December 12, 2023 • 21 mins
Back in the 1960s, a committee of seven Seattle residents met regularly to decide which patients with chronic kidney disease were “worthy” of life-saving dialysis. Whoever wasn’t selected by the committee would likely die within months. An exposé of this so-called “God Squad” helped spark the formation of a new field: bioethics. In this prequel to playing god?, we’ll find out how this committee made life-and-death decisions, and why something like it is unlikely to happen again.
Show Notes:
This episode features interviews with:
Richard M. Mizelle, Jr., Associate Professor of History, University of Houston
Kate Butler, Assistant Professor of Nephrology, University of Washington School of Medicine
The God Squad was just one of many notable cases that led to the formation of the field of bioethics. The Hastings Center, a bioethics research institute, has compiled a timeline of many of the most famous cases and their impact. Check it out here.
The Berman Institute has also collected oral histories– first hand accounts of the doctors, philosophers, lawyers and other scholars who were involved in many of these cases. You can explore that collection here.
To learn more about the ethics issues raised in this episode, visit the Berman Institute’s episode guide.
The Greenwall Foundation seeks to make bioethics integral to decisions in health care, policy, and research. Learn more at greenwall.org.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:02):
Can you imagine having to make a decision about who
gets access to something that could save their lives, and
as a result, who doesn't get access. Would you use
a lottery system an algorithm? Would you make a call
on a first come, first serve basis? Well, in the
nineteen sixties in Seattle, a committee, almost like a jury
(00:24):
of local citizens were asked to do just that.
Speaker 2 (00:28):
When first invited to serve on the committee, I was
very uncomfortable, feeling that I was taking the place of God.
Speaker 1 (00:36):
We're about to hear from Rick Mazel, a medical historian
at the University of Houston. A few years back. Rick
was doing some research when he came across this story.
Speaker 3 (00:47):
I'm a good and for punishment, I like topics that
are difficult to research and find.
Speaker 1 (00:54):
He found this one article about the committee in Seattle
that caught his attention.
Speaker 3 (01:00):
I was curious as to why I didn't know that
much about it. For whatever reason, historians have stirred queer
a bit of this conversation. It was really a fascinating
but difficult scenario to engage.
Speaker 1 (01:15):
So Rick kept digging. He found out the story started
with the grand opening of a medical clinic. The treatment
the clinic provided was highly specialized and time consuming. So
time consuming that patients had to go in twice a
week and get hooked up to a machine overnight.
Speaker 2 (01:33):
All night while they read or talk, or work or sleep.
The entire blood content of each patient as being circulated
through an artificial kidney and clean and pumped back into
the body again.
Speaker 1 (01:49):
These clips from an NBC documentary called Who Shall Live,
filmed a few years after the Seattle Artificial Kidney Center opened.
It aired in nineteen sixty five on Nash Television and
created quite a stir. The kidney Center was revolutionary. It
was the first place in the whole world to offer
long term kidney dialysis, a brand new type of life
(02:12):
saving treatment. There was just one problem.
Speaker 2 (02:17):
The cold, hard fact of the matter is, there are
just so many places available on the kidney machine, and
there are more applicants than places. Somebody has got to
be left out, and somebody has got to decide who
shall live and who shall die?
Speaker 1 (02:34):
Yikes, who shall live and who shall die? When Rick
saw who the people were who would determine that, he
was shocked. The Kidney Center put seven seemingly random people
in charge. They would later come to be known as
the God Squad, the ones to determine the fates of
(02:55):
thousands of their neighbors. It was up to then to
decide which would be saved.
Speaker 3 (03:01):
I thought it was pretty unbelievable that they would have
lay people and community people making this decision.
Speaker 1 (03:10):
This whole thing, this attempt to figure out who should
have access, became so controversial, such a pivotal point that
it would become a wake up call for the need
for a more transparent system. This is a story that
paved the way to what is now known as bioethics.
I'm your host, Lauren Aurora Hutchinson. I'm the director of
(03:33):
the Ideas Lab at the Johns Hopkins Berman Institute of Bioethics.
In this season a Playing God, we went behind the
scenes to discover how some of the most significant medical
innovations impacted people's lives and continued to whether it's saving
lives or creating babies, a new technology was usually waiting
in the wings, along with a multitude of ethical questions.
