Who deserves critical care?

“He was ejected from the car and found unconscious at the scene. In the ED, he had decorticate posturing and was intubated. CT showed subdural and subarachnoid hemorrhage with transtentorial herniation. Neurosurgery did a decompressive craniectomy overnight. He has brainstem reflexes only.”

Your attending shakes his head. “Only 21 years old. What was his tox screen?”

Wondering what difference it makes, you answer, “Ethanol was 332. Urine tox positive for marijuana and cocaine.”

“There you go.” He sighs. “Not that he deserved this, but…”

But what? you think.

But in a way he did?

But now it makes more sense?

It seemed like a tragedy, but not anymore?

Whose lives should we save and why?

It’s a question we rarely ask. On a daily basis, the role of critical care is to preserve life and limb after severe, acute injury or illness. That’s the what. How about the why? Presumably because we believe that when it’s possible, people deserve to live. Which people?

Maybe you and I and Aunt Betty. How about a convicted murderer? Does he deserve to live? What about a 100-year-old man? Does he? Or someone who attempted suicide? Or someone who caused an accident where innocent people were killed? Or a lung cancer patient who smoked for 60 years? Or a young man who drove his car drunk?

We don’t want to think we live in a world where terrible things happen to good people, and random tragedy strikes for no reason. It is easier and more understandable to believe that on some level, people are responsible for their suffering. It makes more sense that way. And indeed, many patients have some responsibility for their disease.

Do they “deserve” critical care? To answer, we need to decide why anybody does.

Maybe because of virtue. Good people deserve good medicine. Yet I’m not sure who is good, and I doubt whether I should be the one awarding them for it with their lives.

Maybe to relieve suffering. This is definitely correct, to some degree. However, we often create more suffering than we relieve. An ICU stay is likely to be the worst experience of a person’s life. Palliative care is far better at this than we are, and of course, is sometimes the better choice.

Maybe it’s to make money. But if someone’s getting rich from this, it’s not me.

Keep it simple

The philosophers known as consequentialists liked to say that what makes a thing right or wrong is the sum of its ramifications. They are fond of ethical math, of “figuring out” what’s good based upon a multitude of factors.

This is too much for me on a lonely night in the unit when I’m called to see another trauma. This sort of complex calculus can wait until later, when you’re sitting with a drink reflecting on the case. In times of stress, we rely upon heuristics, basic principles for guidance— what the ethicists would call deontology rather than consequentialism.

Here’s the guiding principle I propose:

We give people second chances. Everyone deserves a second chance.

I said this once to a nurse, and she asked how many second chances people deserve. The answer, of course, is as many as they need.

Humans are fallible. We make mistakes, and fortunately most are not punished with terrible results, but sometimes they are. Even worse, sometimes we err by design, choosing to hurt others or ourselves. We stumble, we suffer, and in some cases we never get it right.

But we always deserve another try. When we fall, we deserve someone who will catch us, help us back to our feet, dust us off, and say, “Sorry it happened. Hope things get better.” Each time. Every time. We all make bad decisions, but most of us are not bad people, and even bad people should have someone who comes when they call, and brings them to a building with lights and bandages and those who will fight to give them another shot. And maybe fail. But they’ll do their best.

Who deserves critical care? Anyone who wants and needs it.

There are a lot of hard questions in medicine. This isn’t one of them.

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