Saving Lives Should Not Require Permission

When did saving a life start to feel like breaking the rules? When did the doctor at the bedside become less trusted than the people making decisions from far away, such as administrators, regulators, or distant experts who have never met the patient? And how did a profession built on judgment, uncertainty, and moral responsibility end up rewarding people for just following orders?

These aren’t just abstract questions. They decide who can act when someone is dying, and who gets blamed if the official plan fails.

The Apparently Dead Did Not Need Permission

Amsterdam, 1767. A body is pulled from a city canal. The victim is still, not breathing, and shows no clear sign of life. Most people assume the person is dead. But a small group of citizens and doctors started to ask a new question: What if this person only looks dead? What if death is sometimes a process that can be stopped? And if there is even a small chance of life, do we have a duty to try to help?

This idea led to the first Humane Society, a group focused on rescuing and reviving people who seemed to have drowned. In fourteen months, they reported saving nineteen people. By 1793, they said they had rescued 990 lives over twenty-five years.[1] These numbers might not meet the standards of a modern clinical trial, but the idea behind them changed medicine: apparent death did not always have to be the end.

The idea spread fast. Humane Societies popped up in cities like Venice, Milan, Hamburg, Vienna, Paris, London, St. Petersburg, Philadelphia, New York, Boston, and Glasgow. These weren’t just private clubs or government agencies. They were groups of volunteers (doctors, clergy, apothecaries, soldiers, boatmen, scientists, philanthropists, and regular people), working together to save lives. Historians now call them a transnational movement that shared medical knowledge across borders.[2]

Something very similar to what Brownstone Institute is today. Before there were international health organizations or emergency medical systems, these societies compared notes, shared tips, gave out rewards for rescues, and encouraged everyone to help. Their guiding idea was simple, even if it sounds bold today: if a life is at risk, the person who can help has the responsibility to act.

In London, the movement took on a special character. In 1774, doctors William Hawes and Thomas Cogan met with 32 friends at the Chapter Coffee House in St. Paul’s Churchyard to start what would become the Royal Humane Society. Hawes had already been paying boatmen out of his own pocket to bring drowning victims in quickly so resuscitation could be tried.

This was not a government project or a plan from professional managers. It was simply a group of people deciding that giving up was not good enough. Someone pulled from the water might look dead, and experts might say there was no hope. Still, there could be a chance for life, and someone should try to save it.[1]

Experts, Bellows, and Tobacco Smoke

Their methods were a mix of smart ideas, wild guesses, and desperate attempts. Victims were warmed, rubbed, shaken, bled, made to vomit, given mouth-to-mouth breaths, and exposed to heat and electricity. Believe it or not, tobacco smoke was even blown into the rectum using special devices, some kept in barbershops and other public places.

That might sound almost comical now, but there’s a real lesson here. The same people who helped make artificial ventilation a real medical practice also believed a tobacco enema could save a life. They were brave, but sometimes wrong. That’s not a knock on science. It’s how science actually works. Medicine moves forward when people try things, see what happens, learn from mistakes, and aren’t afraid to change course. It doesn’t move forward just because a committee says all the uncertainty is gone.

The Humane Societies became places where different medical ideas competed. The Dutch supported mouth-to-mouth ventilation, but many leading British doctors looked down on it. William Hunter called it something done by “the vulgar,” and some worried that exhaled air was toxic and could not revive anyone.[1] Still, this simple method used by regular people was actually closer to modern resuscitation than the more complex techniques favored by experts.

This does not mean expertise is useless. It means that authority and truth are not the same. Expertise deserves respect when it stays open to new evidence and correction, but it becomes risky when status is used to shut down questions.

John Hunter set a better example. He tested ventilation on animals and saw that when breathing stopped, the heart weakened and then stopped too. When ventilation started again, the heart could recover. He did not use bloodletting, emetics, or tobacco smoke. His use of bellows to help people breathe became common, but later it was found that too much pressure could hurt the lungs.

