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May. 14, 2003 - A doctor has two patients, a mother and her child. He only has the means to treat one of them. How should he allocate his resources? Should he concentrate his efforts on the one in the worst shape? or on the one most likely to survive? Should he consider whether it is worse for the mother to lose her child or the child to lose its mother? Or would justice be found in randomness, in flipping a coin? In this week's episode of ER, Carter decides this dilemma by consulting his own moral judgment: he saves the one that he considers to be the most deserving. And in doing so, he makes the right decision, but for the wrong reason.

Members of a cult take cyanide in an effort to perform mass suicide. They are brought to the ER, where antidote runs short. More antidote packets are on their way from other hospitals. In the meantime, Carter must choose between treating a woman or her child. The child, he reasons, was probably coerced by the cult to take the poison. In Carter's eyes, the child is not culpable for her condition, and so is more deserving of the antidote.

By this rationale, those who sustain injuries from elective activities, like sky diving or down hill skiing or drunk driving, should be treated after those whose medical needs are the result of accident. In some respects, this accords with a well-established cultural idea of fairness: As you sow, so shall you reap. By linking elective behavior to medical consequences, this logic perceives a hierarchy of the deserving regarding resource allocation. To adherents of this belief system, for example, it is eminently unfair that a person who has ruined her liver through excessive alcohol consumption should ever get a transplant before a cancer patient. Those who need treatment through no fault of their own ought to be prioritized above those who brought their problems upon themselves.

However morally charming it may be, this view is unattainable because it requires a god's eye perspective. Only the most highly refined perception could sort out those conditions in a person's life which she brought upon herself and those which were thrust upon her. Many situations and habits in people's lives today are closely linked to where and when and to whom they were born: while a person's exercise of her free will certainly plays a role in determining her adult life, luck and circumstance cannot be ignored. In our society, a person's social class, race, and gender (among other factors) may influence not only to the choices she makes but also the choices she perceives herself to have. Free will does not alone determine whether a person eats organic, or smokes cigarettes, or has a child out of wedlock, or relies too much on Tylenol PM, or lives next to a toxic waste dump, or bicycles to work, or endures a physically abusive relationship, or takes multi-vitamin supplements, or is obese. The incidence of these conditions often falls along lines of race and class; if we are not comfortable with allocating medical resources according to race or class, then neither may presence of such factors determine allocation. While it may be appealing to align medical treatment with moral worthiness, doing so requires an accuracy of perception notoriously lacking among mere mortals.

The principle of triage employed in emergency situation where resources are limited does not entertain such high-minded ideals. In triage, the first to be treated is the person for whom treatment means the difference between life and death, regardless of the cause of her condition. When two people are similarly situated on the brink of life or death, as in the case of Dr. Carter's patients, other criteria must be used to determine whom to treat.

Carter makes the right decision - to treat the child - but for the wrong reason. He manufactures a god's eye perspective of who is more deserving, and elects to treat the child first. Carter's error lies not in result but in reasoning.

If Carter is to avoid playing god, he must ignore the circumstances which brought the mother and child to the ER. His decision of who to treat must either be random or depend on other facts. To decide the question randomly is commit an error to the other end of the spectrum. We may not have a god's eye view, but we are not entirely blind. There are facts about the two patients pertinent to determining whom to treat.

Both the child and her mother stand to lose the same thing, namely their lives; however, the mother has had the advantage of living more of hers so far than her child has. We may agree that premature loss of life is tragic, whether it befalls an adult or a child. Without disturbing this principle, we may yet compare the particular injustice attendant upon the premature loss of life to an adult and to a child. The adult has had the opportunity to experience life more than the child has. We need not say which life is more worthy to live - we need only say which person has had less time to live.

Resources
James F. Childress, "Who Shall Live When Not All Can Live?" Soundings, Vol. 53 (Winter 1970).

John Harris, "The Value of Life," in Bioethics: An Anthology, edited by Helga Kuhse and Peter Singer, Blackwell Publishers, 1999.

Robert M. Veach, "Voluntary Risks to Health: The Ethical Issues," Journal of the American Medical Association, Vol. 243 (January 4, 1980).