Maryland

Maryland is presented as a testing ground for public participation in disaster triage: a statewide effort to ask residents how scarce medical resources should be allocated before an emergency forces the choice. Its significance lies not only in the policy questions under discussion, but in the method. Instead of treating such decisions as the exclusive province of specialists, the project made them subjects for informed, structured public conversation.

A Statewide Deliberation

At a June 2013 meeting, critical-care physician Elizabeth Lee Daugherty introduced volunteers to an overwhelmed-system scenario, such as a pandemic, in which patients outnumbered available care. The dilemma recalled the evacuation choices at Memorial Medical Center during Hurricane Katrina: who should receive priority when there is no way to help everyone at once? Participants considered whether priority should go to the sickest, to patients most likely to survive their immediate illness, or to those with better prospects for long-term survival. They also examined whether age, patients’ potential contribution to the response, need-based first-come-first-served allocation, or a lottery could offer a fairer rule.

The discussions were not a single expert panel’s attempt to settle the issue. Maryland health professionals sought input from a broad sample of residents through small-group sessions held across the state over two years. Daugherty described the approach as beginning public conversation before a framework for decisions had been developed. In the book’s account, Maryland was, as far as the organizers knew, the first state to take that particular approach.

Daugherty’s Rationale

Daugherty’s interest in scarce medical resources began during college, on a medical missionary trip to Bogotá with her physician father, and deepened through her own work as a doctor in impoverished regions. Later, as medical control chief for the Office of Emergency Management at Johns Hopkins Hospital, she was asked to help design a pandemic plan. The gap between the hospital system’s substantial resources and the demand anticipated in a pandemic made her recognize, in an exceptionally well-resourced institution, a version of the chronic scarcity she had encountered elsewhere.

The prospect of deciding which patients might be turned away from intensive care troubled her. She questioned whether a physician could remove one patient from a ventilator to make room for another with a better chance of recovery, and whether clinicians should make such life-and-death judgments alone. That concern was especially pressing around Johns Hopkins, in a low-income Baltimore neighborhood where trust in medicine was already damaged by historical discrimination and ethically questionable research. Public participation was therefore not simply a way to gather opinions: it addressed who would have a voice in choices made by institutions whose legitimacy could not be assumed.

How the Conversations Were Designed

Daugherty and her colleagues wanted residents to consider nuanced ethical questions, while recognizing that people might have little prior exposure to them or react angrily to the prospect of limiting care. They turned to Carnegie Mellon University’s Program for Deliberative Democracy, whose approach draws on ideas associated with Jürgen Habermas and John Rawls and on Jim Fishkin’s deliberative polling. The method is intended to capture how opinions may change when people have the opportunity to learn about policy choices and consider them carefully.

The project’s public setting extended across markedly different communities. Sessions took place at Zion Baptist Church in an inner-city Baltimore neighborhood of boarded-up row houses and at a wellness center in affluent Howard County. This range gave the effort a geographic and social breadth: the question of emergency allocation was not confined to hospital administrators or policy specialists, but brought into places where residents could discuss its consequences together.

What Maryland Demonstrated

The experiment’s early significance was that ordinary residents could engage with difficult ethical questions rather than merely receive rules devised elsewhere. At Zion Baptist Church, a facilitator asked volunteers to consider whether age should be the primary basis for allocating resources in a disaster. One young participant objected by imagining a ventilator going to him instead of a twelve-year-old or a four-year-old, and described that outcome as deeply sad. The exchange made the abstract principle concrete without resolving the competing claims: equal treatment across stages of life, chances of survival, and the urgency of need could point in different directions.

Maryland’s approach also stood in contrast to a New York ventilator-allocation plan whose authors had described public review as important to transparency and fairness, but whose proposed focus groups were never held. The Maryland sessions instead placed public discussion before the creation of a framework. In the book’s argument, that sequence matters: residents demonstrated that they could learn from one another and grasp ethical concepts officials had sometimes assumed were suitable only for experts, making deliberation itself part of disaster preparedness.