In 1837, the Society stopped recommending bellows ventilation because it could damage the lungs.[1] This process is important: try something new, use it, notice problems, rethink, and change course. The bellows were not kept just because respected people liked them. When harm was clear, the advice changed. That is how medicine should work.

The Societies tried using electricity before anyone really understood how the heart’s electrical system worked. Luigi Galvani had shown that electricity could make muscles contract, and in 1788 Charles Kite described using electricity to try to revive people. By 1795, the Humane Society of New York had a method for sending electric current through the heart area of someone who seemed dead, more than a hundred years before doctors fully understood ventricular fibrillation.[1]

In medicine, practice often comes before full understanding. Today, we like to think everything moves neatly from lab discovery to trials, guidelines, and approval. But often, doctors notice that something works before they know why. An observation is not proof, but it is often the start of proof.

The best stories were always about people, not equipment. James Parkinson (yes, the same Parkinson whose name is now linked to a disease) got a silver medal for helping save someone in 1777. Czar Alexander I supposedly helped with resuscitation for three hours after a Polish peasant was pulled from the Vilia River. Mrs. Ann Newby, who ran the City of London Lying-in Hospital, was given a medal in 1802 after saving 500 newborns.[1] Five hundred babies got a chance at life because she had the knowledge, courage, and heart to act. She wasn’t looking for fame; the lives she saved were her legacy. This is what the Humane Societies stood for: life-saving knowledge is for everyone, and its true value comes when one person uses it to help another.

A Protocol Has No Conscience

I have spent more than four decades in emergency departments, intensive care units, and hospital wards. I have participated in resuscitations in which protocols were indispensable. When a patient loses a pulse, chaos is the enemy. Chest compressions must begin. The rhythm must be identified. Defibrillation, medication, airway management, and the search for reversible causes must proceed in an organized fashion.

A good protocol helps a team move as one when seconds matter, and no serious physician should dismiss that achievement. Modern resuscitation is one of the clearest examples of standardization saving lives.

But the algorithm has limits. It cannot see the patient’s face, know the sequence of events that preceded the arrest, interpret the significance of a sudden change in skin color, or recognize that a familiar pattern does not fit this particular person. It cannot decide whether the cause is a pulmonary embolus, a tension pneumothorax, profound hypovolemia, a toxic exposure, or something no one considered when the code began. It cannot tell a physician when one more cycle is persistence and when it has become the prolongation of dying.

I have followed resuscitation protocols while simultaneously departing from the mental comfort they can create. The protocol organizes the work; it does not assume responsibility for the patient. When the code ends, the algorithm does not face the family. The physician does.

Sepsis offers another example. Early recognition, prompt antibiotics, cultures, hemodynamic assessment, and rapid support are essential. Protocols helped hospitals identify sepsis earlier and made dangerous delays less acceptable. Yet a septic patient is not a standardized container into which a predetermined volume of fluid can be poured without thought. An elderly patient with severe heart failure and renal dysfunction may not tolerate the same resuscitation strategy as a young adult with profound dehydration.

I have stood at the bedside trying to restore perfusion while also watching the lungs, the neck veins, the urine output, the blood pressure trend, the lactate, the bedside ultrasound, and the patient’s response to each intervention. The question is never simply whether the bundle was completed. The question is whether the patient is improving.

The history of early goal-directed therapy for septic shock is instructive. A highly specified protocol once became the standard that institutions were urged to reproduce. Later, three large multicenter trials, ProCESS, ARISE, and ProMISe, found no survival advantage for mandated early goal-directed therapy over contemporary usual care.[3-5] This did not prove that early recognition or resuscitation was unimportant. It showed that ordinary care had evolved and that the exact protocol was not a universal law.

The lesson should have produced humility: a protocol may capture the best understanding of a moment, but medicine keeps moving. Instead, healthcare systems too often freeze yesterday’s recommendation into tomorrow’s compliance measure, long after the clinical world that produced it has changed.

