1 00:00:15,356 --> 00:00:22,436 Speaker 1: Pushkin from Pushkin Industries. This is Deep Background, the show 2 00:00:22,476 --> 00:00:25,476 Speaker 1: where we explore the stories behind the stories in the news. 3 00:00:25,916 --> 00:00:30,756 Speaker 1: I'm Noah Feldman. We're continuing our ongoing coverage of different 4 00:00:30,756 --> 00:00:36,276 Speaker 1: aspects of the coronavirus pandemic. Today, our topic is medical 5 00:00:36,356 --> 00:00:40,596 Speaker 1: ethics and how they apply in a crisis. There have 6 00:00:40,636 --> 00:00:43,116 Speaker 1: been reports of doctors in some countries around the world 7 00:00:43,196 --> 00:00:47,516 Speaker 1: having to ration care, including ventilators, for patients who are 8 00:00:47,516 --> 00:00:51,156 Speaker 1: sick with the coronavirus because they don't have sufficient supplies 9 00:00:51,436 --> 00:00:55,116 Speaker 1: to care for everyone. It looks at least possible that 10 00:00:55,156 --> 00:00:58,036 Speaker 1: the same thing could be happening here in the United States. 11 00:00:58,596 --> 00:01:02,036 Speaker 1: The situation is especially pressing in New York, where there 12 00:01:02,076 --> 00:01:04,876 Speaker 1: is a shortage of ventilators and where the possibility of 13 00:01:04,916 --> 00:01:09,996 Speaker 1: splitting ventilators has been considered by some hospitals. What happens 14 00:01:10,036 --> 00:01:12,996 Speaker 1: when hospitals have to decide who gets a ventilator and 15 00:01:13,036 --> 00:01:16,236 Speaker 1: who doesn't. What happens at the end of life, when 16 00:01:16,276 --> 00:01:18,956 Speaker 1: we're trying to figure out what sort of heroic measures 17 00:01:18,956 --> 00:01:21,156 Speaker 1: should be used to save people who are close to 18 00:01:21,236 --> 00:01:24,876 Speaker 1: dying from the coronavirus. To discuss these issues, I'm joined 19 00:01:24,916 --> 00:01:29,156 Speaker 1: today by doctor Lydia Dugdale. She's an Associate Professor of 20 00:01:29,196 --> 00:01:32,636 Speaker 1: medicine and director of the Center for Clinical Medical Ethics 21 00:01:32,676 --> 00:01:37,316 Speaker 1: at Columbia University. She's practicing medicine on the front lines 22 00:01:37,556 --> 00:01:40,516 Speaker 1: of this pandemic, both in the hospital and in the 23 00:01:40,556 --> 00:01:43,276 Speaker 1: temporary tent that Columbia University has set up in its 24 00:01:43,316 --> 00:01:46,956 Speaker 1: own parking lot to deal with the overload of Corona cases. 25 00:01:47,556 --> 00:01:50,436 Speaker 1: She's also the author of a forthcoming book, The Lost 26 00:01:50,596 --> 00:01:56,236 Speaker 1: Art of Dying. Lydia, thank you so much for joining me. 27 00:01:56,476 --> 00:01:59,916 Speaker 1: I wonder if we could begin by talking about something 28 00:01:59,956 --> 00:02:02,156 Speaker 1: that I think the whole world is focusing on now, 29 00:02:02,236 --> 00:02:05,756 Speaker 1: but that you do every day, and that is the 30 00:02:05,796 --> 00:02:11,316 Speaker 1: fundamentals of medical ethics. How do you go about thinking 31 00:02:11,356 --> 00:02:15,556 Speaker 1: in a systematic way about the rationing questions that may 32 00:02:15,596 --> 00:02:18,876 Speaker 1: not have quite yet emerged in the United States, but 33 00:02:19,036 --> 00:02:21,076 Speaker 1: which are on the edge of emerging, and which have 34 00:02:21,156 --> 00:02:25,356 Speaker 1: already emerged in lots of other countries. Medical ethics typically 35 00:02:25,396 --> 00:02:29,236 Speaker 1: focuses on the doctor patient relationship. That's really the core 36 00:02:29,756 --> 00:02:34,036 Speaker 1: of what we do in non crisis times. As such, 37 00:02:34,116 --> 00:02:38,916 Speaker 1: we tend to focus on principles of beneficence and non maleficence. 