By Asna Tabassum
Peer Reviewed
I distinctly remember sitting in my third-grade classroom, frontal lobe far from fully developed, staring at a worksheet that asked me to do the impossible: of ten passengers on a sinking ship, pick three to escape on a rowboat.
Our classroom of 30 seven-year-olds held jury. We shouted and argued, attempting to persuade each other through frantic justifications—He’s too old! She’s too young! He has kids! She’s a doctor!—and learning, for the first time, that ethics was complicated. But at the end of it all, this was just a worksheet: abstract, inconsequential, and the last thing between me and recess.
It was this memory that first came to mind when I learned about the 1962 Admissions and Policies Committee of the Seattle Artificial Kidney Center—where passengers on a sinking ship were now neighbors with kidney failure, and the rowboat was an experimental dialysis machine.
In the early 1960s, Seattle’s Swedish Hospital initiated a long-term hemodialysis program with the new Scribner shunt. This shunt eventually became a hallmark innovation in the world of dialysis. Prior to the shunt’s inception, repeated cannulation quickly destroyed blood vessels and prevented long-term treatment. In 1960, Seattle nephrologist Dr. Belding Scribner employed a non-stick, non-clotting Teflon conduit to develop a U-shaped shunt connecting an artery and vein, the beginnings of what would later become the classic dialysis fistula. On March 9th, 1960, the world’s first shunt was implanted into the arm of a 39-year-old aircraft machinist Clyde Shields. He lived 11 more years on hemodialysis—transforming a death sentence into a manageable condition.1
However, the dialysis machines remained scarce, and the process cost a staggering $15,000 a year per patient, which would be $170,000 nowadays—meaning only one in 50 candidates could be accommodated. There were now more patients to save than machines that could save them.
Doctors had begun the difficult process of selecting dialysis candidates by excluding children and adults over the age of 45, who were thought to have lower medical viability. But the doctors stopped there. Believing that the choice of who should live was a societal rather than a medical one, the King County Medical Society appointed seven laypeople of Seattle to decide the rest: a lawyer, a minister, a banker, a housewife, a state official, a labor leader, and a surgeon. The Admissions and Policies Committee of the Seattle Artificial Kidney Center met anonymously in a small nurse’s residence library, burdened with the task of deciding who would live.
What intrigued me the most were the factors with which the Committee eventually assessed social worth:
- Age
- Sex
- Marital status and number of dependents
- Income
- Net worth
- Emotional stability, with particular regard to the patient’s capacity to accept the treatment
- Educational background
- Nature of occupation
- Past performance and future potential
- Names of people who could serve as references
Which, interestingly, was not unlike the types of factors that our third-grade classroom had considered—He’s too old! She’s too young! He has kids! She’s a doctor! In addition to these factors, the Committee eventually went on to consider churchgoers, who were considered mentally durable, as well as Seattle taxpayers, whose dollars had funded the research. All candidate information was in metrics on paper.
Eventually, the first five patients were selected: an oil businessman, a car salesman, a physicist, an engineer, and an aircraft machinist. Each underwent a bedside procedure under local anesthesia to form the Scribner fistula, and soon after underwent 10-12 hour overnight dialysis sessions twice weekly. Hemodialysis earned the spotlight as the life-saving therapy it was.
But later on, in November of 1962, LIFE magazine columnist Shana Alexander published an article named “They Decide Who Lives, Who Dies.”2 It shifted public interest from dialysis to what she called the Life or Death Committee, with personal interviews of the seven anonymous committee members demonstrating a variety of perspectives. I found the clergyman’s reflection quite interesting, with a deep appreciation of the gravity of their task:
Clergyman: “As we tried to work out our ground rules for selection, I felt a deep sense of awe, almost that we were going beyond our domain… But I often wonder—suppose I should somehow meet a man I had voted against? What would I say to him? I believe I would face it. I would tell him my reasons.”
In an opposite perspective, the lawyer played devil’s advocate:
Lawyer: “The so-called ‘rejected’ patients would have died with or without the committee—as, of course, we all will some day. I cannot honestly say I am overwrought by the plight of the patients we do not choose—the ones we do choose have an awfully rugged life to look forward to. Not all men would wish it.”
But it was, ironically, the banker with a succinct balance:
Banker: “The situation, as I see it, is life and death, complicated by limitations of money.”
It was an interesting set of perspectives that, I think, partially accomplished being a microcosm of the larger Seattle community. However, many decades later, bioethicists analyzed the outcomes of the committee and found that those with the best chance for acceptance were middle-aged, middle-class, white males.3 It was an imperfect committee, reflecting the implicit bias of its members. Why, then, did the physicians outsource this decision? From another excerpt of the clergyman’s account, we learned:
Clergyman: “The purpose of our committee is to protect the medical men from just such highly emotional situations. If they have to go through emotional stress, they cannot conserve their energies for their own work. A doctor’s job is the practice of medicine.”
In the context of how we train and practice in the medical field today, this opinion feels alien. “The medical men” now integrate emotions into the essence of medical care, with age, sex, and all the other factors of the committee’s assessment now known as the social determinants of health. Admittedly, the “emotional stress” and “conserv[ing] energies” portions of his statement have not been adequately addressed by healthcare culture yet.
Ten years later, in 1972, pressure from advocates moved Congress to establish universal funding for dialysis through Medicare. The supply of dialysis machines and facilities increased overnight. The Life or Death Committee, later termed the God Committee, was now unnecessary.
But as a medical student in a healthcare system where demand continually exceeds capacity, I see God Committees every day. On the transplant psychiatry service, I learned how emotional stability and capacity to accept treatment were very subjective factors that decide who gets the newest liver or heart and who does not. I saw this during the COVID-19 pandemic, as clinicians drafted ventilator protocols and tiered vaccine rollouts. I see it in the physicians yelling on the phone in the hallway between appointments, attempting to get insurance coverage for life-saving treatment for their patients. The clergyman’s goal—to protect doctors from the “emotional stress” of selection—failed. Today’s physicians live in a world of scarcity, bearing the burden of the God Committee alone as part of the job description.
John Myers, the oil businessman among the first five selected by the God Committee, perhaps put it best:
“I guess that as long as facilities are not unlimited, somebody has to pick and choose. And then they have to go home and sleep at night. What a dreadful decision! It’s like trying to play God.”
Asna Tabassum is a Class of 2027 medical student at NYU Grossman School of Medicine
Peer Reviewed by Michael Tanner, MD, Executive Editor, Clinical Correlations
Image courtesy of National Institute of Diabetes and Digestive and Kidney Diseases, Public domain, via Wikimedia Commons
References
- Sherrard J. “How a Seattle doctor and patient transformed the treatment of kidney disease.” The Seattle Times. 18 Apr 2024. https://www.seattletimes.com/pacific-nw-magazine/light-overcame-darkness-for-seattles-pioneer-kidney-patient-clyde-shields/. Accessed 17 Apr 2026.
- Alexander S. “They Decide Who Lives, Who Dies.” LIFE Magazine, LIFE. Nov 1962. https://www.nephjc.com/news/godpanel Accessed 17 Apr 2026.
- Warrick P. “Questions of Life and Death: Who Lives? Decision by Committee.” Los Angeles Times, Los Angeles Times, 4 Aug 1991, www.latimes.com/archives/la-xpm-1991-08-04-vw-25-story.html. Accessed 17 Apr 2026.