(03:59):
We looked at where we draw the line, should we
draw the line, what's right and what's wrong when it
comes to our bodies, And we turned to bioethicists to
answer these questions. But in this bonus prequel episode, we're
doing something different. We're going back in time to immerse
you in one of the most important foundational stories of
(04:22):
modern bioethics from Pushkin Industries and the Johns Hopkins Berman
Institute of Bioethics. This is playing God. By the nineteen fifties,
if someone had kidney disease, they could be surgically connected
to a machine called an artificial kidney, also known as
(04:44):
the dialysis machine. Dialysis at the time worked well for
anyone whose kidneys needed help for just a short while,
but people whose kidneys had failed needed ongoing dialysis for
life or they would die. Connecting to a dialysis machine
did a lot of damage to blood vessels, so there
(05:05):
were only so many sessions a patient could do. In
nineteen sixty, a young Seattle nephrologist named Belding Scribner decided
to do something about it. He designed a little U
shaped piece of hollow teflon called a shunt. It could
be left in a patient's arm or leg permanently to
use again and again to connect to a dialysis machine.
(05:28):
This meant chronic kidney disease would no longer be a
death sentence. I just want to pause here for a moment,
because even with the Scribner shunt, it wasn't possible to
treat everyone. So who should be granted access when there
isn't enough of something life saving to go around? This
question around the allocation of resources is one of the
(05:49):
most central questions in bioethics that's still being asked about
all sorts of things today. What's the best way, or rather,
what's the least bad way to resolve this kind of dilemma?
Speaker 4 (06:02):
Well, here's what.
Speaker 1 (06:03):
Happened in this case. In nineteen sixty two, the Seattle
Artificial Kidney Center opened at Swedish Hospital. Initially, the center
had just three machines and could only treat up to
nine patients. Each person selected would need to continue to
be treated for the rest of their life. At the time,
chronic kidney disease killed tens of thousands of people in
(06:26):
the US each year. Regular dialysis was their only shot
at staying alive. So how would the center choose which
patients would get a second chance at life? To begin?
Belding and the hospitals set up an initial screening process
to whittle down the thousands of patients to hundreds, and
(06:46):
in order to even be considered for a spot in
the first place, each candidate needed a referral from their doctor.
Rick says, we.
Speaker 3 (06:54):
Don't know if they accepted referrals from black physicians, and
there were not many black physicians in the nineteen sixties,
which is part of what I argue is problematic about
the committee. You know, Seattle is still a city that
is highly racialized, highly segregated. It's not Alabama or Mississippi,
but there were still segregation in hospitals, which.
Speaker 1 (07:17):
Of course had implications as to who would get referrals
to even be on the list. The center then had
specific criteria. Patients had to be between fifteen and forty
five years old. The hospital advised that children might not
be able to handle ongoing long term dialysis both mentally
(07:38):
and physically. Those of the right age then had to
show they could pay for three years of the treatment
upfront thirty thousand dollars the equivalent of three hundred thousand
dollars today, and they had to be able to access
the center twice a week.
Speaker 3 (07:55):
Perhaps most problematic is they could not have underlying conditions,
so diabetes, hypertension, all of those things would disqualify you
from the possibility of chronic dialysis.
Speaker 1 (08:07):
The medical advisory committee also interviewed the candidates to get
a sense of their psychological health.
Speaker 3 (08:13):
So people who were emotionally unstable, who were poor, who
did not have certain kinds of jobs, who were unmarried,
who did not go to church were largely considered inherently
biologically flawed by the medical committee. Those were the individuals
who were not emotionally stable enough to deal with long
(08:33):
term dealysis.
Speaker 1 (08:36):
The treatment center evaluated about fifty candidates for each available slot.
They would then whittle that number down and hand the
final decision over to the God Squad. The God squad
would then have to choose one person out of about
four candidates per slot. The people on the God squad
were not experts in kidney disease or dialysis. Only two
(08:58):
of them were medical professionals.
Speaker 2 (09:00):
I am a banker, I am a surgeon, I am
a lawyer, I am a physician, I am a labor leader,
I am a housewife, I am a clergy many.
Speaker 1 (09:15):
Belding, Scribner and his colleagues decided it was unfair to
burden physicians with making the final call. Their reason since
all of the candidates on their list would benefit from
the treatment and were deemed good candidates, the choice of
who to save was now really more of a social
one than a medical one. I can't help noticing where
(09:35):
they drew the line between this being a social decision
rather than a medical one, because to me, it seems
like so many of these factors were actually social anyway.
