Playing God
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Listener supported. WNYC Studios. Hey there. Lula Miller here with an intense episode. We're going to play one today that is from the archives. We made it back in 2016 in collaboration with the New York Times, where we take on the concept of triage, a word that at its core means sorting the value of lives. This topic is really tricky because

Do you save the oldest, the youngest, the people with the most medical training? Do you pick it randomly? These questions are obviously just as relevant and unanswered today. And we thought it would be a good time to take a listen back. Produced by Simon Adler and Annie McEwen with reporting from Sherry Fink playing God. Wait, you're listening? Okay. All right. Okay. All right. You're listening to Radiolab.

By the way, we're going to start with Kosovo. When did you as a writer become obsessed with all of this? Well, this obsession about triage came about when I was working on my...

Last book. This is Sherry Fink, reporter from the New York Times. She's the author of the book Five Days at Memorial. Which was about triage in an emergency in Hurricane Katrina. We brought Sherry in to tell us a series of stories that grew out of the reporting she did for that book. But we actually are going to start with some tales before she wrote the book, when she was at the border of Kosovo and Macedonia. So this was back in 1999. Kosovo!

The U.S. and other, I think, NATO allies were involved in a bombing campaign in Serbia. This is basically like the last gasps of war in the former Yugoslavia. You had Serbia attacking ethnic Albanians in Kosovo. NATO was trying to protect them, bombing Serbia, which was creating a huge exodus of refugees.

Now Sherry, at the time, was not yet fully a reporter. She was fresh out of med school, volunteering at a human rights organization, working on a book about a war hospital in Bosnia. And since she knew the landscape, she was able to convince this organization to let her go to Macedonia to document what was happening. I remember I went to the border of Kosovo and Macedonia and

Like 100,000 refugees had shown up. They were trying to cross the border into Macedonia, but the Macedonian government had closed its border with Kosovo, so people who were fleeing got trapped. They got stuck in this muddy no-man's land between the two borders. And the Macedonian Red Cross and this one charity had gotten permission to set up a makeshift medical station in that border area.

I was there to collect information, but when I got there, the doctor who I had interviewed previously, this really tall Albanian, Kosovo-Albanian doctor, looked out and he told the Macedonian border guards, "Let her in. We need her. She's a doctor."

They just grabbed you and pulled you into this tent? Yes. So you were just out of med school when this happened? I had just finished med school, yeah. But suddenly she says she was tossed in with all these war doctors. And here's the key. Eventually she gets posted at the door of the tent. And what I ended up doing, or what they put me in charge of, was triage.

Now, triage is a French word. It means to sort for quality. And a few hundred years ago, the word began to be applied to sorting different kinds of casualties on a battlefield. And that suddenly was her job. Literally, I stood outside of this makeshift medical station and

And every minute, every couple minutes, there would be another patient brought to the door of our medical tent. And so my job was to stand outside that door and decide who gets in and who doesn't. And how did you do that? How did you make that choice? Well, I don't remember having guidelines. I remember just having to wing it.

She says she just went on instinct. And so the people who seemed like they might be having a heart attack or a seizure, those were the ones who went into that tent. But, you know, people with physical disabilities, no. People who have chronic conditions. No. Psychiatric issues. No. Everybody else, I had to direct to this other tent. And someone ended up calling it the tent of the damned.

I remember appealing for help from the Macedonian health ministry saying, you know, take these people into Macedonia. They're not a threat. Open your border, take them in. They need care. And the health ministry kept refusing. And so they stayed in this tent day after day. Sometimes for four, five, six days. And several of the people in this tent, they died. Sherry says this experience haunted her.

And years later, when she was a full-blown reporter and traveling all around the world looking at triage and different scenarios, she would return to this memory again and again and wonder, how do people in that situation make that decision? How should they? This is the scenario that people in New Orleans have been fearing for a long time. A Category 5 hurricane headed right toward the city. Okay, so this is going to be our first stop. We all...

Have heard the story of Katrina told and retold. But in this story, the hurricane is really just a backdrop. Really, we're going to focus in on one building. This hospital, Memorial Medical Center, built in 1926 in one of the lowest parts of that city, which is really like a bowl. It was a sturdy brick building, eight stories tall, stretching over two city blocks. It had served in every storm until that point. It was really seen as somewhere safe.

And this hospital became for Sherry a kind of portal.

into these questions about triage. She ended up spending six and a half years interviewing doctors at the hospital, patients, nurses, family members, government officials, ethicists, hospital administrators. In all, she conducted over 500 interviews to reconstruct moment for moment what happened at the hospital during Hurricane Katrina.

Get ready. The most intense part of the storm is getting ready to come across. Day one, Monday, August 29th, 2005. Around 6 a.m., Katrina hits. I've never seen anything in my life like this. And they get through the storm okay.

The city power's gone, but they've got their backup power. But this hospital, it had a vulnerability a lot of American hospitals have, which is that they had moved the generators to the second floor. So that they would be higher up in case of flooding. But electricity is all about circuits. And they had elements of that backup power system that were below flood level. Things like switches and other electrical material. But they got through the first day okay. And it seemed at that point that the worst was over.

