I used to think that all those ethics case discussions about how to manage several needy patients with limited resources were purely imaginary. After all, this is America. Even though the cost may be astronomical, and the hospital may have no chance of ever recouping that cost (they’ll get a fraction from the insurance companies, if the case managers are very good, and less than that from the family of a real train wreck), patients still get the best possible care. (To be precise, we never really discussed this stuff in ethics; the cases were more along the lines of, sister wants to withdraw life support, brother and nephew disagree, what do you do? or, trisomy 18 baby in a woman who’s at high risk for significant cardiac disease, what do you advise her? Something even as vaguely practical as allocation of scarce resources never crossed the lips of the ethics professors.)

But a few months ago I worked in a unit where there were several sick patients: seriously sick, as in a mortality rate of close to 50%, with treatment. Without treatment, the mortality rate would have been 100%, and three days ago. The hospital had a limited number of nurses with the training and experience necessary to staff that unit. There was a limit to the number of OR-hours and surgeon-hours available to perform the repeated surgeries that each of the patients needed on a fairly regular basis. Sometimes (don’t ask me whether we ought to be blaming the nursing staff (I suspect not), the pharmacy (I suspect yes), or the hospital administration (always in the running when blame is being assigned) ) we came close to running out of certain medications.

So when one person can have surgery today, and the other will have to wait for a day, and perhaps slide further into sepsis in the meantime, who gets to go first? The sicker person, who more desperately needs the surgery, or the less sick one, who has a better chance of surviving the surgery? Who gets the medicine, the sicker patient, or the one more likely to recover at some vague point in the future? Who gets more nursing attention, the younger but sicker patient, or the older patient who’s less sick, but also has less of a reserve with which to fight the illness? To add a twist: who gets surgery/medicine/attention, the less-sick patient whom we suspect to be on the verge of permanent vegetative state, but not quite (if only we could ever get the sedation low enough to make ourselves sure), or the totally septic patient whom we hope to have fairly well preserved mental status? In the calculus of deserts (in the old sense of things deserved), how do you rank severity of illness, likelihood of recovery, age/youth, likelihood of meaningful neurological recovery? What about family? If the family doesn’t care enough about this person to come and visit even once over the course of weeks, does that tell us that they’re a pretty worthless person? Or does it say that we need to advocate even more strenuously for them since they lack the natural advocacy of relatives? Does the number of relatives who show up weeping at the bedside have anything to do with the value that we assign to one patient compared to another, or does it merely make it more difficult for us to give sad messages to the larger family?

Thank God, we never had to make an explicit decision along these lines. Perhaps the patients just sorted themselves out; or perhaps the residents kept their doubts to themselves and let the attendings, in their own consciences, reach a conclusion, and then announce to us who needed surgery tomorrow, and who could wait for a few days. I don’t know how objective their decisions were. That’s why I’m in no hurry to be an attending.

(It would be interesting to hear from friends in Africa how they handle these dilemmas. I suspect that when resources are truly and absolutely limited, there’s no hesitation in choosing the youngest patient, the healthiest patient, the most neurologically intact, and the one with the largest number of caregivers/family members.)