Seattle and King County

Seattle and King County became a setting for public deliberation about disaster triage: an exercise there revealed that choices about scarce medical resources were not merely technical judgments. Participants challenged plans that would withdraw life-sustaining care and questioned whether survival statistics could fairly determine who received treatment. The exercise brought public values into view, including concerns that ostensibly neutral criteria could reproduce inequalities in the healthcare system.

The public weighs emergency triage

A public-engagement exercise in Seattle and King County, funded by the Centers for Disease Control and Prevention, asked participants to consider decisions that arise when medical resources are scarce. Many objected to withdrawing life-sustaining care, as proposed in several pandemic triage plans. Their objection was partly about the immediate treatment decision and partly about its wider consequence: they feared that such practices would erode public trust in medicine.

The exercise made visible a tension in disaster planning. Clinicians and policymakers may frame triage as a problem of applying medical criteria under pressure, while members of the public also judge what those criteria express about obligations to patients. The public response suggested that a plan’s legitimacy cannot be separated from whether people regard its treatment of vulnerable patients as fair.

Concerns about statistical fairness

Participants also questioned the use of survival statistics to determine access to scarce resources. They worried that such measures could be inherently discriminatory if they reflected unequal treatment already embedded in healthcare. Where African Americans and immigrants had not received the same quality of care, differences in recovery rates or other measures of survivability might encode those disparities into a triage system.

This concern shifted attention from the apparent neutrality of a numerical rule to the conditions that produced the numbers. A statistic can look like an objective measure of who is most likely to benefit, yet still carry the effects of unequal access and treatment. In the exercise, fairness therefore involved not only applying a consistent formula but asking whether the information used by that formula had been shaped by institutional racism.

Public participation and policy authority

Roger Bernier, a senior advisor at the Centers for Disease Control and Prevention, argued that involving non-experts in these discussions was both possible and necessary. His case for public participation rested on the claim that communities hold public values and are well placed to weigh competing social priorities. He also criticized the limited effort made to seek public judgment on policy choices, framing that shortfall as a failure to make meaningful use of democratic deliberation.

The exercise also points to the difficulty of acting on public input. Consultation can reveal divergent or conflicting views, leaving policymakers to decide how to weigh majority and minority positions and whether to share authority over the final decision. The book contrasts this problem with a 2009 effort by the Centers for Disease Control and Prevention to gather feedback on emergency vaccination for a new flu strain: public opinion differed substantially from expert opinion, but the policy was essentially settled by the time the feedback had been collected.

Place in the wider debate

The Seattle and King County exercise forms part of a broader argument for involving the public in the design of disaster-care guidelines. In 2012, the Institute of Medicine endorsed public participation in developing rules for dividing medical resources in emergencies. Its recommendations addressed the ethical stakes highlighted by the exercise: crisis conditions may require limits on scarce treatments, but providers still have duties to care for patients, treat them fairly, and steward resources.

The wider debate also challenged the use of do-not-resuscitate orders as disaster-triage criteria. Such orders express advance planning and personal preferences about end-of-life care; they are not necessarily reliable estimates of a patient’s likelihood of survival. The exercise’s significance lies in bringing these questions of trust, equity, and authority into public view, rather than treating emergency allocation as a decision for medical professionals alone.