keep the debate from resolving into an abstract calculation. Gina Isbell continued to see her Katrina patients’ faces in nightmares and slept poorly; after leaving Memorial by boat, she found that her home and community in St. Bernard Parish had been lost. She felt guilty about the staff she had scheduled and terrible about the patients who died. A hurricane-shaped pendant and a memory of a patient’s grandmother thanking her for helping keep her alive became part of how she carried the experience. Isbell believed that she and her colleagues had done the best they could, and said she would serve in another storm if asked.

Karen Wynn, too, found that recounting the crisis for legal preparation could make it feel newly present; after some meetings, it took weeks to feel able to move forward again. Such aftermath does not prove that every decision was right or wrong. It does make the stakes of “A duty to die” harder to reduce to a formula: decisions made in a disaster remained with the people who made them, the patients they concerned, and the families and colleagues who had to live with what followed.