In a modern industrialized society like the United States, we tend to take certain things for granted. One of these things is that if someone needs emergency medical care, that care will always be available. The Covid-19 pandemic is calling that assumption into question.
For a time in late spring, many hospitals in New York State were overwhelmed by Covid-19 patients who needed ventilators to keep from dying. Even with ventilators, many died anyway, and it took weeks for the healthcare system there to recover to the extent that it could handle its normal emergency traffic along with the extraordinary Covid-19 patient load.
In Texas, where I’m writing this on July 12, we are currently being warned that if the Covid-19 infection rate continues to rise like it has in the last few weeks, we may be in a similar situation with maxed-out hospitals and the need to set up emergency wards in convention centers.
Broadly speaking, a modern healthcare system is a technology in the same sense that a postal system is a technology. It involves machinery, to be sure, but it also involves complex human relationships, states of training, and command structures that are just as essential as MRI machines and ventilators. It takes a huge amount of resources in money, time, and investments of lifetimes of training and practice to develop the capabilities represented in a modern hospital.
So it’s not surprising that when demands are placed on it that it wasn’t designed for, you run into problems. But the problems you run into aren’t just failures of equipment. It’s things like what happened to Michael Hickson at St. David’s South Austin Medical Center in Texas.
Until three years ago, Mr. Hickson was a reasonably healthy husband and father of five children. In 2017, he had a heart attack while driving his wife to work, and suffered permanent brain damage from lack of oxygen before he received emergency treatment. The injury left him a quadriplegic and in need of continuous medical care, which he was receiving at an Austin nursing and rehabilitation center when he tested positive for Covid-19 on May 15. He ended up in St. David’s ICU on June 3, and on June 5 the hospital informed Mrs. Hickson that he wasn’t doing well.
That day at the hospital, she had a conversation with an ICU doctor regarding her husband’s care. The situation was complicated by the fact that she had temporarily lost medical power of attorney to a court-appointed agency called Family Eldercare. Someone recorded this conversation, and it makes for chilling listening and reading (the YouTube version is captioned).
When Mrs. Hickson asks why her husband isn’t receiving a medication that can alleviate symptoms of Covid-19 and being considered for intubation, the doctor explains that her husband “doesn’t meet certain criteria.”
The doctor explains that doing these things probably wouldn’t change his quality of life and wouldn’t change the outcome. When she asks him why the hospital decided these things, the doctor replies, ” ‘Cause as of right now, his quality of life . . . he doesn’t have much of one.”
Mrs. Hickson asks who gets to make the decision whether another person’s quality of life is not good. The doctor says it’s definitely not him, but the answer to the question about whether more treatment would improve his quality of life was no.
She asks, “Being able to live isn’t improving the quality of life?” He counters with the picture of Mr. Hickson being intubated with a bunch of lines and tubes and living that way for more than two weeks, but Mrs. Hickson gets him to admit that he knows of three people who went through that ordeal and survived. She tells him that her 90-year-old uncle with cancer got Covid-19 and survived.
His response? “Well, I’m going to go with the data, I don’t go with stories, because stories don’t help me, OK?” Toward the end of the conversation, he says, “. . . we are going to do what we feel is best for him along with the state and this is what we decided.”
The next day, Mr. Hickson was moved to hospice care. According to Mrs. Hickson, there they “withdrew food, fluid, and and any type of medical treatment” from him, and he died on June 11, despite his wife’s attempts to gain medical power of attorney back from the court-appointed agency.
There are at least two sides to this story, and in recounting this tragedy I am not saying that the Hicksons were completely in the right in all regards, nor that the hospital, its doctors, or Family Eldercare was completely in the wrong. But clearly, the hospital was under pressure to allocate its limited resources to those who would benefit from them the most.
And it fell to the unhappy ICU doctor to explain to Mrs. Hickson that her quadriplegic, brain-damaged (and maybe I shouldn’t mention this, but he was also Afro-American) husband was going to be left behind in their efforts to help others who had what the hospital and the state determined were higher qualities of life.
It isn’t often that conflicting philosophies clash in a way that gets crystallized in a conversation, but that happened when the doctor said, “I’m going to go with the data, I don’t go with stories.” In going with the data, he declared his loyalty to the science of medicine and its supposed objective viewpoint that reduces society to statistics and optimized outcomes.
In refusing to go with stories, he rejected the world of subjectivity, in which each of us is the main character in our own mysterious story that comes from we know not where and ends—well, indications are that the Hicksons are Christians, so their conviction is that their stories end in the Beatific Vision of the face of God.
But Mrs. Hickson would have been willing to look into the face of her beloved husband for a little longer. Unfortunately, the ICU doctor and the state had other ideas. Mr. Hickson might have died even if he had received the best that St. David’s could offer.
But the lesson to engineers in this sad tale is that the best designs at the lowest price mean nothing if the human systems designed to use medical technology fail those that they are intended to help.
This article has been republished with permission from Engineering Ethics.