Making the Tough Choices

Two massive earthquakes – 2 very different patterns of death and destruction
I knew this one would be different than a year ago, when people asked- “So are you going to Japan to help?” The answer was quickly “No, they really don’t need me.” By the same token, my colleague Glenn Braunstein, Chair of Medicine at Cedars and a superb endocrinologist, has been bombarded with requests for interviews and advice regarding potassium iodide to reduce the risks of radiation exposure.

The drama unfolding in Japan is no less riveting than what happened in Haiti, but for different reasons. The patterns of death and injury were not from collapsing buildings or lack of infrastructure – it was rapid and massive related to the Tsunami. The Japanese government is well organized to deal with earthquakes and has teams and supplies available. Building codes are strict. But no one could anticipate the difficult decisions related to the Fukushima Dai-ichi nuclear plant. The risks of additional injury and death are significant, and resources are being poured into the area to minimize harm. Although rescue and recovery operations continue, they seem to have taken a lower priority to preventing additional catastrophes.

What we see in action in Japan is similar to other disaster scenarios - the use of triage. Triage actually originated during the Napoleonic wars with Dominque Larrey, a French battlefield surgeon. He designed some of the first ambulances used on the battlefield, would treat enemy soldiers along with his own countrymen. He recognized that you needed to make a best guess at how to get the most good for the most patients, which may mean not treating those who were likely to die, or would consume disproportionate resources. It is a form of utilitarianism where one tries to maximize benefit for the greatest number, even if the decisions may not be best for an individual.

We saw triage in Haiti, when we were truly resource constrained. Patients that would have survived in the States, were allowed to die comfortably. Others might have quality of life worse than death. Throughout my surgical career, I have been faced with the decisions – they don’t get easier, but after some time, you gain perspective.

Like it or not, we will be performing some type of high level triage if health care in America is to survive. For now, we seem to have unlimited resources, but just because we CAN do something, doesn’t me we SHOULD. Resources spent in futile care, are resources that could immunize a child, provide safe water, or help educate a generation. This isn’t about Death Panels - it’s about having an honest dialogue about where priorities are placed to stabilize the present and build to the future.

There may be a few setbacks along the way for the Japanese. But a year from now, unlike Haiti, they will be back on their feet and stronger with the knowledge of what they learned.