And then... The levees fail. Water surrounds this hospital. It fills New Orleans. And as the water started to rise around the hospital, that is the moment that the people in charge knew they were in big, big trouble.

They knew what their vulnerability was. How many patients were in the hospital at this point? There were 250 patients. There were about 2,000 people because you had so many staff and then all the visitors who had come with the staff members and with the patients. So Sherry says mid-morning on that second day, this is Tuesday, August 30th,

just as the waters were starting to rise. A group of doctors got together and they did come up with a system which evolved a little bit over the crisis, but they decided first get the babies out, get the critical care patients out, and they knew that they had two high-water trucks from the National Guard and the water wasn't so, so high yet. At that point, it was only partway up the sloping emergency room ramp. And they decided to put patients who could walk on those trucks.

So helicopters start to arrive. The medical staff start to bundle tiny babies in incubators, ICU patients in wheelchairs, onto the elevator, and up to the helipad. How many patients can a single helicopter take? Yeah, like the ones that were landing, how many can they do? One or two. Wow, so this is slow going. Yeah. It was late evening before they got all the intensive care unit patients out. And they get all the babies in? They get all the babies in.

All in all, on that second day, they evacuated about 60 people. These are 60 of the most critical patients. Although we should also say that if a patient had signed a DNR, a do not resuscitate order, the doctors decided those patients should not go first and they were held back. And we'll sort of explain their thinking on that in just a second.

Okay, so darkness falls on day two. The doctors and nurses are exhausted. They'd been working really, really hard carrying patients in the heat. Many of them lay down on cots in vacant beds. To rest for the night, and then before the sun rises, a few hours before, about 2 a.m., the buzz of the generators suddenly just stopped. It's quiet.

The water had reached those electrical switches in the basement. Dr. Cook, Ewing Cook, a longtime ICU doctor, he was lying not far from where those generators were. And he said to me it was, quote, the sickest sound of his life. Sound of absence. Yeah. And that is when it became an absolute emergency in this hospital. ♪

It's pitch blackness. Some of the medical equipment, they have backup batteries. They started beeping to warn that the electrical power had stopped. You still had nine patients who relied on ventilators to breathe.

it became a hive of activity. They've got to get everyone out. Everybody was running around with flashlights, these beams in the blackness, trying desperately to move those patients down the stairs. Now there's no elevators. That's the other big thing. Fortunately, somebody found a hole

in the machine room wall on the second floor that led directly to a parking garage. And so they figured out they could pass patients through this roughly three by three foot hole onto the back of a pickup truck, drive them up to the eighth story of that parking garage, and then carry them up three rickety flights of steps to this formerly unused helipad.

And five of the nine patients on ventilators died just right then. It's just like I said, I've been trying to put it away. Yeah. But I want to make this as accurate as I can for you. This is tape of an interview that Sherry did back in 2008 when she was doing research for this story. Okay.

Introduce yourself. My name is Gina Isbell. Isbell, okay. Just like it's spelled. Gina was a nursing director working on the seventh floor of the hospital that day. She'd actually been attending to those nine patients that didn't make the first helicopter run. And she described to Sherry that right after the power went out and after the ventilator shut down, one of her patients flatlined. And we brought him back.

We had run out of oxygen, the whole hospital. That's what she'd been told. And he needed oxygen. And so we brought him down the stairs to the second floor. They brought him down in the dark and then got in line to wait for their turn to go through the hole in the wall up to the heliport. And she says that since his ventilator wasn't working anymore, the whole time they were standing there, they had to hand-squeeze this ventilator back to keep air out.

going into his lungs. You know, he kept twitching and I knew he needed oxygen. So I was in line and it was my turn at the window. I kept bagging him and bagging him. One of the physicians came over and said, you do know that he needs oxygen? I said, yes, sir. He said, we don't have any oxygen and we can't get any and you have to let him go. And at that point, you know, I'm standing there and I'm like...

"How do you do this? How do you do this?" You just let him go. But he was right. I mean, I knew it was neurological and that he needed oxygen and he wasn't gonna make it without it. So I just hugged him and stroked his hair and I waited and just kind of held him and he died in my arms. And you know, you're not prepared for that. You're prepared to help people and to save people. You know, it's just not enough.

Everything you've done is just not enough. Day three, Wednesday, August 31st, 2005. Sun rises, and that's when they're expecting all the helicopters to come back. And they wait, and they wait, and they wait. And an occasional helicopter comes, but this concerted rescue effort that had taken place the evening before has stopped.

Now, we know now, looking back, that on that Wednesday... The helicopters were doing their own triage. Coast Guard rescuing people. And looking at people on rooftops, waving rags. The entire family is on that roof right now. But the people inside the hospital...

Most of them had no idea. All they knew was we're in this horrific situation. Where are the helicopters? At this point, there's still nearly 200 patients at the hospital. And...