Covid and the Cult of Obedience

During the Covid-19 pandemic, this tension became impossible to ignore. I worked for more than 250 consecutive days in a hospital filled with patients whose disease behaved in ways we were still learning to understand. Many arrived with frightening oxygen saturations, extensive lung involvement, abnormal inflammatory markers, and a trajectory that could change in hours.

We needed protocols because exhausted teams caring for large numbers of critically ill people required structure. Infection control, anticoagulation assessment, respiratory support, laboratory monitoring, nursing care, and escalation plans could not be improvised independently for every patient. A protocol can preserve collective memory when individuals are tired, and the ward is under siege.

At the same time, no protocol should replace observation. I remember patients whose oxygen numbers looked terrifying while they remained awake, communicative, and capable of being supported without immediate intubation. I also remember others whose outward appearance was deceptively calm while their work of breathing, mental status, or hemodynamics warned that delay would be disastrous.

I had to decide when to continue high-flow oxygen, when to prone an awake patient, when to change anti-inflammatory or anticoagulation strategies, and when the ventilator had become unavoidable. Those decisions could be informed by guidelines, but they could not be outsourced to them. The patient in front of me was always more current than the document written weeks or months earlier.

Early in the pandemic, the momentum in many institutions favored intubation before a patient deteriorated further. The logic was understandable, but the consequences of mechanical ventilation were not trivial, and some of us became increasingly cautious about allowing a frightening oxygen saturation alone to dictate the decision. Contemporary clinicians warned against reflexive early intubation,[7] and later trials showed that awake prone positioning could reduce treatment failure in selected patients receiving advanced respiratory support.[8]

None of this meant that intubation was wrong. It meant that timing mattered, physiology mattered, and the individual patient mattered. A ventilator could save a life, but it could not be permitted to become the automatic answer to a number on a monitor.

Yet we were repeatedly pushed toward actions that made little clinical or human sense. Across hospitals, patients were isolated from the people who knew them best. Families were treated as hazards rather than partners in care. Bedside physicians were expected to implement rapidly changing directives written by committees and agencies far from the bedside, often with little opportunity for honest dissent.

Treatments could become professionally radioactive before the evidence was settled because their names had acquired political meaning. A molecule does not know which political party favors it or which television network attacks it, but during Covid, too many physicians behaved as if it did.

One of the photos from my career that spread the furthest showed me in full protective gear, hugging an elderly Covid patient who was crying for his wife. He was surrounded by machines and monitored by exhausted staff, but in that moment, what he needed most was simple: human contact. I hugged him because leaving him alone felt wrong.

That picture struck a chord around the world, not because it showed advanced medicine, but because it revealed what medicine had started to forget. In trying so hard to control every risk, we ended up treating love, touch, family, and presence as if they were optional extras, not essentials.

We Followed the Wrong Leaders

The first months of a new pandemic will always produce mistakes. That is not a scandal. Honest error under uncertainty is part of medicine, and any physician who claims never to have been wrong has either not practiced long enough or has not been paying attention. The scandal begins when leaders refuse to admit uncertainty, when yesterday’s hypothesis becomes today’s commandment, and when questioning an official recommendation is treated as disloyalty. Science requires revision. Bureaucracy experiences revision as a threat to authority.

During Covid, we too often followed the wrong leaders. We followed titles instead of results, institutions instead of observations, and television experts instead of physicians actually caring for the sick. Authority moved farther from the patient’s room while becoming more confident about what had to happen inside it.

Some of the people setting the tone had not managed a ward full of hypoxemic patients, had not held the hand of a dying person whose family was forbidden to enter, and would never be required to explain to that family why the approved strategy had failed. Yet their certainty traveled downward through agencies, hospital systems, professional societies, electronic order sets, media organizations, and technology platforms until uncertainty itself became unacceptable.

