Random allocation of life-saving resources

Random allocation of life-saving resources is the proposal that scarce, potentially lifesaving aid should sometimes be assigned by chance rather than by ranking people according to medical need, likelihood of benefit, or the number of lives a choice may save. Its appeal lies in a moral restraint: when no fair basis exists for preferring one person, a lottery gives each an equal chance and limits the power of decision-makers to choose who will receive help. The book presents this proposal not as a rule Memorial Medical Center followed, but as a counterpoint to the urgent classifications made during the hospital’s evacuation in Hurricane Katrina.

The Case for Chance

The argument entered a sustained philosophical debate in the late 1970s. Its proponents rejected the assumption that saving the greatest number should always be the central measure of a rescue decision. A lottery, they argued, recognizes each person’s claim without allowing authorities to convert competing lives into a single calculation of total benefit. It also limits the risks of giving any group the power to determine whose need matters most.

John M. Taurek’s influential contribution challenged the idea that suffering can simply be added across individuals: many people’s lesser pain does not become equivalent to one person’s greater pain merely because there are more sufferers. C. S. Lewis had expressed a related objection years earlier. In this account, the point is not that consequences are irrelevant, but that a sum of suffering cannot erase the separate experience and claim of each person. Random allocation follows from that doubt about arithmetic as a complete moral answer.

A Challenge to Ranking by Need or Outcome

Chance-based allocation stands apart from both maximizing the number of survivors and prioritizing the patients most likely to benefit medically. In ordinary emergency care, priority commonly goes to those in the most immediate danger without treatment, even when others must wait. That approach treats urgency as a reason to rank claims; a lottery instead asks whether any such ranking is sufficiently justified to decide who gets access to a resource that could save a life.

The proposal is therefore not simply another triage formula. It questions the authority behind the formula: who may classify people, which differences count, and how much certainty a decision-maker can claim in an emergency. Its strongest rationale is procedural equality under scarcity. Its difficulty is practical and ethical: chance can treat claims impartially while disregarding differences in urgency, and it does not make a shortage or its consequences disappear.

Memorial’s Evacuation as a Contrast

At Memorial, the evacuation plan was organized through priority categories rather than random selection. When Susan Mulderick told a hastily assembled command meeting that floodwaters were approaching, Karen Wynn recalled the room’s shift toward the urgency of a military operation: staff had to act before the power failed. Mulderick proposed sending patients most dependent on life support or mechanical aids first. That group included patients in the intensive-care units and newborn nursery, high-risk pregnant patients, dialysis patients, and two vulnerable bone-marrow transplant patients. The discussion began from assessed need and dependence, not equal chances drawn by lot.

The hospital’s doctors also made an exception to the plan: patients with do-not-resuscitate orders would be evacuated last. Four ICU patients fell into that category, including Jannie Burgess, an African American nurse who had spent decades caring for patients in New Orleans hospitals and nursing homes. A DNR order meant that a patient whose heartbeat or breathing stopped should not be revived; it was distinct from a living will requesting that life-sustaining treatment be withheld or withdrawn. Richard Deichmann later explained that he believed DNR patients had the least to lose if disaster struck. The rule shows how a medical classification could become an evacuation ranking, even though the order itself concerned resuscitation rather than a patient’s general claim to rescue.

That decision also sits against Burgess’s history of racial exclusion from care. Although she could treat patients at many private hospitals, she could not receive care at them; it took more than four decades after Memorial opened as Southern Baptist Hospital for her to become a patient there. Her experience does not establish why the DNR rule was adopted, but it makes the consequences of apparently administrative categories harder to detach from the unequal history surrounding care.

Authority Under Pressure

The helicopter evacuations further demonstrate how allocation depended on judgments made in the moment. On the helipad, doctors argued with a Coast Guard pilot about how many patients his helicopter could carry. An Air Force captain intervened, trusting the pilots’ expertise about aircraft capacity, and took charge of clearing the helipad so pilots could land. In another dispute, neonatal nurses resisted a flight plan that would take babies to a hospital other than the one arranged to receive them. The nursing director said the babies would not leave unless the pilot could obtain approval to fly to Baton Rouge; approval came within minutes.

These scenes do not enact a lottery. They expose the decisions a lottery would set aside: which patients go first, how capacity is judged, and whose professional authority governs a rescue. The book’s account makes random allocation a demanding ethical alternative to ranking, not a description of Memorial’s policy. Its central question is whether equal chances can restrain arbitrary power without ignoring urgent differences in need—a question made concrete when scarce transport, failing infrastructure, and competing claims forced people to decide who would be moved and when.