Some of the staff, they're panicked because it takes them so long to move the patients to the top of the parking garage just below that helipad. So she says on that third day at about 7 in the morning, a bunch of doctors and hospital administrators... Maybe a dozen, dozen and a half. They got together and they decided that they needed a system, a way of organizing their patients so that when those helicopters started to show up again...

they wouldn't waste any time at all. They'd know exactly who to evacuate in what order. In other words, who are we going to get out first? That was the question. And that's the moment where they come up with the ones, twos, and threes. This is triage. There are a limited number of resources, in this case helicopters and a few boats, and we have to decide which people get access to those resources. ♪

There are a couple of ways to look at this. Sherry says if you go back to the very beginning of triage. The first conception of it. 1790s. Napoleon's chief surgeon. He made a rule on the battlefield. That you take the people who are in the acute need first. So the sickest are going to be treated first and with the most resources. And this is the way it works in most emergency rooms. There's a long waiting line of fevers and cuts. But if you got a heart attack, you get right to the front of the line.

Another way to look at it is the utilitarian concept. This got its start with some philosophers in the 18th and 19th centuries. The core of this idea seems simple. Try to do the greatest good. You want to maximize some sort of good outcome amongst a population. So rather than think about what one individual needs, you think...

How can I save the most number of lives or the most number of years of life? If we want to maximize years of life, we might want to pick people who have a better chance of surviving or younger people. And this method of triage is what you often see in a war zone where, say, there's a bombing and you have more injured victims than there are ambulances or medics. So one, two, three.

Imagine a lobby area in a hospital, a waiting area. Sherry says in this case what the doctors did... They asked the staff to get everyone out of their rooms. Bring them down to that second floor lobby. And then some doctors, including one whose name might be relevant for later, Dr. Anna Poe. She was a head and neck surgeon. She and another doctor, they stationed themselves on the landing where the patients were brought down to on that second floor. And as the nurses would bring them there,

they would look quickly at the patient's chart, look at the patient, and decide on a number. And the nurses would take a magic marker and a piece of paper and write either 1, 2, or 3 on that paper. And then she says they would tape that number onto the patient's gown. So the ones where you're relatively healthy patients, patient maybe who had an appendicitis and their appendix out, but they're looking good, they could even be discharged.

The ones would be rescued by boat, presumably among the first. The twos were your more typical hospital patients. Patient maybe who had a heart attack, who wasn't fully recovered, who would need ongoing care. They would go by helicopter, presumably second. And then the threes were those super sick patients or anyone with a do-not-resuscitate order.

those patients would go last. One of the doctors, when I said, why did you choose the sickest patients to go last, one of them said, well, I figured anyone with a do-not-resuscitate order would have a terminal or irreversible condition, which, by the way, isn't always the case. And he said, I thought that that patient would have, quote, the least to lose. So it sounds like in some way they went to more of a utilitarian way of thinking.

Yeah. And you could see everything that follows as flowing from that utilitarian decision. And actually they made it a few different points to prioritize the healthiest people first and the sickest people last. These choices ultimately did become very consequential. In any case, all three groups were placed in different parts of the hospital. And the threes were kept in the lobby, the second floor lobby. To just wait. Wait.

So as the day goes on, the area started to get really full. Patient next to patient on these cots. In one corner, she says, you had about 18 people lined up side by side. And these were people with heart conditions, symptoms of pneumonia, stroke. There were nurses standing around fanning people. It just, it was so, so hot. Some people guessed that the temperature inside the building must have been 100 degrees. I don't know if there's any way for me to describe to you

how intense the heat was. This is Dr. Anna Poe in an interview with 60 Minutes. She was one of the doctors who did the numbering. It was relentless.

It was suffocating. It made it extremely difficult to breathe. And with the heat came the terrible smell. It just started to smell really bad. And the bathrooms were so bad. That's Gina Isbell again. She said sewage was sort of backing up in the toilets. I mean, they just had sewage everywhere. On the ground, everywhere. You just... Personally, I didn't want to eat or drink anything because I didn't want to have to use the bathroom.

As the day went on... Some people started really feeling abandoned.

Why aren't they here? Why aren't they helping us? We're in a war zone here. It looks like a war zone. On the seventh floor, there was this radio that was playing in the corridor. The local talk station. And the radio was one of the only ways they were getting information from the outside. The mindset, the needs, the hunger, the anger, the rage is growing among people.

Some of the nurses have carts that they would roll around and they'd have the little radio on the cart and they'd be listening. Basic jungle human instincts are beginning to creep in. And there were tales on the radio that were alarming the staff. Someone is breaking into businesses and looting merchandise. These people should be shot. Things that turned out not to be true, like... You know, we're under martial law here. That they had declared martial law.

There was literally a deputy sheriff who got on air and told people that... We even both commented and said, oh, it looked like a shark's fin. He saw a shark swimming around a hotel. They're walking like zombies, like knights of the living dead. Just imagine how that would feel if you were in this hospital and that was the only word you were having about what was going on outside. One of our employees was like having a breakdown, freaking out in the garage.