This distinction was frequently lost during the pandemic. Under conditions of profound uncertainty, many institutions treated compliance as a substitute for reasoning. Physicians were told, explicitly or implicitly, that deviation from approved pathways carried professional, legal, or reputational risk. Some feared losing hospital privileges, professional standing, research opportunities, or even the ability to speak publicly.

A treatment could be discussed as plausible one week and unacceptable the next, not always because decisive evidence had appeared, but because institutional consensus had shifted. The tragedy was not that protocols existed. The tragedy was that questioning a protocol was sometimes treated as evidence of irresponsibility, even though the protocol itself had been created in the middle of an evolving emergency.

We did not follow the wrong leaders because every recommendation they made was wrong. Many recommendations were reasonable, and some undoubtedly saved lives. We followed the wrong leaders when we surrendered the responsibility to think to them. We let institutional prestige stand in for evidence and allowed fear to turn provisional guidance into moral law. Covid did not create this system. It exposed it.

When Compliance Becomes the Treatment

Evidence-based medicine was never supposed to mean obedience to a document. Its foundational definition joined the best available external evidence with individual clinical expertise.[6] Both elements matter. Evidence without clinical judgment becomes bureaucracy. Judgment without evidence can become arrogance. Good medicine requires their union, applied to the patient’s values and circumstances.

Yet modern systems increasingly measure what can be recorded rather than what can be understood. The electronic record can confirm that a box was checked, a medication was ordered within a specified interval, and a form was signed. It cannot easily capture why a physician withheld fluid, delayed intubation, continued a resuscitation, or abandoned a recommended pathway because the patient was deteriorating under it.

This is how protocols, which should be tools, become authorities. Once tied to reimbursement, quality scores, liability review, or disciplinary exposure, they acquire a force far beyond their scientific content. A physician may know that the patient does not fit the average population from which a recommendation was derived, yet still feel compelled to comply because explaining an individualized decision after a bad outcome is more dangerous than documenting adherence to a recognized pathway.

The result is a moral inversion: the safest action for the institution may not be the safest action for the patient. The clinician is rewarded for following the map even when the terrain has visibly changed.

I have faced this conflict repeatedly. Sometimes I have followed a protocol because it was sound, because it coordinated the team, and because it gave the patient the best chance to survive. At other times I have followed a protocol while knowing that I needed to watch for the moment it ceased to fit. And there have been times when trying to save a life required me to explain, defend, and document why the standard pathway was insufficient.

We no longer document only the care we provide; increasingly, we document our defensibility. None of this means that a physician should have unlimited license to experiment without consent, evidence, or accountability. It means that accountability must remain attached to judgment. A system that grants the physician no meaningful discretion should not pretend that the physician still bears full moral responsibility for the outcome.

Permission to Try, Permission to Die

The same problem appears when a dying patient seeks access to an investigational treatment. The federal Right to Try Act created a pathway for certain patients with life-threatening disease who have exhausted approved options and cannot participate in a clinical trial to seek an eligible investigational drug.[9] The law does not guarantee access; manufacturers may still decline, and the practical obstacles remain substantial.

But its moral premise resembles the question asked beside the Amsterdam canals: when conventional judgment has declared that nothing more can be done, are we certain that the only humane response is to stop trying? Some experimental treatments will fail, and others may cause harm. Those risks must be explained honestly. But a competent patient facing death should not be reduced to a passive object protected from every choice except the certainty of decline.

The Humane Societies did not possess our laboratories, monitors, ventilators, pharmaceuticals, imaging, or statistical methods. They made serious errors, and some of their remedies now seem absurd. We should not romanticize 18th-century medicine. Modern regulation, ethical review, professional standards, and clinical guidelines emerged for good reasons, often after terrible abuses. They protect patients from fraud, recklessness, exploitation, and avoidable inconsistency. The lesson is not that we should return to an era in which anyone with a bellows and a theory could declare himself a resuscitation expert.