It was at this point they decided to turn it
over to the ordinary people of Seattle. It was their
job to evaluate these patients and determine who should live
(09:56):
and who should die.
Speaker 3 (09:58):
There was a woman who was up for evaluation and
husband and sons said that she was no longer cleaning
the house. That was part of what they brought up
to evaluate her as to her worthiness of dialysis.
Speaker 1 (10:12):
We'll be right back after the break. The God Squad's
official name was the Admissions and Policies Committee of the
Seattle Artificial Kidney Center at Swedish Hospital.
Speaker 3 (10:29):
They, of course say that it represents a cross section
of the Seattle population. It was mostly men, mostly middle.
Speaker 1 (10:38):
Clayer's administrators from the kidney center hand selected the God
Squad members. That's right, hand selected. The hospital gave the
committee an information packet on each candidate, with their medical records,
psychological evaluations, financial information, even letters of reference. One of
the doctors who briefed the committee later said, we told
(11:00):
them frankly, that there were no guidelines. They were on
their own. We really dumped it on them. The committee
decided to review every piece of biographical information they could
get their hands on. They also decided to enlist other
people to help them, a social worker and a psychologist.
What they were looking to determine was what they called
(11:21):
a person's social worth.
Speaker 3 (11:24):
One of the criteria that the Patient Advisory Committee often
considered was the common good.
Speaker 1 (11:30):
Rick says, if you read through the committee's records, you
can piece together what the members thought made someone worthy.
Speaker 3 (11:37):
Being a white collar worker was better than being a
blue collar worker. A woman who was a known prostitute
was rejected for a woman who was a mother of four.
Another one that sticks out is a young man who
was considered to be, and this is the term that
they use, a never do or will a playboy, and
(11:57):
so he does not have the right temperament or morality,
then he's not worthy of theallises.
Speaker 1 (12:04):
The committee members were kept anonymous, and their work happened
behind closed doors, But in nineteen sixty two, a prominent
reporter named Shana Alexander revealed their inner workings to the
world in a Life magazine article. Amazingly, all of the
committee members agreed to be interviewed as long as they
were not identified. The committee even re enacted one of
(12:27):
their first liberations so Shana could hear how they sounded
in action. Their conversations made it clear that to committee members,
what made someone worthy of saving was a matter of
personal opinion. We had voice actors read from the article.
Speaker 5 (12:44):
If we are still looking for the men with the
highest potential of service to society, I think we must
consider that the chemist and the accountant have the finest
educational backgrounds of all five candidates.
Speaker 6 (12:55):
How do the rest? Do you feel about number three,
the small businessman with three children. I'm impressed that this
doctor took special pains to mention this man as active
in church work. This is an indication to me of
character and moral strength.
Speaker 7 (13:09):
For the children's sake, we've got to reckon with the
surviving parents' opportunity to remarry, and a woman with three
children has a better chance to find a new husband
than a very young widow with six children.
Speaker 6 (13:21):
How can we possibly be sure of that?
Speaker 1 (13:25):
Shanea's article not surprisingly caused outrage.
Speaker 3 (13:29):
Lawyers at the time, you know, argue that it was
really just a way for physicians to avoid the responsibility
of making a difficult decision that they did not want
to make and that nobody wants to make.
Speaker 1 (13:43):
Mostly, Rick says, people pointed out the obvious flaws with
a metric worthiness.
Speaker 3 (13:48):
Someone who is, you know, an activist in the civil
rights movement. That's a social good, but it might not
fit within the ideals of what it is that they
think as a social good. So you could have a
respected business person who was still unethical in a number
of different ways.
Speaker 1 (14:05):
In the end, the committee selected the first group of patients,
among them a physicist, an engineer, a car salesman, an
aircraft worker, and an oil company executive. By most accounts,
the God Squad kept meeting until nineteen seventy two. That year,
Congress passed legislation making dialysis available to everyone whose kidneys
(14:30):
have failed, but the committee lived on in public imagination.
Many people didn't get the life saving treatment they needed
because they were deemed less worthy. The God Squad were
people who just had to make up the rules as
they went along. There was no template yet for best
practices or ethical guidance in making these kinds of decisions.