By the afternoon of that third day, that Wednesday, some of the staff are having nervous breakdowns. Morale is really, really low because all these patients are still there, basically. So there's this level of panic. What happened?

Well, so there is also the situation of the pets, and this may make no sense to most people, but they would offer staff members, they could bring their pets if they were coming in to work a storm. And they turned medical records over into a kennel. And people started to worry about their pets. Apparently on that Wednesday, one of the larger dogs in Newfoundland started having seizures from the heat. So some of the staff chose to have dogs

doctors euthanize their pets. And then just try to imagine if you can. Looters are running free. Residents trying to shatter windows and climb into stores. It's hot. People are dying. You're hearing gunshots in the neighborhood. You're afraid. You don't know if there's real violence breaking out in the city. There are bodies floating in the water there. You don't know how many rescue resources are going to come. It's nighttime.

And your colleague walks up to you and says, you know, we're euthanizing the pets to put them out of their misery. What about these suffering patients? Shouldn't we put some of them out of their misery? And I interviewed all these people and trying to figure out, like, where did this idea come from and tracing it back? And there were all these little informal conversations. And this starts just going around the hospital, this sort of idea thing.

of putting patients out of their misery. I don't know who told me that, but that's what I heard. And, you know, in those circumstances, what do you do? And if you're at war and you have someone that's not going to be picked up and you can't carry them to safety and they're bleeding to death, what do you do? You let them suffer. Do you let them? I don't know.

Cherry says that as this idea spread around the hospital, people fell into different camps. Some people thought this was the most humane thing they could do. It would be criminal to let people suffer more. Other people, when they heard about it, were outraged. For example, Dr. Bryant King, whose colleague, Dr. Fournier, she walks up to him and says, there's this discussion going on and, you know, what do you think? And he says... You gotta be f***ing kidding me that you actually think that that's a good idea.

This is Dr. King in an interview on CNN. How could you possibly think that that's a good idea? Day four, Thursday, September 1st. Here's what ends up happening. And accounts here are a bit vague and in dispute. But according to Dr. King, who spoke about this on CNN...

He says, and other people say they saw this as well, he says he saw one of the doctors we talked about earlier. Dr. Anna Poe. Who was still there that Thursday morning. Caring for patients, these patients on the second floor who were chosen to go last. He says he saw her talking to patients while holding a handful of syringes. Anna standing over there with a handful of syringes talking to a patient. And the words that I heard her say were, I'm going to give you something to make you feel better.

And she had a handful of syringes. And nobody walks around with a handful of syringes and goes and gives the same thing to each patient. That's just not how we do it. To jump forward for a beat, after this whole ordeal was over and the rescue teams and the mortuary teams arrived... Many bodies were found in this hospital.

about 45 bodies found. And so there was an investigation launched. They found these bodies. They tested these bodies for drugs. And what they found was that nearly two dozen patients had received either morphine or Versed, a powerful sedative, or a combination of the two in a very short time period on that Thursday, September 1st, 2005. Wait, how many? It was, I think, 21 in the end.

But it's complicated. In medicine, what is comfort and what is murder depend to a large degree on the intentions of the doctor. It's called the principle of the double effect. It's sometimes credited to St. Thomas Aquinas. And it's this idea that an act that can cause harm, but if your intention is to do good, then that's ethical.

And Dr. Anna Poe? Did you murder those patients, as the Attorney General alleges? No, I did not murder those patients. And I want everybody to know that I am not a murderer, that we are not murderers. In that 60 Minutes interview, Dr. Poe flatly denies euthanizing anybody. And at various points in the interview, she is clearly distraught at the accusation. It completely ripped my heart out.

Because my entire life, I have tried to do good. And my entire adult life, I have given everything that I have within me to take care of my patients. But Sherry did talk to one doctor, Dr. Ewing Cook. We mentioned him earlier when we were talking about the generators. He's a doctor who deals a lot with end-of-life care, and he was very open with her about the decisions he made. He had gone upstairs, visited Mrs. Burgess. Cancer patient. To see her.

see how she was doing. And he was just thinking to himself,

She's so, so sick. She's got advanced cancer. I can't imagine she would have more than maybe a week to live at the best of circumstances. She is weighted down with fluid, which can happen toward the end of life. So she weighs a lot. She's on the eighth floor. So we'd have to carry her downstairs. And plus, there's four nurses up here taking care of her. Couldn't we use them somewhere else? So he literally turned to one of the nurses and said, can you give her enough morphine till she goes?

And that nurse charted huge increase in morphine for her, and she died. And that was his thought. So he made this decision, and to this day, or at least the last time we spoke, he felt he did the right thing. He said to me he thought it was desperate. He saw only two choices, quicken their deaths or abandon them.

And, I mean, if that was the real situation, there's some ethicists would say either of those choices would be, you know, not justified, but excusable. But one of the arguments you could make is that when you give up on one person, it then becomes a little bit easier to give up on the next person and then the next person. And then suddenly you're on a slippery slope. And Sherry did tell us about this one case. His case was very haunting.

