When Death Isn't Dead: Implicit Social Rationing during Resuscitative Efforts

In this paper, I address the relationship between social death and clinical-biological death during resuscitative efforts. In Western societies, resuscitative efforts are the medical intervention of choice when sudden death occurs. The widespread use of this technology puts emergency department staff in a difficult gatekeeping position. They are expected to save lives, but, at the same time–when their efforts become futile–to prepare for a dignified death. I show that certain groups of patients are much more likely to be considered socially dead regardless of their clinical viability, while others are less likely to be considered socially dead even when irreversible biological death has set in. The result is an implicit rationing of the lifesaving endeavors based on the social worth of the patient. This rationing annihilates initiatives, such as advance directives, which were instituted to empower patients. Social scientists usually suggest that the solution to the negative effects of rationing is to increase accessibility for all populations; however, resuscitative efforts are a prime example in which less access for all groups–instead of for some–might be preferable. This paper is based on observations of 112 resuscitative efforts during a fourteenth-month period and interviews with 42 health care providers.