Content Warning: mentions of assisted dying.
The couple sits across from me, her hand in his, and I ask myself if I have the strength to break their hearts. Her face hides nothing: tears already quiver, ready to fall no matter what I say. His fist rests on a rapidly bouncing knee.
I tear my eyes away from the screen.
“I’m so sorry. There is an incredibly high demand for fertility treatment. You aren’t eligible.”
What comes next is painful enough, but not for the first time, it strikes me that I’m more than just another stranger in their lives. I’m not the passerby walking carelessly through a family photo, nor the tiresome subject of a story they’ll tell over Christmas lunch. For the rest of their lives, they’ll remember my face, my words, on the day they learned they would never have children of their own.
I miss the days when a patient’s thrumming heartbeat or the whoosh of air in their lungs meant something. It is all about technology now. Someone who never set foot inside a hospital, who never saw the naked hope in a patient’s eyes, decided an advanced algorithm could determine a patient’s eligibility for treatment. All you need are their symptoms, medical history, and genetic profile.
But rising costs of healthcare mean more and more people are missing out.
And I’m the messenger.
Pa calls me on the train home, pulling me away from memories of strangled sobs and tear-stained shirts. His voice is weak.
“My belly’s killing me, son,” he mumbles. “And I can’t crap.”
“You’re constipated again. Did you take your laxatives?”
He sighs. “I must’ve forgotten. The pain’s too much these days.”
I know he’s not just talking about his belly. Two years ago, he tripped and fell down the stairs - often a death sentence for a frail ex-smoker in his mid-eighties. Instead, he somehow pulled through, even if he’s now dependent on a walking frame to get around.
Worst of all, the excruciating pain in his hip never went away. My Pa is a fighter, but he’s not too proud to call me in tears first thing in the morning, too stiff to get out of bed. Once, he pinched me hard on the arm, and when I yelped, he told me he felt that in his hip all the time.
The opioids and anti-inflammatories take the edge off, but they clog his bowels and space him out. I worry he’ll fall again. If he does, that’ll be the end of it.
“I know, Pa. The pain medication is your best bet. You aren’t eligible for surgery.”
“I just want the pain to stop. Can’t you rejig the algorithm or something?”
My silence is enough of an answer. He makes a noise that breaks my heart, sniffs, and hangs up.
A curious pair sits across from me today. She is over ninety and looks it: her skin is tinged yellow and thin as clingfilm, and her back is hunched almost ninety degrees. Even seated, she grips a wooden walking stick to keep herself steady. Yet, she is not the patient.
The elderly man sitting beside her in a wheelchair is her son. Seventy, and paraplegic. He is past the point of tears. He has a downcast look about him, as if he knows he’s the kind of patient the algorithm spits out and sticks under the table, discarded and forgotten.
“It starts in my hips,” he says, “then it spreads down both of my legs into my feet. Feels like I’m being electric-shocked. Stings something awful. Think I’m immune to the medication, doc. It doesn’t do nothing for the pain anymore.”
I nod sympathetically. “That sounds horrible. Yes, you are on the maximum dose. Unfortunately, the scans show that surgery is the only way to relieve your symptoms permanently.”
“Please, doc,” he whispers. “I don’t know how much more I can take. It’s too much.”
His words remind me of Pa. Chronic pain has a way of exhausting hope, and I wonder if there is any purpose in running the algorithm when we can all predict the outcome.
But before I can respond, his mother speaks up.
“I know what you’re gonna say. Time for the bloody algorithm,” she croaks. Her eyes fix on me defiantly, as if I've bullied her child at the playground.
The screen glows an upbeat green as it waits for me to enter his details. As with every patient, an analysis of his bloodwork has already been made. Once I enter the details of his pain, along with a list of medications he has trialled, the algorithm will estimate his potential surgical benefit, weighing this against the average score of other patients.
Unsurprisingly, paraplegia does his eligibility no favours.
I look back at them to begin my usual condolences, but something sticks the words in my throat. It could easily be my Pa sitting there without hope.
“Congratulations. You’re eligible,” I say. “I’ll have your surgery booked immediately.”
Their faces transform; the walking stick clatters to the floor as his mother almost leaps out of her seat to embrace him. Great, shuddering sobs wrack his body.
He spurs his wheelchair forward and takes my hand.
“Thank you, doc. This’ll change my life.”
I squeeze his hand back. “You deserve it.”
The algorithm doesn’t look kindly on disabled children. For a tool that is meant to be objective, it seems to share many of the biases of whoever created it - or perhaps those of society as a whole.
The child gamboling before me looks perfectly healthy for a six-year-old with Down Syndrome. Thus far, her development has followed the expected trajectory, and all of her vital signs are within normal parameters. All this despite the lump of cancer cells growing inside her brain.