Speaker 4 (14:59):
They were starting from s, you know, and I think
that we have a much more robust literature. You know,
we have a history of bioethecal analysis to lean on now,
and of course we're still improving over time and how
we think about these things.
Speaker 1 (15:12):
This is Kate Butler. She's a clinical neprologist based in Seattle,
and she says, what is key is to design a
system that's fair. But of course fairness can be understood
in lots of different ways.
Speaker 4 (15:26):
Do we want to make the very best use of
resources in terms of saving the most lives in terms
of having the most life years lived? Do we want
to consider quality of life years lived? And if so,
who decides on quality? And or do we want to
make sure that we're allocating resources in a way that
(15:46):
feels equitable to us? And again, who is that us?
Who's making the decision about whether the system is equitable.
Speaker 1 (15:54):
Kate told us that nowadays systems are based on ethical foundations.
For example, one way of doing things would be to
prioritize recipients who we expect to live the longest after
a transplant, which would be a utilitarian approach. Or you
could use a lottery so that everyone on the list
gets an equal chance of a transplant, which would be
(16:15):
based on the principle of equality. I mean, which one
do you think would be most fair? Kate gave an
example the National Weight List for kidneys, which is a
modified version of waiting until your number is.
Speaker 4 (16:27):
Called, and that process has been worked out over decades
as a collaboration between clinicians, bioethicists, the community by way
of community forums.
Speaker 1 (16:39):
There's an organization that monitors the systems to see if
it's working the way it's supposed to. It's called the
United Network for organ Sharing. In twenty fourteen, they discovered
a flaw. The waiting list wasn't accounting for some groups
of people, mainly people of color, having a harder time
getting on the list in the first place. In bioethics,
(17:01):
equity is a key principle. It's important to account for
disadvantage or underrepresentation. So they made a change.
Speaker 4 (17:10):
There was an intentional effort to change the WEIGHTLISS criteria
to give you retroactive time for time since you started
on dialysis, so people would get points for the time
spent on the witlist or how long they had been
on dialysis, whichever is longer.
Speaker 1 (17:26):
The change was apparent within months. The system still isn't perfect,
but Kate says, as an example of how the field
of bioethics has evolved since the time of the God Squad.
Speaker 4 (17:37):
There's more to medicine than just clinical analysis of individual
cases that considering the bioethical implications of these decisions was
necessary and important. I think that's why people refer to
this example as the birth of bioethics today.
Speaker 1 (17:56):
It's part of the process to consider ethics in medical advance.
Speaker 4 (18:01):
Any situation in which you have resource scarcity for something
so consequential as healthcare, there's going to be tragedy, right
There's going to be someone who doesn't get the care
you want for them. We're not going to be able
to design a perfect system.
Speaker 1 (18:18):
As we have heard from this series, the landscape is
ever shifting. Every time there's a new medical innovation, there's
a whole new set of ethical questions. If you've enjoyed
playing God, then we're going to have plenty more stories
like this coming out of the Ideas Lab at the
Johns Hopkins Berman Institute of Bioethics. Playing God is a
(18:42):
co production the Pushkin Industries and the Johns Hopkins Berman
Institute of Bioethics. Special thanks to our guests in this episode,
Rick Mozelle and Kate Butler. Emily Vaughan is our lead producer.
Production support from Sophie Crane and Lucy Sullivan. Our editors
are Karen Chakerjee and Kate Parkinson Morgan. Theme music and
(19:06):
mixing by Echo Mountain, Engineering support from Sarah Brugare and
Amanda Kaiwang. Show art by Sean Carney, fact checking by
David jar and Arthur Gompertz. Our executive producer is Justine
Lang at the Johns Hopkins Berman Institute of Bioethics. Our
(19:26):
executive producers are Jeffrey Kahan and Anna Mastriani, working with
Amelia Hood and with support from Susan Snead, Aaron Henkin,
Abigail Brickler, Kim bikermer Anna Oakes, and Jamie Smith. Funding
provided by the green Wall Foundation. Special thanks to voice
(19:46):
coach Vicky Merrick. This is our last episode, so we'd
like to thank some of the many people at Pushkin
who've supported this show throughout the season, including Jacob Weisber,
Heather Fame, John Snarz, Letal Malad, Greta Cohne, Carl Migliori,
(20:10):
Jasmine Perez, Eric Sandler, Jordan mcmill Isabella Navarez, Nicole op
Den Bosch, Maya Kanig, Jake Flanagan, Owen Miller, David Glover,
Nina Lawrence, Mia LaBelle, and Ian Petsa. To learn more
(20:35):
about Bioethics and the issues presented in this series, please
visit Bioethics dot jhu dot edu forward, slash Playing God.