Emmett Everett, a 61-year-old doting grandfather, very, very heavy. He weighed 380 pounds and he was up on the seventh floor of the hospital. He was conscious, alert, fed himself breakfast, asked his nurses, are we ready to rock and roll?

He said to one nurse who never forgot it, Cindy, don't let them leave me behind. Don't let them leave me behind. But he had had a spinal cord stroke. He couldn't walk. He was on the seventh floor of a hospital with no working elevators. And the staff told me they couldn't imagine how they would carry him down those flights of stairs, let alone would a helicopter take a man of his size.

And he was one of the patients who was found with this drug combination in his body. And he died? He died. His body was found. And by the way, the other tragedy was just as those injections took place was when the helicopters finally were focused on this hospital. Did a judge or jury find anyone guilty of manslaughter or murder or second-degree murder? No, nobody. Nobody ended up getting convicted.

And again, just to remind you how quickly a hospital can go from a normal American, well-regarded, functioning hospital to a place where this was even considered and discussed was so short. Monday morning, the storm hits. Tuesday morning, the water rises. Early Wednesday morning, all power goes out. And this is Thursday. Wow. That's kind of chilling to think.

After Katrina, as we'll hear after the break, people started paying all kinds of attention to triage, thinking about it in new ways and, as you'll hear, some surprising new places. That's coming up. Hey, I'm Jad Abumrad. I'm Robert Krolowicz. This is Radiolab. And this hour we are talking about triage. And before the break, we were talking to reporter Sherry Fink about what happened in one hospital in New Orleans during Hurricane Katrina.

and the consequences of some of the decisions made there. But now we shift focus. God, if all of that began with a triage decision about which patient should go first...

I'm trying to put myself in the position of the people at that hospital, and I'm thinking to myself, God, it would be really nice to have like a checklist, like a checklist on a wall that says here's how you do this so that I can just check the boxes because, God, I wouldn't be able to think my way through that. So that's where I go next. I wonder whether this story you've just told us leads us anywhere. The first place it would lead me would be to ask, is there a system that people could set up

People who are reasonable and who have the expectation that something like this is going to happen again, somehow, somewhere, maybe in my town, my hospital, my place. So what could we do to make this not happen? Well, it's interesting you ask because, of course, after Katrina, there have been efforts since then to come up with a protocol. According to Sherry, the experience in Katrina was basically a wake-up call for doctors and hospitals and state governments to think about

Like how should we ration medical resources? Like if something bad happens again –

Which patients do we prioritize first? Which patients don't we prioritize? How do we do this? And one of the interesting things was that the state of Maryland decided we're going to throw this open to our population and have what they call deliberative democracy. So pull people together in a room from all walks of life. And have them grapple with this. And I was there. Oh, you went to the very first one. I did. I'm imagining like a town hall meeting. Was it like that? Or no? Yeah. Yeah.

So just imagine a church basement in inner city Baltimore or a conference room in wealthy Howard County. Thank you for coming, for giving up this gorgeous Saturday to have what we think is a really, really important conversation. There's refreshments. People have been recruited to be a part of this. And when I say people, it's just people.

regular folks. So the researchers, let's call them that, they get people together and... We're going to get started. Good morning. The sort of scenario is laid out. So my name is Lee Daugherty. I am an intensive care doctor just down the road at Johns Hopkins. And what we're going to be talking about today is...

how we make decisions about who gets life-saving resources in a situation when we literally cannot take care of everyone. Today, the scenario we'll talk about is pandemic influenza. They basically tell people, okay, imagine a flu is sweeping the country. Millions of people are sick, coughing, some are dying. The only way that folks are going to get better, they say, is if they have a ventilator to help them breathe. But the problem is there just aren't enough.

This is horrible stuff. This is a terrible situation we're talking about. So here you have too many patients, too few resources. How do we choose? Who gets those ventilators? What are the acceptable options? What might be the right answers? The researchers then essentially lay out three different kinds of options.

Number one. Try to save the most lives or years of life by picking people with the best chance of surviving the pandemic. Such as giving the ventilators to young people or healthier people. Number two. Picking people who will be the most helpful during the pandemic. So first responders, health care providers, vaccine workers, etc. Or number three. Leave it up to fate. Something like first come first serve or a lottery.

You know, pick.

those protocols will be black and white. I've never seen any situation in life where it was black or white. Some things are black and white. I'm saying it shouldn't be black and white. Well, my immediate reaction to the lottery was it's a leveler. It's all the same. I think it is the scientifically least responsible way to go. I think ultimately it's fair. If somebody's going to live but be very sick, should that go into the decision? If we...

If we've set up guidelines, then yes. Is every kind of doctor, you know what I mean, going to be essential? I didn't say that. No. Now the good news is... If I would get a ventilator and a four-year-old wouldn't, I just think that would be the saddest thing. People were willing to engage in this question. And there weren't any fistfights? No. But, as you can also hear... I'm all for the first-come, first-served, and nobody has to put that in their conscience. Well, you did it first because you're there, and I got there half a second, and I ended up with my voice. Probably.

