"The Doctor's Dilemma"

Playwright Bernard Shaw's 1906 drama raises questions about the allocation of scarce medical resources: Who is worth saving? and Why? How and by Whom?

A not-so-hypothetical scenario
On the chalkboard in a college classroom, eight stick figures were drawn inside eight rectangles to represent patients lying on makeshift cots in a hospital tent in West Africa.

To one side of this depiction of rows of cots, were two squiggles representing two vials of serum that has been effective in combating Ebola. Alongside the vials were two chalked circles meant to represent two pints of blood, and a chalked square meant to represent a dialysis machine and dying generator.

Reactions to the scenario:

"I want to know how old those victims are; the age of each patient." That was the criterion proposed by a Computer Science student.

"We should know what they do; what they would do, be able to do, if they survive," volunteered an Occupational Therapy student.

"We should prioritize after assessing each patient's medical history," insisted a Nursing student, who added, "We need to know of any other health issues, pre-existing conditions, immune-system issues, which might make recovery all the more difficult."

"Yes, of course, we have to anticipate for complications, reactions, risks," was the duet from a Physician's Assistant student and a Physical Therapy student. "There could be vulnerabilities and infirmities to take into account."

"How about a medi-vac airlift to get them to a larger, better-supplied hospital?" was the possibility raised by a Communications major.

"Yeah, okay, but who would go first if a helicopter only had room to carry two patients?" was the rejoinder from the Computer Science student.

"Can the serum be divided into smaller doses? and still work?" asked an Economics major. "If not, I'd save the youngest because, actuarially, in all likelihood, they would have more to contribute over time."

At that point I wanted to say something about the judgment and wisdom, perspective and erudition - the value - that those of more advanced decades might have to offer. Instead of my self-serving self-preservationist notion (which elicited chuckles and a few wry comments), my thoughts turned to the "weighing" that Bernard Shaw provocatively installed in his didactic play The Doctor's Dilemma - which takes place in 1903, in London, and which was first performed in 1906.

The set-up from dramatist G. B. Shaw
In the play, Dr. Colenso Ridgeon has just been knighted for his work in developing a serum which, if inoculated at the most propitious moment, can completely cure consumption.

Overworked and agitated by entreaties from tuberculosis sufferers and their supplicants, Ridgeon asked his housekeeper to turn away a particularly insistent supplicant. Exasperated, he relents and meets "an arrestingly good-looking young woman" who has "the grace and romance of a wild creature" along with "the elegance and dignity of a fine lady." Smitten with this supplicant - who is probably thirty years younger than him - he responds to her "great distress" and "mortal anxiety" by explaining that, most regrettably, he cannot "undertake" another case:

"I have at the hospital ten tuberculosis patients whose lives I believe I can save.... Try to think of those ten patients as ten shipwrecked men on a raft - a raft that is barely large enough to save them - that will not support one more. Another head bobs up through the waves. Another man begs to be taken aboard. He implores the captain of the raft to save him. But the captain can only do that by pushing one of his ten off the raft and drowning him to make room for the new comer. That is what you are asking me to do."

The beautiful young supplicant will not be deterred or dissuaded: "Doctor, you must save my husband. You must. When I explain to you, you will see that you must. It is not an ordinary case, not like any other case. He is not like anybody else in the world: oh, believe me, he is not."

As proof, she opens an artist's portfolio and produces her husband's drawings. She declares that those samples are not even his best, but surely are ample evidence of his genius.

Though weakening, Dr. Ridgeon tries to make her see his predicament:

Not enough cure for even one more case
"My laboratory, my staff, and myself are working at full pressure. We are doing our utmost. The treatment is a new one. It takes time, means, and skill; and there is not enough for another case. Our ten cases are already chosen cases. Do you understand what I mean by chosen?"

She is not moved. Her husband, she insists, must be among the chosen.

Dr. Ridgeon tries another explanation to get her see his predicament:

"You've got to understand and to face it. In every single one of those ten cases I have had to consider, not only whether the man could be saved, but whether he was worth saving. There were fifty cases to choose from; and forty had to be condemned to death. Some of the forty had young wives and helpless children. If the hardness of their cases could have saved them they would have been saved ten times over."

The plot coagulates and clots
For his dramatic purposes, G. B. Shaw orchestrated events so that one of the ten "chosen" patients expires prior to Dr. Ridgeon's treatment. Thus, there is an opening - an empty bed. Smitten, yet still tethered to some moral code, Ridgeon challenges the beautiful young supplicant to convince him that her husband's life "is more important than the worst life I am now saving."

She insists that her husband, a man of true genius, is the one person worth saving: "I am asking you to save the life of a great man," she declares.

Who is worth saving? and by what criteria?
Several of Ridgeon's stuffy colleagues (stuffed with their social prominence, medical self-importance, and omniscience) are also enchanted - seduced by her charms. They are about to be convinced that her artist husband is the one man to be saved; though another man will die as a result of the artist's ascension to Ridgeon's care.

Shaw's pen introduces aspects of the husband's character, which the young wife has not and cannot recognize. He is "an appalling bounder," a scoundrel, a con man, a cad, a cadger, a blackguard, and a bigamist to boot.

To make matters all the more interesting, Shaw's pen adds "weight" to the balance-beam of the drama: A doctor whose patients "are all clerks and shop-men who daren't be ill; can't afford to be ill" is himself "touched" with TB.

To his well-to-do colleagues he had explained that his wretched health correlates to the throes of his poor, downtrodden patients. While the well-to-do physicians "can send their patients to St. Moritz or to Egypt, or recommend horse exercise or motoring or champagne jelly or complete change and rest for six months. I might as well order my patients a slice of the moon."

Even in his poverty, this "public physician" has pride: He will never ask for handouts, but will accept (with humility) a hand-me-down: "Well, if you have an old frock-coat to spare? You see, what would be an old one for you would be a new one for me. Remember me the next time you turn out your wardrobe."

Departing a gathering of the swells, the amoral artist "borrows" tidy sums from all the hosts and enjoys a comfortable carriage-ride home to his garret.

Leaving the same gathering, the impoverished "public physician" has no money for carriage fare. He'll take the drafty night train home: Bravely, humbly, he declines charity by assuring the swells that the hotel porter or a stationmaster will give him "some brown paper; a few thicknesses of brown paper across the chest are better than any fur coat."

The scales are set for the swell doctors to weigh.

Trust, in readiness and efficacy
News headlines open memory cabinets to recollections of the contamination of what should have been the full supply of vaccines for the anticipated bird-flu and swine-flu viruses. In hospital cabinets are there vials to combat MERS, SARS, and the Enterovirus?

How quickly will pharma labs be able to respond to Ebola ravages? and in what quantities? Who will get the first doses?

Preceding the 105-page text of The Doctor's Dilemma, G. B. Shaw intruded his 79-page polemic: "Preface on Doctors" - which excoriated surgeons: "mutilators" for their unnecessary "de-limbings" - "accomplished burglars" for their "extirpations of internal organs."

He railed against what he saw as doctors' presumed omnipotence and infallibility; their microbe superstitions; and the "fad" of inoculation immunization.

Despite all that bile, the dilemmas portrayed in Shaw's 1906 play might inform some thinking about how we distribute decontamination equipment and intensive-care teams; how we allocate protective gear, bio-containment facilities, isolation rooms, and life-saving vaccines.