I'm Laurena Rora Hutchinson. Thanks for listening to Playing God.
(21:00):
If you're interested in learning more about these stories and discussions,
visit the Berman Institute's guide to the podcast at Bioethics
dot j u dot ed u, slash Playing God, or
find us on social media at Burman Institute
Can you imagine having to make a decision about who
gets access to something that could save their lives, and
as a result, who doesn't get access. Would you use
a lottery system an algorithm? Would you make a call
on a first come, first serve basis? Well, in the
nineteen sixties in Seattle, a committee, almost like a jury
(00:24):
of local citizens were asked to do just that.
Speaker 2 (00:28):
When first invited to serve on the committee, I was
very uncomfortable, feeling that I was taking the place of God.
Speaker 1 (00:36):
We're about to hear from Rick Mazel, a medical historian
at the University of Houston. A few years back. Rick
was doing some research when he came across this story.
Speaker 3 (00:47):
I'm a good and for punishment, I like topics that
are difficult to research and find.
Speaker 1 (00:54):
He found this one article about the committee in Seattle
that caught his attention.
Speaker 3 (01:00):
I was curious as to why I didn't know that
much about it. For whatever reason, historians have stirred queer
a bit of this conversation. It was really a fascinating
but difficult scenario to engage.
Speaker 1 (01:15):
So Rick kept digging. He found out the story started
with the grand opening of a medical clinic. The treatment
the clinic provided was highly specialized and time consuming. So
time consuming that patients had to go in twice a
week and get hooked up to a machine overnight.
Speaker 2 (01:33):
All night while they read or talk, or work or sleep.
The entire blood content of each patient as being circulated
through an artificial kidney and clean and pumped back into
the body again.
Speaker 1 (01:49):
These clips from an NBC documentary called Who Shall Live,
filmed a few years after the Seattle Artificial Kidney Center opened.
It aired in nineteen sixty five on Nash Television and
created quite a stir. The kidney Center was revolutionary. It
was the first place in the whole world to offer
long term kidney dialysis, a brand new type of life
(02:12):
saving treatment. There was just one problem.
Speaker 2 (02:17):
The cold, hard fact of the matter is, there are
just so many places available on the kidney machine, and
there are more applicants than places. Somebody has got to
be left out, and somebody has got to decide who
shall live and who shall die?
Speaker 1 (02:34):
Yikes, who shall live and who shall die? When Rick
saw who the people were who would determine that, he
was shocked. The Kidney Center put seven seemingly random people
in charge. They would later come to be known as
the God Squad, the ones to determine the fates of
(02:55):
thousands of their neighbors. It was up to then to
decide which would be saved.
Speaker 3 (03:01):
I thought it was pretty unbelievable that they would have
lay people and community people making this decision.
Speaker 1 (03:10):
This whole thing, this attempt to figure out who should
have access, became so controversial, such a pivotal point that
it would become a wake up call for the need
for a more transparent system. This is a story that
paved the way to what is now known as bioethics.
I'm your host, Lauren Aurora Hutchinson. I'm the director of
(03:33):
the Ideas Lab at the Johns Hopkins Berman Institute of Bioethics.
In this season a Playing God, we went behind the
scenes to discover how some of the most significant medical
innovations impacted people's lives and continued to whether it's saving
lives or creating babies, a new technology was usually waiting
in the wings, along with a multitude of ethical questions.
(03:59):
We looked at where we draw the line, should we
draw the line, what's right and what's wrong when it
comes to our bodies, And we turned to bioethicists to
answer these questions. But in this bonus prequel episode, we're
doing something different. We're going back in time to immerse
you in one of the most important foundational stories of
(04:22):
modern bioethics from Pushkin Industries and the Johns Hopkins Berman
Institute of Bioethics. This is playing God. By the nineteen fifties,
if someone had kidney disease, they could be surgically connected
to a machine called an artificial kidney, also known as
(04:44):
the dialysis machine. Dialysis at the time worked well for
anyone whose kidneys needed help for just a short while,
but people whose kidneys had failed needed ongoing dialysis for
life or they would die. Connecting to a dialysis machine
did a lot of damage to blood vessels, so there
(05:05):
were only so many sessions a patient could do. In
nineteen sixty, a young Seattle nephrologist named Belding Scribner decided
to do something about it. He designed a little U
shaped piece of hollow teflon called a shunt. It could
be left in a patient's arm or leg permanently to
use again and again to connect to a dialysis machine.
