Saving lives should not require permission

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.