38 00:02:39,476 --> 00:02:44,956 Speaker 1: Beneficence is doing good for patience, and non maleficence is 39 00:02:45,316 --> 00:02:49,116 Speaker 1: not doing harm, So that's sort of that hippocratic It's 40 00:02:49,156 --> 00:02:52,956 Speaker 1: typically called the hippocratic idea of first doing no harm 41 00:02:52,996 --> 00:02:55,756 Speaker 1: to one's patience. So that's what we talk about in 42 00:02:56,356 --> 00:03:02,196 Speaker 1: non crisis times in medicine. However, with this current coronavirus pandemic, 43 00:03:02,836 --> 00:03:07,716 Speaker 1: we've shifted the current framing for medical ethics to more 44 00:03:07,836 --> 00:03:11,876 Speaker 1: of a public health fix, which takes into account different 45 00:03:12,076 --> 00:03:15,596 Speaker 1: principles and they're sort of a different framing for how 46 00:03:15,636 --> 00:03:19,476 Speaker 1: we think about decisions, and we tend to focus more 47 00:03:19,596 --> 00:03:22,276 Speaker 1: on a duty to care for everyone, so there's more 48 00:03:22,276 --> 00:03:26,276 Speaker 1: of a community bent to things. There is a commitment 49 00:03:26,276 --> 00:03:29,556 Speaker 1: to stewarding resources, this is what we've heard about a 50 00:03:29,556 --> 00:03:31,676 Speaker 1: lot in the media, making sure we have enough equipment. 51 00:03:32,156 --> 00:03:36,316 Speaker 1: There's certainly a duty to plan governments. Healthcare administrators are 52 00:03:36,316 --> 00:03:40,436 Speaker 1: expected to anticipate foreseeable crises and sort of come up 53 00:03:40,436 --> 00:03:42,956 Speaker 1: with a plan to respond to these. There's also a 54 00:03:42,996 --> 00:03:46,156 Speaker 1: commitment to distribute of justice, making sure that we have 55 00:03:46,276 --> 00:03:51,276 Speaker 1: allocation protocols in place that will meet the most needs 56 00:03:51,316 --> 00:03:54,476 Speaker 1: possible in a way that is most fair. And then, 57 00:03:54,476 --> 00:03:57,156 Speaker 1: of course transparency is fundamental to this. We want to 58 00:03:57,156 --> 00:03:58,996 Speaker 1: make sure that the public knows what we're doing in 59 00:03:59,036 --> 00:04:03,316 Speaker 1: these unique situations when everyone's already on edge. We want 60 00:04:03,316 --> 00:04:04,876 Speaker 1: to do everything we can to sort of shore up 61 00:04:04,916 --> 00:04:08,996 Speaker 1: public trust so that everyone knows that the healthcare system 62 00:04:09,356 --> 00:04:12,196 Speaker 1: and the policymakers still have their back and will really 63 00:04:12,236 --> 00:04:15,436 Speaker 1: work to prioritize their health and well being. Could we 64 00:04:15,556 --> 00:04:19,676 Speaker 1: drill down to what you called allocation protocols, which I'd 65 00:04:19,716 --> 00:04:21,996 Speaker 1: take it as a fancy way of saying who gets 66 00:04:22,036 --> 00:04:26,596 Speaker 1: which medical supplies or medical technologies when and products? The 67 00:04:26,596 --> 00:04:30,116 Speaker 1: allocation part and protocol implies that you'd have a kind 68 00:04:30,156 --> 00:04:32,876 Speaker 1: of model or an algorithm that you would follow in 69 00:04:32,876 --> 00:04:37,316 Speaker 1: individual instances. Now, those things are super tricky and they 70 00:04:37,356 --> 00:04:40,236 Speaker 1: require sort of unveiling a lot of the values that 71 00:04:40,276 --> 00:04:42,956 Speaker 1: you were talking about. So would you talk a little 72 00:04:42,996 --> 00:04:45,996 Speaker 1: bit about how you think about allocation protocols. Let's use 73 00:04:46,036 --> 00:04:50,836 Speaker 1: an example that's really concrete, the example of ventilators. So, 74 00:04:50,956 --> 00:04:53,636 Speaker 1: hospitals all over the country right now and over the 75 00:04:53,716 --> 00:04:57,156 Speaker 1: last few weeks have been debating how to handle the 76 00:04:57,156 --> 00:05:01,316 Speaker 1: possibility of a ventilator shortage. It's worth pointing out, though, 77 00:05:01,356 --> 00:05:04,956 Speaker 1: that perhaps more than an actual ventilator shortage. There's a 78 00:05:04,996 --> 00:05:08,636 Speaker 1: concern that we would have a shortage of healthcare personnel, 79 00:05:08,676 --> 00:05:12,716 Speaker 1: particularly respiratory therapists and critical care doctors who know how 80 00:05:12,716 --> 00:05:18,276 Speaker 1: to manage these very complex and sophisticated devices. However, having 81 00:05:18,316 --> 00:05:22,516 