(05:28):
This meant chronic kidney disease would no longer be a
death sentence. I just want to pause here for a moment,
because even with the Scribner shunt, it wasn't possible to
treat everyone. So who should be granted access when there
isn't enough of something life saving to go around? This
question around the allocation of resources is one of the
(05:49):
most central questions in bioethics that's still being asked about
all sorts of things today. What's the best way, or rather,
what's the least bad way to resolve this kind of dilemma?
Speaker 4 (06:02):
Well, here's what.
Speaker 1 (06:03):
Happened in this case. In nineteen sixty two, the Seattle
Artificial Kidney Center opened at Swedish Hospital. Initially, the center
had just three machines and could only treat up to
nine patients. Each person selected would need to continue to
be treated for the rest of their life. At the time,
chronic kidney disease killed tens of thousands of people in
(06:26):
the US each year. Regular dialysis was their only shot
at staying alive. So how would the center choose which
patients would get a second chance at life? To begin?
Belding and the hospitals set up an initial screening process
to whittle down the thousands of patients to hundreds, and
(06:46):
in order to even be considered for a spot in
the first place, each candidate needed a referral from their doctor.
Rick says, we.
Speaker 3 (06:54):
Don't know if they accepted referrals from black physicians, and
there were not many black physicians in the nineteen sixties,
which is part of what I argue is problematic about
the committee. You know, Seattle is still a city that
is highly racialized, highly segregated. It's not Alabama or Mississippi,
but there were still segregation in hospitals, which.
Speaker 1 (07:17):
Of course had implications as to who would get referrals
to even be on the list. The center then had
specific criteria. Patients had to be between fifteen and forty
five years old. The hospital advised that children might not
be able to handle ongoing long term dialysis both mentally
(07:38):
and physically. Those of the right age then had to
show they could pay for three years of the treatment
upfront thirty thousand dollars the equivalent of three hundred thousand
dollars today, and they had to be able to access
the center twice a week.
Speaker 3 (07:55):
Perhaps most problematic is they could not have underlying conditions,
so diabetes, hypertension, all of those things would disqualify you
from the possibility of chronic dialysis.
Speaker 1 (08:07):
The medical advisory committee also interviewed the candidates to get
a sense of their psychological health.
Speaker 3 (08:13):
So people who were emotionally unstable, who were poor, who
did not have certain kinds of jobs, who were unmarried,
who did not go to church were largely considered inherently
biologically flawed by the medical committee. Those were the individuals
who were not emotionally stable enough to deal with long
(08:33):
term dealysis.
Speaker 1 (08:36):
The treatment center evaluated about fifty candidates for each available slot.
They would then whittle that number down and hand the
final decision over to the God Squad. The God squad
would then have to choose one person out of about
four candidates per slot. The people on the God squad
were not experts in kidney disease or dialysis. Only two
(08:58):
of them were medical professionals.
Speaker 2 (09:00):
I am a banker, I am a surgeon, I am
a lawyer, I am a physician, I am a labor leader,
I am a housewife, I am a clergy many.
Speaker 1 (09:15):
Belding, Scribner and his colleagues decided it was unfair to
burden physicians with making the final call. Their reason since
all of the candidates on their list would benefit from
the treatment and were deemed good candidates, the choice of
who to save was now really more of a social
one than a medical one. I can't help noticing where
(09:35):
they drew the line between this being a social decision
rather than a medical one, because to me, it seems
like so many of these factors were actually social anyway.
It was at this point they decided to turn it
over to the ordinary people of Seattle. It was their
job to evaluate these patients and determine who should live
(09:56):
and who should die.
Speaker 3 (09:58):
There was a woman who was up for evaluation and
husband and sons said that she was no longer cleaning
the house. That was part of what they brought up
to evaluate her as to her worthiness of dialysis.
Speaker 1 (10:12):
We'll be right back after the break. The God Squad's
official name was the Admissions and Policies Committee of the
Seattle Artificial Kidney Center at Swedish Hospital.