“Why even run the algorithm?” her father asks. “She obviously needs surgery. You need to get that thing out.”
“It’s part of the healthcare protocol, sir. There’s a process that needs to be followed."
“Screw your protocols. My daughter has a brain tumour. You don’t need a fancy degree to figure out she needs surgery.”
“I’m sure she’ll be eligible,” I say truthfully. I don’t voice my suspicion she might be waiting months for her operation, given the absence of any major symptoms.
“Every minute we wait is a minute that thing’s inside her head, damaging her brain. I just want her to live a normal life. Please, do it quick.”
I run the algorithm. The green screen blinks, then flips to blue. The computer chimes a confirmation.
“She’s eligible,” I tell him.
“Good. How long?”
I click through several more screens. My heart sinks.
Preparing myself for a verbal onslaught - there is usually at least one per day - we lock eyes for a tense moment. But then he looks away and kneels next to his daughter, whispering something in her ear that makes her giggle. He strokes her hair and wipes his eyes with his shirtsleeve.
“Why be a doctor?” he says finally. “Why do this, if you can’t help people?”
I consider saying that I did help. That she is getting surgery. But I don’t, because I know those words are just as pointless as my condolences.
“There might be more I can do,” I say.
The child’s positive eligibility test has placed her on the waiting list for an operation. The eight-month timeframe is a guarantee, but if another patient loses their place, she could have surgery within a month. I enter her details, looking for a “less worthy” patient for her to replace.
Only one patient pops up.
A paraplegic man who was never meant to be eligible at all.
On the train ride home, when I should think of the ecstatic father bouncing up and down with his daughter on his shoulder, whooping and punching the air, instead I consider my Pa and people like him. The ones society always remembers last.
It’s been over a year, and my paraplegic patient is struggling. His pain is severe enough that he over-medicates himself in a futile effort to live a normal life. The electric shocks have spread into his arms, his fingers tingle, and his feet have permanent pins-and-needles.
I book him another appointment to deliver the news about his surgery. Before they even enter the room, I can hear dull, rhythmic thuds under the mechanical whir of his wheelchair, like a heartbeat trapped in a cage of machinery.
His mother leans heavier on her walking stick, but it is his appearance that affects me the most. His face is wan and sunken; devoid of colour. The pain has taken its toll.
“My boy’s still suffering. Why are we here?” she says without preamble.
My expression must have given it away, because he speaks first.
“Never getting surgery, am I?”
His voice is oddly changed, compared to his face. It’s stronger than before. More resolute.
I shake my head, unable to meet his eye. His mother glares at me. Her hand snakes across and rubs his shoulder.
“Then I’ve had enough,” he says.
“What?” she chokes out. Her attention shifts to him, and the hand holding her walking stick starts to tremble.
“Can you do the algorithm again, doc?” he pleads.
“It won’t change the result,” I reply.
“Not for the surgery. I told you the first time: it’s too much. Can’t live with it anymore. If you can’t fix it - if I can’t stop suffering - at least let me choose a quick, painless way to go. On my own terms.”
She's shaking her head now. She watches her son with an intensity I've never seen. As if she wants to memorise every last wrinkle on his face.
Two desperate pairs of eyes bore into me as I turn back to the computer. I imagine my Pa in such a position - confronting mortality. I wonder if he would look at me the same way.
Ignoring the lump in my throat, I run the algorithm again, this time for physician-assisted dying.
The green screen turns blue, chimes joyfully. Eligible.
He sighs in relief, all the air rushing out of him at once. A bit of colour returns to his face. For the first time in a year, he smiles.
“No,” his mother whimpers.
When their appointment ends twenty minutes later, she pauses at the door.
“Run along for a minute,” she sniffs to her son, waving a hand as if he’s five years old again. The whirring fades into the corridor.
“How can I help?” I ask, dreading the answer.
She blinks and looks up at me. “I’m ninety-four, dear. Everything hurts, and all of my senses are failing. There’s not much left to live for. Only him.”
“I see.” I’m already moving back to the computer.
She shuffles close behind, still sniffing. I sit down, open up her file, and enter in her details.
“Are you sure about this?”
Her eyes take on the glaze of long-held memory. There's the shadow of a smile.
“Yes. As sure as when I first wanted a child of my own.”
I run the algorithm, reminded of what it had once taken from a devastated couple in the same seat. I consider why an equation capable of denying new life can equally save it. How a system designed to preserve lives can easily take them.
And I ask myself if I still have the strength to bear the algorithm’s message.
It now deliberates the weight of one life - or two.
Green turns to blue.