There wasn't a lot of agreement. I respect your opinion, but I'm just dealing with it. No, you don't. Yes, I do. I think in a time of crisis, there's no room for emotion. The reality is, some people are going to have to die. So one of the big findings was that there are certain ways in which we will not make these decisions. There were things that the researchers wanted to be off the table, like not even contemplating.

come into the discussion. We're not going to make decisions based on gender, race, socioeconomic status. Like people's jobs and incomes and... Citizenship status. You know, whether they had a criminal history or were they upstanding members of society. Those things are out of bounds. I just want to say up front, that's not...

That's not up for grabs. But those things kept popping up. You may have like a young pastor, and you might have a reprehensible, alcoholic, criminal type person, and he might have more years to live.

Well, the years of the pastor are going to be more beneficial to society than the years of this criminal, reprehensible, alcoholic, bad person. Whoa, you are straying into iffy territory there. Whoa!

That is a personal value adjustment. There were people who thought that undocumented immigrants shouldn't get ventilators, alcoholics, smokers. The world will be a better place in the end. In the most brutal terms possible, they are saying, do you deserve to survive? Not can I save you, but should I try and save you?

What's interesting is that people were really comfortable making utilitarian choices, like saying, yeah, that person should get the ventilator because they're going to benefit the greater good in some way. But if that ever got formulated in a slightly different way, which is to say that person should get the ventilator because they deserve it more than another, because their life has more value than another person, well, then people were not cool with that. And yet you would hear people say it that way again and again and then immediately be repulsed

when they heard someone else say it that way. And this was particularly acute when participants were asked this second... Can we move to an even more controversial topic? Really hard question. Would it be acceptable to you, do you think it's acceptable to ever remove a ventilator from one patient...

to give it to somebody else. This one I definitely don't have a clear answer myself. Some people said, well, of course. If it doesn't seem like someone is going to make it through the treatments, then maybe we need to cut their treatment short and pass that ventilator on to someone else. But

You're going to murder my father? There were other people who said no. You take my father off that runaway car, and you are going to be sued for the rest of your life. I'm never going to sign off on that. It's a terrible thing to think about. But it's necessary. I don't know how I feel about anything. It's so complicated.

Did they come to a conclusion? Did the public? Did you hear a conclusion? The number one response was to try to get out of the situation and find ways to avoid having to ration. That's the most important part of this. Wait, wait, wait. Before we prejudge this, what is it that the researchers are going to take away from all this? Well, a couple of things that they got out of it. Number one, remember we talked about the different ways of deciding that they put out for people to discuss? Mm-hmm.

It turns out they wanted to combine some of those different perspectives. According to Sherry, a lot of people thought, sure, let's start out utilitarian. Let's try and save the most lives by picking the people who are most likely to survive. If they're likely to survive and they need it. But, but...

chances are there's going to be a lot of people who fit in that category. So if everybody's just about the same and we can't, we don't have like great science that allows us to know which patient is going to survive and which one's not going to. So for that second tier, let's do it randomly. Let's just be really, really fair and give everyone an equal chance. So it's like you introduce a little bit of fate to keep things honest. Exactly. And the researcher said, you know what, this is a good idea. Let's see if we could maybe put this concept into the protocol.

Am I right in thinking that these guidelines, whatever they end up being, are designed to avoid that sort of like sorting based on who deserves it and who doesn't? Yeah. I mean, there's some fairness in having guidelines and especially guidelines that were developed with the input of lots of people. Yeah. So even if we don't like the choices that are made, we don't end up getting the ventilator or our loved one doesn't.

if you know that there's a protocol out there and this is the rule, here's why we had to adopt this rule. It's being applied to everybody and you're not going to be advantaged or disadvantaged over money or over these other things. It sort of helps you accept it. Yeah. In theory, that sounds plausible. But when you put theory to practice, which we're going to do right after the break, things get very hard. That's coming up.

Hey, I'm Jad Abumrad. I'm Robert Krolwich. This is Radiolab and returning now to our collaboration with the New York Times and reporter Sherry Fink. This is our final stop, many ways our hardest stop, because it's the closest we're going to come to sort of the heart of the issues we've been talking about. And you realize that when you get up close, as Sherry's about to, sometimes what's a success and what's a failure are kind of hard to measure.

I remember being in Haiti after the Haiti earthquake back in 2010.

I was embedded with a group of U.S. disaster responders, the International Medical and Surgical Response Team, IMSERT. What's your name again? Sherry. We were in this tent hospital, and at this point, maybe about a week and a half after the earthquake, there were so, so many casualties. More than 100,000 people could be dead. There was patient after patient kind of lined up in a row. Most of the things we've had are...

Dehydration, sepsis, festering wounds, open fractures. And they didn't have enough resources, and they were running out of oxygen tanks. And then they were also trying to use these oxygen concentrators, which pull oxygen from the environment. But they rely on power, and they were running out of diesel for the generators. Logistics, we're at a critical level with our diesel supply and oxygen for the OR generators.