Speaker 3 (10:29):
They, of course say that it represents a cross section
of the Seattle population. It was mostly men, mostly middle.
Speaker 1 (10:38):
Clayer's administrators from the kidney center hand selected the God
Squad members. That's right, hand selected. The hospital gave the
committee an information packet on each candidate, with their medical records,
psychological evaluations, financial information, even letters of reference. One of
the doctors who briefed the committee later said, we told
(11:00):
them frankly, that there were no guidelines. They were on
their own. We really dumped it on them. The committee
decided to review every piece of biographical information they could
get their hands on. They also decided to enlist other
people to help them, a social worker and a psychologist.
What they were looking to determine was what they called
(11:21):
a person's social worth.
Speaker 3 (11:24):
One of the criteria that the Patient Advisory Committee often
considered was the common good.
Speaker 1 (11:30):
Rick says, if you read through the committee's records, you
can piece together what the members thought made someone worthy.
Speaker 3 (11:37):
Being a white collar worker was better than being a
blue collar worker. A woman who was a known prostitute
was rejected for a woman who was a mother of four.
Another one that sticks out is a young man who
was considered to be, and this is the term that
they use, a never do or will a playboy, and
(11:57):
so he does not have the right temperament or morality,
then he's not worthy of theallises.
Speaker 1 (12:04):
The committee members were kept anonymous, and their work happened
behind closed doors, But in nineteen sixty two, a prominent
reporter named Shana Alexander revealed their inner workings to the
world in a Life magazine article. Amazingly, all of the
committee members agreed to be interviewed as long as they
were not identified. The committee even re enacted one of
(12:27):
their first liberations so Shana could hear how they sounded
in action. Their conversations made it clear that to committee members,
what made someone worthy of saving was a matter of
personal opinion. We had voice actors read from the article.
Speaker 5 (12:44):
If we are still looking for the men with the
highest potential of service to society, I think we must
consider that the chemist and the accountant have the finest
educational backgrounds of all five candidates.
Speaker 6 (12:55):
How do the rest? Do you feel about number three,
the small businessman with three children. I'm impressed that this
doctor took special pains to mention this man as active
in church work. This is an indication to me of
character and moral strength.
Speaker 7 (13:09):
For the children's sake, we've got to reckon with the
surviving parents' opportunity to remarry, and a woman with three
children has a better chance to find a new husband
than a very young widow with six children.
Speaker 6 (13:21):
How can we possibly be sure of that?
Speaker 1 (13:25):
Shanea's article not surprisingly caused outrage.
Speaker 3 (13:29):
Lawyers at the time, you know, argue that it was
really just a way for physicians to avoid the responsibility
of making a difficult decision that they did not want
to make and that nobody wants to make.
Speaker 1 (13:43):
Mostly, Rick says, people pointed out the obvious flaws with
a metric worthiness.
Speaker 3 (13:48):
Someone who is, you know, an activist in the civil
rights movement. That's a social good, but it might not
fit within the ideals of what it is that they
think as a social good. So you could have a
respected business person who was still unethical in a number
of different ways.
Speaker 1 (14:05):
In the end, the committee selected the first group of patients,
among them a physicist, an engineer, a car salesman, an
aircraft worker, and an oil company executive. By most accounts,
the God Squad kept meeting until nineteen seventy two. That year,
Congress passed legislation making dialysis available to everyone whose kidneys
(14:30):
have failed, but the committee lived on in public imagination.
Many people didn't get the life saving treatment they needed
because they were deemed less worthy. The God Squad were
people who just had to make up the rules as
they went along. There was no template yet for best
practices or ethical guidance in making these kinds of decisions.
Speaker 4 (14:59):
They were starting from s, you know, and I think
that we have a much more robust literature. You know,
we have a history of bioethecal analysis to lean on now,
and of course we're still improving over time and how
we think about these things.
Speaker 1 (15:12):
This is Kate Butler. She's a clinical neprologist based in Seattle,
and she says, what is key is to design a
system that's fair. But of course fairness can be understood
in lots of different ways.
Speaker 4 (15:26):
Do we want to make the very best use of
resources in terms of saving the most lives in terms
of having the most life years lived? Do we want
to consider quality of life years lived? And if so,
who decides on quality? And or do we want to
make sure that we're allocating resources in a way that
(15:46):
feels equitable to us? And again, who is that us?
