The story, all names, characters, and incidents portrayed in this production are fictitious. No identification with actual persons (living or deceased), organizations, places, buildings, and products is intended or should be inferred.  The concepts, however, are all real.

The first weird thing about the donation to Nowheresville Hospital was the amount.  Well, the amount combined with the donor.  Five million dollars would normally be a sizeable though not groundbreaking donation to a hospital, but Bert Smith was a multibillonaire.  He could have added two zeros to get a new ward with his name splashed across it, and barely have noticed the dent in his finances.  Which led to the second weird thing: he'd asked to remain anonymous.  But the third thing was the weirdest.  He'd earmarked his donation for "whatever would do the most good," and left an email address to tell him what got picked and why.

Sheila looked at this and frowned in confusion.  She was the one in charge of the overall budget for Nowheresville Hospital.  She would have to allocate this donation and email Mr. Smith, in her very first year on the job.  And "whatever would do the most good" seemed like no earmark at all.  Wasn't the point of having a budget to allocate resources?  Wasn't the point of a hospital to do good, to save and improve lives?  But no matter how much she frowned, the facts remained the same.  There would be five million more dollars in this year's budget, and she was to decide where to put them.

She pulled up her provisional budget spreadsheet from yesterday; she'd been halfway done planning for the next fiscal year, perhaps she could just add to it?  But the more she went through the many departments and their requests, the more she wondered what would do the most good.  Every department had uses for more money, and every last request seemed like it would help patients.  How, then, was she to find out what would be best?

It would help to know how much good each option would do.  From that she could compare the options.  And that was something she could get information on!  If a particular type of life-saving surgery cost ten thousand dollars to perform and always worked, then five million dollars of funding towards those surgeries would save five hundred lives.  People made breakdowns of how much various medical interventions cost, and studied their success rates!  She dove into searching for data on potential lives saved by each request...

... only to discover that it wasn't that simple.  Many of the results weren't in simple "lives saved", but in QALYs and DALYs and other metrics, all trying to capture the idea that it was better for the person whose life was saved to continue living a long and healthy further life than to foreseeably wind up disabled or dead a year later.  The basic idea was so obviously correct that she chided herself for not seeing it - despite being trained in accounting and business rather than medicine - but the profusion of metrics seemed hopeless.  How was she to know which was the truest good, if any of them even were?

She set that question aside to think about after a lunch break and getting small, easy tasks out of the way.  An hour later, it occurred to her that "how should I measure doing good" was at least a reasonable question to ask Mr. Smith.   So she wrote a draft email in the polite-but-terse form she'd learned for dealing with important people, read it over three times the next morning, and took five deep breaths before finally hitting Send.

Two days later, she had a reply.

If we knew a One True Way to quantify the good or bad of an action, we wouldn't have so many metrics.  And our imperfect metrics are subject to Goodhart's Law - the more we use them to make decisions, the more they diverge from our intentions.

Blast!  So much for picking a metric and running the numbers.

But you're on the right track.  QALYs, DALYs, HLYs, ... all have a point, and none are useless.  Instead of giving you a metric, I'll give you some advice.

First off, don't worry about re-donating the money somewhere else.  If I wanted it to go to disease prevention in the developing world, extreme poverty, or any other cause, I would have donated it there.

But other than that, be open to ideas.  One hospital I donated to earlier used the money to overhaul their signage, helping their staff remember procedure checklists even under stress.  Another used it to improve their cafeteria, so patients struggling with the obvious hospital foods could still find nourishment.  It doesn't have to be given to a particular department or existing program.  In fact, it might be better used on something the existing programs have neglected.

And finally, don't let it swallow you.  It does no one any good if you don't put the money to use at all, or exhaust yourself.  Give yourself a week, if that fits your budget deadline, and then see how you feel about your ideas.


So.  On the one hand, thinking up neglected possibilities seemed much harder than considering requests in front of her.  On the other hand, she now had a clear stopping point.  Look for and think about ways Nowheresville Hospital could do more good for a week.  She couldn't guarantee perfection, but she could think.

A neglected opportunity would be exactly the sort of thing that didn't get lobbied for in political discussion or requested by a large department.  They wouldn't come knocking on her door, so she would have to go to them.

She double-checked that her calendar marked her as "busy" and left her office to walk through the hospital.  Seeing her own face blurred in the elevator doors reminded her that the patient-facing staff wouldn't recognize her.  She hadn't really met them.  Was that a bad thing?  Was she too out of touch?

There was a resident sleeping up ahead in the hallway, where none of the patients could see.  She'd heard of residency being an intensely overworked stage of medical training, but she'd never seen it before for herself.  Surely that couldn't be good for their rate of medical errors or their learning.  And while she couldn't overturn the structure of medical training all by herself, perhaps she could give them decent cots to sleep on as an interim measure.

Was the broken coffee maker leading staff to spend less time with patients?  Could the disease information pamphlets be rewritten to prevent common and dangerous misunderstandings?  Were elderly and disabled patients less likely to receive care in the first place due to poor transportation?  The more she looked, the more she saw things that maybe could be better now.  Potentially better places to put a lot more than just five million dollars...

Suddenly it felt wrong that so much of the budget was caught up in lobbying, earmarks, internal office politics, producing good press, producing warm fuzzy glows of helping, or simply doing what was done last year.  "Whatever would do the most good" should have been no earmark at all, and yet it wasn't.

When she returned to her desk, she threw out the half-finished budget and started over.

At the end of the week, she wrote another email; this time she didn't need five deep breaths before sending it.

I realized that I couldn't just look at how your donation would do the most good without looking at how the whole budget would do the most good.  There are a lot of constraints I can't change, but I was able to encourage and fund more effective plans than last year.  Your donation is going to kick off a new program to reduce accidental medication overdoses and missed doses, by sending patients home with pill boxes when we give them demanding medication schedules.

If you would indulge my curiosity, what made you choose to donate this way?

It led you to build your judgement, did it not?  That is worth every penny.


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