The lesson is that the Humane Societies organized life-saving activity without extinguishing the human instinct to act. They distributed knowledge rather than hoarding it. They encouraged ordinary people to become rescuers. They created forums in which ideas could compete. They rewarded courage. They revised recommendations when harm became apparent. Most importantly, they understood that an institution should help people save lives, not provide them with an excuse to watch helplessly while responsibility is transferred elsewhere.

Modern medicine has achieved things the founders of those societies could not have imagined. We can restart a fibrillating heart, oxygenate blood outside the body, replace failing organs, visualize the brain in real time, and keep a premature infant alive at a size once thought incompatible with survival. Yet with every layer of sophistication has come another layer of permission: hospital policies, formularies, utilization review, prior authorization, scope restrictions, liability rules, quality metrics, and administrative oversight. Some of these are necessary. Together, however, they can create a culture in which the first question is no longer, “What might save this patient?” but “What am I allowed to do?”

That change is not merely administrative. It alters the character of the physician. A doctor trained primarily to comply will eventually stop seeing possibilities that fall outside the approved pathway. A nurse repeatedly punished for initiative will learn to wait. A patient told that every option must first survive a chain of institutional permissions will begin to understand that the system’s first duty is to itself. Once that culture becomes normal, no single villain is required. Everyone can behave properly, every form can be complete, every protocol can be followed, and the patient can still be abandoned. When healers become hostages to the system, healing becomes incidental.

Will We Follow the Same Leaders Again?

The first Humane Societies were created to rescue the apparently dead. Their founders refused to accept that stillness proved finality or that uncertainty justified inaction. They were not always right, but they were willing to learn, to correct themselves, and to keep responsibility close to the human being in danger. More than two centuries later, medicine needs to recover that same moral courage: the ability to distinguish standards from commandments, caution from paralysis, and regulation from wisdom.

A protocol can guide my hands, but it cannot carry my conscience. When a life is slipping away, the physician must still be permitted to think, to judge, and, when necessary, to refuse to stop trying.

If another pandemic arrives tomorrow, whom will we follow: the patient in front of us or the official who has never entered the room? Will we again allow fear to turn protocols into commandments, uncertainty into censorship, and experts into authorities who cannot be questioned? Will we repeat actions that make no clinical or human sense simply because the correct institution has ordered them?

The Humane Societies asked whether the apparently dead could be resuscitated. Our question is now more unsettling: can medicine recover its courage before its conscience is gone?

References

1. Sternbach GL, Varon J, Fromm RE Jr, Baskett PJF. The humane societies. Resuscitation. 2000;45(2):71-75. doi:10.1016/S0300-9572(00)00201-X.
2. McCabe C. The Humane Society Movement and the transnational exchange of medical knowledge in the late eighteenth and early nineteenth centuries. J R Coll Physicians Edinb. 2019;49(2):158-164. doi:10.4997/JRCPE.2019.218.
3. ProCESS Investigators. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370(18):1683-1693. doi:10.1056/NEJMoa1401602.
4. ARISE Investigators; ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014;371(16):1496-1506. doi:10.1056/NEJMoa1404380.
5. Mouncey PR, Osborn TM, Power GS, et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med. 2015;372(14):1301-1311. doi:10.1056/NEJMoa1500896.
6. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312(7023):71-72. doi:10.1136/bmj.312.7023.71.
7. Tobin MJ, Laghi F, Jubran A. Caution about early intubation and mechanical ventilation in COVID-19. Ann Intensive Care. 2020;10(1):78. doi:10.1186/s13613-020-00692-6.
8. Ehrmann S, Li J, Ibarra-Estrada M, et al. Awake prone positioning for COVID-19 acute hypoxaemic respiratory failure: a randomized, controlled, multinational, open-label meta-trial. Lancet Respir Med. 2021;9(12):1387-1395. doi:10.1016/S2213-2600(21)00356-8.
9. U.S. Food and Drug Administration. Right to Try [Internet]. Silver Spring (MD): FDA; 2024 [cited 2026 Sep 1].