Who's making the decision about whether the system is equitable.
Speaker 1 (15:54):
Kate told us that nowadays systems are based on ethical foundations.
For example, one way of doing things would be to
prioritize recipients who we expect to live the longest after
a transplant, which would be a utilitarian approach. Or you
could use a lottery so that everyone on the list
gets an equal chance of a transplant, which would be
(16:15):
based on the principle of equality. I mean, which one
do you think would be most fair? Kate gave an
example the National Weight List for kidneys, which is a
modified version of waiting until your number is.
Speaker 4 (16:27):
Called, and that process has been worked out over decades
as a collaboration between clinicians, bioethicists, the community by way
of community forums.
Speaker 1 (16:39):
There's an organization that monitors the systems to see if
it's working the way it's supposed to. It's called the
United Network for organ Sharing. In twenty fourteen, they discovered
a flaw. The waiting list wasn't accounting for some groups
of people, mainly people of color, having a harder time
getting on the list in the first place. In bioethics,
(17:01):
equity is a key principle. It's important to account for
disadvantage or underrepresentation. So they made a change.
Speaker 4 (17:10):
There was an intentional effort to change the WEIGHTLISS criteria
to give you retroactive time for time since you started
on dialysis, so people would get points for the time
spent on the witlist or how long they had been
on dialysis, whichever is longer.
Speaker 1 (17:26):
The change was apparent within months. The system still isn't perfect,
but Kate says, as an example of how the field
of bioethics has evolved since the time of the God Squad.
Speaker 4 (17:37):
There's more to medicine than just clinical analysis of individual
cases that considering the bioethical implications of these decisions was
necessary and important. I think that's why people refer to
this example as the birth of bioethics today.
Speaker 1 (17:56):
It's part of the process to consider ethics in medical advance.
Speaker 4 (18:01):
Any situation in which you have resource scarcity for something
so consequential as healthcare, there's going to be tragedy, right
There's going to be someone who doesn't get the care
you want for them. We're not going to be able
to design a perfect system.
Speaker 1 (18:18):
As we have heard from this series, the landscape is
ever shifting. Every time there's a new medical innovation, there's
a whole new set of ethical questions. If you've enjoyed
playing God, then we're going to have plenty more stories
like this coming out of the Ideas Lab at the
Johns Hopkins Berman Institute of Bioethics. Playing God is a
(18:42):
co production the Pushkin Industries and the Johns Hopkins Berman
Institute of Bioethics. Special thanks to our guests in this episode,
Rick Mozelle and Kate Butler. Emily Vaughan is our lead producer.
Production support from Sophie Crane and Lucy Sullivan. Our editors
are Karen Chakerjee and Kate Parkinson Morgan. Theme music and
(19:06):
mixing by Echo Mountain, Engineering support from Sarah Brugare and
Amanda Kaiwang. Show art by Sean Carney, fact checking by
David jar and Arthur Gompertz. Our executive producer is Justine
Lang at the Johns Hopkins Berman Institute of Bioethics. Our
(19:26):
executive producers are Jeffrey Kahan and Anna Mastriani, working with
Amelia Hood and with support from Susan Snead, Aaron Henkin,
Abigail Brickler, Kim bikermer Anna Oakes, and Jamie Smith. Funding
provided by the green Wall Foundation. Special thanks to voice
(19:46):
coach Vicky Merrick. This is our last episode, so we'd
like to thank some of the many people at Pushkin
who've supported this show throughout the season, including Jacob Weisber,
Heather Fame, John Snarz, Letal Malad, Greta Cohne, Carl Migliori,
(20:10):
Jasmine Perez, Eric Sandler, Jordan mcmill Isabella Navarez, Nicole op
Den Bosch, Maya Kanig, Jake Flanagan, Owen Miller, David Glover,
Nina Lawrence, Mia LaBelle, and Ian Petsa. To learn more
(20:35):
about Bioethics and the issues presented in this series, please
visit Bioethics dot jhu dot edu forward, slash Playing God.
I'm Laurena Rora Hutchinson. Thanks for listening to Playing God.
(21:00):
If you're interested in learning more about these stories and discussions,
visit the Berman Institute's guide to the podcast at Bioethics
dot j u dot ed u, slash Playing God, or
find us on social media at Burman Institute
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