Tia Powell

Tia Powell appears in the book as a physician and public-policy figure confronting a question that disaster exercises made difficult to evade: when life-support equipment is scarce, how should its use be allocated? As former executive director of the New York State Task Force on Life and the Law, she was part of the effort to plan for decisions that hospital staff at Memorial Medical Center had been forced to face amid catastrophe, without comparable guidelines prepared in advance.

Role in Pandemic Planning

State health officials ran exercises based on H5N1, or bird flu, scenarios and found that hospitals repeatedly ran short of ventilators. Powell recalled the task force’s reaction: “They kept running out of ventilators,” followed by, “What on earth are we going to do?” The exercise turned a projected shortage into an immediate policy problem: demand for life support could exceed not only available machines but the capacity to operate them.

The group first considered ways to stretch supply, including canceling elective surgeries during a severe pandemic. New York also purchased and stockpiled ventilators, but that supply could address a moderate outbreak, not a pandemic on the scale of the 1918 influenza pandemic. Because ventilators were costly, required trained operators, and consumed oxygen that might itself become scarce, those measures could not resolve the most extreme case. The task force therefore worked on rationing guidance intended to save as many lives as possible within an ethical framework.

Rationing and Prepared Rules

The proposed guidance represented a departure from ordinary medical practice, which centers on doing everything possible for each patient. Drawing in part on an Ontario proposal developed during the SARS crisis, planners used the Sequential Organ Failure Assessment score to help determine which patients would receive intensive care during an emergency. The New York protocol could deny ventilators to some patients with the highest scores, as well as to patients with serious chronic conditions such as kidney failure, cancers that had spread with a poor prognosis, or severe irreversible neurological conditions likely to be fatal.

The plan also contemplated reassessing patients after a trial period and removing ventilators from those who were not improving, potentially without permission from their families. That provision raised a legal obstacle: state law barred doctors from withdrawing life support without express consent from patients or their authorized health agents. Planning therefore involved more than choosing clinical criteria. It required considering whether emergency authority could alter the rules governing those decisions.

From Guidance to Emergency Authority

Powell emphasized how quickly a policy that was not yet operative could become enforceable in a crisis: “You can take something today that’s not necessarily active and overnight flip the switch and make it into something that has those teeth in it.” Her warning marks the transition from planning on paper to the exercise of public authority: emergency rules might protect clinicians making allocation decisions, but they could also permit restrictions on treatment that would be impermissible under ordinary conditions.

The book places Powell’s remarks in a wider debate over disaster-care protections. Some states had prepared emergency orders that could allow hospitals to turn away patients, protect doctors limiting care, or authorize public-health interventions. Louisiana and Indiana instead addressed such questions through legislation; Louisiana’s legislative effort was associated with Anna Pou’s advocacy after the grand jury declined to indict her. Powell is not identified as the author of those laws. Her contribution in this account is to clarify the stakes of advance planning: criteria, legal protections, and the authority to activate them must be considered before exhausted clinicians confront scarcity at the bedside.