So I'm freaking today. I mean, I am freaking. Pray for us in logistics today. This was a hospital that had set up to do surgery. They needed oxygen. They didn't have enough. So the question became, who were they going to give it to and who were they not?

And at one point, I was following a couple of the doctors. We walked into this tent and we met this woman.

Hi. She had braided hair, a white nightgown on, and this tube running into her nose. What's your name? My name is Natalie. Natalie LeBourne. And how old are you? 38. 38, she's 38 years old. Oh, okay. Tell her we're almost the same age. How are you feeling today?

In speaking to her, I found out that she was from Port-au-Prince, the capital, and that during the earthquake, her house had collapsed. And everyone inside it, she said, which was most of her extended family, they died.

I'm so sorry. She told me that, amazingly, she had survived because she wasn't at home when the earthquake hit. She had checked into this hospital very shortly before the earthquake happened.

happened because she had had chronic lung problems. So she was there to get treatment. And after the earthquake, she was transferred to this American hospital. How do you feel about the treatment that you got here? Oh, they treat me well. Way, way better than anywhere else that she's been.

I'm happy to see a smile on your face.

I started to speak with the staff about her. You've been taking care of her part of the time? Yeah, basically. And I found out that Natalie had just won the hearts of the surgical staff there. People loved her. She was so thankful. But she has a chronic illness, which is severe heart failure and hypertension, and it's very hard for us to see her leave.

They told me they had plans to take her off oxygen.

They were going to turn down the oxygen slowly to try to make it more comfortable. And then they were going to send her off to a Haitian facility that didn't have oxygen, but where she would presumably die. And if you're thinking in terms of cold, hard triage theory, you know, this makes sense because they were trying to save oxygen. She has a chronic problem that probably won't get better. So that's like the theory of it. But the practice of it was quite different.

She had absolutely no idea that they were about to do this. She had all this hope for her future. Hopefully when she gets well, she prays to God that she will have an opportunity to earn a living. She wants to know what she did at the hospital. Is there any way possible that the people would give her like somewhere to stay, like some kind of shelter?

I mean, I'm a journalist and I don't know the answer to that, but I don't know what to say. It's such a hard situation right now. And I remember the nurse who was doing the triage, who'd made that decision to cut off her oxygen. I'm Patrick Cadillac. I'm the commander for the IMCR team. Had never met her. No, I never met the patient.

But that's the role that I'm at. We're running out of oxygen. The country itself doesn't have oxygen. So I have to make the decision, no, she can't have the oxygen. Turn it off. I have to look at the greater good that we can provide with the limited resources we have. And so...

Then I followed that woman. I wanted to see this on a human level as well as on the abstract level.

The transporters came a few hours later. He was the 82nd Airborne, actually, who were providing that service. They were amazing, and they came to pick her up. They saw she was on oxygen. They said, okay, we're going to put her on their portable oxygen tanks. And the representative from the hospital said, oh, no, no.

She doesn't get oxygen. So they yank the oxygen. Interpreter? What's up, Wes? All right, ready? Strapped her onto a stretcher. Get up here. Lifted her up, stuck her in the back of this Humvee ambulance. Watch your head. Coming with? Yeah. Okay. We're going to hop in the cargo Humvee. They're pulling up. All right.

I rode with her. She started getting short of breath. She put this asthma inhaler in her mouth and she kept hitting it over and over again. She thought it was oxygen.

It was horrific to watch her start to suffer. I felt complicit. I was doing a story and I knew very well that they had chosen for her to die. And just watching didn't feel right.

And so... The heavy had stopped at this hospital and I nodded over toward her and some of the medical staff went to look at her. They could see she was in distress. They brought her inside.

She was really struggling to breathe, but then... Yeah, she's definitely in big-time CHF. I saw one of my medical school professors, an emergency doctor, and I told him about her. Whose is this? It's hers. Is that hers? Yes. Here, I need this. Mama, why don't you sit up? Okay, Mama. No, slide back a little bit. And...

He improvised. He used like all these diuretics to get fluid off her lungs. And he found one tank of oxygen that had a teeny bit left in it. There. This will make you breathe breath better, okay? Keep it in your nose, in your nose. Okay? Breathe in better.

And he was able to extend her life. All right. Good night. I'll see you tomorrow. All right. Ultimately, I actually felt a responsibility for her that outlasted the story that I did. And so after that came out, I did attempt to help her. Really? Yeah. How?

Well, I found a charitable group that was willing to bring her to the U.S. under a certain type of visa program that allowed for humanitarian aid.

like a medical treatment. And the cardiologist who had examined her in Haiti had thought she had a rheumatic heart disease that was causing her lung problems and that it could be surgically corrected. But when she came to the U.S., in fact, it was found that she had a much more serious condition and she really needed a transplant and she didn't make it. Does this make you wonder, so here you've got a rule,

And maybe in some broad way it's helping, but in that vehicle, looking at this woman, you wanted to break the rules for very moral and decent reasons. In these extreme circumstances where life and death are wrestling with each other, can you make rules? Yeah, because it's like you can't fault the people for taking her off the oxygen, and you can't fault you for trying to get her on the oxygen. So...

What's the conclusion to draw? Well, let's not give up. You know, the conclusion is let's not give up.

Like, it turns out there was, there were options for this woman. It turns out that somebody was able to extend her life. Now, you could very well argue that she should have died in that moment because look at all the resources that were spent. But I just feel like there was some value in her existence. There was so much value. She came to the U.S. and my God, she took up a collection for all the patients back in the Haitian hospital who she was friends with. She contributed to the day she died.

I don't know how to do the math on this one. This is the problem, though. Well, real quickly, guidelines require like a lack of compassion, the cold, hard rigidness of it. And everything you're talking about has to do with compassion. This is Simon Adler, by the way, our producer. And how do you make compassion work on that large of a scale?

Without caring about people and then you care about some people more than other people and now we're hurting people. That's a very good point. If you don't systematize it, you risk choosing people based on factors that are really not fair. Exactly. Because part of me does wonder, like, what if Natalie weren't such a nice person? Would...

Would that have changed things? Well, you know, if Natalie was a mean person, I don't think I would have felt any better watching her suffer. It's just about the person in front of you. And I think that the more unbearable it is, so the more you have to look someone in the eyes, the more it makes us try to figure out creative ways to avoid doing it. Okay, but I do feel you somehow refusing to acknowledge the subject when it really, really gets tough.

You say, let's avoid that toughness over and over again. No, I'm facing the real problem, which is that it's a problem to have to ration. You know what? We're not going to figure out the best way to ration because there is no one best way because everyone in society will have a different view on that. I think that that's in some way unimpeachable. I think you're absolutely right. We should always strive to not have to make the choice. But if we do have to make the choice, how do we do it? Let me tell you that I think what you've hit upon here is an impossible solution.

piece of human business. Rationing, triage, whatever you call it, is an inhuman act which humans are trying to do, but the fact of their humanity makes it impossible. You have a God role and nobody fits it.

We have so many people to thank for this hour. Let's start with Lily Sullivan and Pat Walters for really getting us thinking about all of this. Thank you, Lily. Thank you, Pat. Thank you also to PRI's The World, a version of the Haiti story first appeared on that show. And a huge thanks to New York Times correspondent Sherry Fink. All the stories you heard in this hour came as a result of her reporting for the book Five Days at Memorial.

Which is, by the way, a very fine book, and you should check it out. Sherry has an article that coincides with this podcast about the Maryland Project. We will link you to it from radiolab.org, or you can read it at nytimes.com slash triage. And thank you, New York Times, for lending us Sherry for a bit of time. Yes. This story was produced by Simon, Band for Life, Adler, Annie, there can be only one McEwen. We had original music from both Simon and Annie. Also from Taylor Dupree and Kenneth Kirshner.

I'm Chad Abumrad. I'm Robert Krolwich. Thanks for listening. Hey, Lulu again. In the years since we released this episode, we've made another piece about triage. During the pandemic, we worked on a piece with disability activist and author Alice Wong about the guidelines that actually were put in place in New York State that ended up allowing for the taking of someone's personal ventilator to give to someone else.

deemed to be a higher priority of saving. Alice, who uses a BiPAP machine herself, called this, quote, breath-stealing and put together a truly amazing audio essay for us as part of our breath show. You can find it at Radiolab.org or right here in the liner notes to this episode. Thanks so much for listening.

Radio Lab was created by Jad Abumrad and is edited by Soren Wheeler. Lulu Miller and Latif Nasser are our co-hosts. Susie Lechtenberg is our executive producer. Dylan Keefe is our director of sound design.

Our staff includes Simon Adler, Jeremy Bloom, Becca Bressler, Rachel Cusick, Akedy Foster-Keys, W. Harry Fortuna, David Gable, Maria Pascu-Tieres, Sindhu Nyanasambandham, Matt Kielty, Annie McEwen, Alex Neeson, Sarah Khari, Anna Rusket-Pas, Sarah Sandbach, Ariane Wack, Pat Walters, and Molly Webster, with help from Andrew Vinales.

Our fact checkers are Diane Kelly, Emily Krieger, and Natalie Middleton. Hi, this is Finn calling from Storrs, Connecticut. Leadership support for Radiolab's science programming is provided by the Gordon and Betty Moore Foundation, Science Sandbox, a Simons Foundation initiative, and the John Templeton Foundation. Foundational support for Radiolab was provided by the Alfred P. Sloan Foundation.

On Notes from America, we have conversations with people across the country about how we can truly become the nation that we claim to be. Each week, we talk about race, our politics, education, relationships, usually all of them, because everything's connected. And you, our listeners, are at the center of those conversations. I'm Kai Wright. Join me on Notes from America, wherever you get your podcasts.