Speaker 1: said that, assuming that there is a ventilator shortage or 82 00:05:22,516 --> 00:05:25,956 Speaker 1: that there will be one, hospitals are trying to figure 83 00:05:25,956 --> 00:05:28,996 Speaker 1: out what is the best way to make sure that 84 00:05:29,036 --> 00:05:33,236 Speaker 1: we save the most lives possible. That's really the driving 85 00:05:33,316 --> 00:05:37,316 Speaker 1: question here. And even though there has been certainly a 86 00:05:37,356 --> 00:05:41,396 Speaker 1: lot of concern expressed that these allocation principles are going 87 00:05:41,436 --> 00:05:46,236 Speaker 1: to cut off the elderly or not serve those with disabilities, 88 00:05:46,556 --> 00:05:51,236 Speaker 1: that's not at all the aim of these allocation protocols. 89 00:05:51,276 --> 00:05:54,836 Speaker 1: In New York State, for example, there was put forward 90 00:05:54,876 --> 00:05:57,956 Speaker 1: in twenty fifteen by the New York State Department of 91 00:05:57,996 --> 00:06:02,556 Speaker 1: Health allocation guidelines for ventilators in the event of a 92 00:06:02,596 --> 00:06:06,116 Speaker 1: flu epidemic. New York was trying to anticipate how they 93 00:06:06,116 --> 00:06:08,236 Speaker 1: would meet the needs of New Yorkers, particularly in this 94 00:06:08,556 --> 00:06:12,076 Speaker 1: congested urban area, if flu were to sort of go haywire, 95 00:06:12,716 --> 00:06:15,476 Speaker 1: and a lot of hospitals around the country currently have 96 00:06:15,716 --> 00:06:19,476 Speaker 1: looked back to those twenty fifteen guidelines as a starting point, 97 00:06:19,796 --> 00:06:22,316 Speaker 1: and there are other other similar guidelines out there, so 98 00:06:22,356 --> 00:06:26,196 Speaker 1: we're sort of wrestling with these and then applying them 99 00:06:26,396 --> 00:06:30,236 Speaker 1: to COVID. So, of course, coronavirus and the way it's 100 00:06:30,276 --> 00:06:32,996 Speaker 1: playing out does not look exactly like influenza in a 101 00:06:33,036 --> 00:06:36,996 Speaker 1: typical season, so we're having to adapt these guidelines. The 102 00:06:37,036 --> 00:06:40,436 Speaker 1: formula that you used was the goal of saving the 103 00:06:40,436 --> 00:06:44,356 Speaker 1: most lives possible, and I guess what I want to 104 00:06:44,356 --> 00:06:47,636 Speaker 1: ask you about is if we really are committed to 105 00:06:47,636 --> 00:06:50,436 Speaker 1: saving the most lives possible, then our protocol is presumably 106 00:06:50,476 --> 00:06:53,956 Speaker 1: going to ask how likely is this person to survive 107 00:06:54,436 --> 00:06:58,636 Speaker 1: if given the scarce ventilator, and if you're younger and healthier, 108 00:06:59,236 --> 00:07:03,196 Speaker 1: that probably on the whole enhances your chances of surviving. 109 00:07:03,876 --> 00:07:06,996 Speaker 1: What's your view about how we should think that through. 110 00:07:07,556 --> 00:07:10,516 Speaker 1: So the score that a lot of us are looking at, 111 00:07:10,716 --> 00:07:14,156 Speaker 1: or at least studying and considering, is something called the 112 00:07:14,156 --> 00:07:19,276 Speaker 1: SOFA score. SOFA it stands for the Sequential organ Failure Assessment, 113 00:07:19,796 --> 00:07:23,116 Speaker 1: and this is a score interestingly that doesn't take age 114 00:07:23,236 --> 00:07:27,596 Speaker 1: into account, but it does take into account the health 115 00:07:27,956 --> 00:07:31,596 Speaker 1: of six organ systems. So the SOFA score looks at 116 00:07:31,636 --> 00:07:34,756 Speaker 1: the lungs, the heart, the kidneys, the liver, the brain, 117 00:07:34,956 --> 00:07:39,396 Speaker 1: particularly with regard to mental status, how alert is an individual, 118 00:07:39,636 --> 00:07:42,796 Speaker 1: and also blood clotting, so you know, doctors will call 119 00:07:42,796 --> 00:07:46,396 Speaker 1: this the hematologic system. So the SOFA score takes into 120 00:07:46,396 --> 00:07:50,156 Speaker 1: account that the healthy functioning or lack of health of 121 00:07:50,196 --> 00:07:54,876 Speaker 1: these six organs, which in times of severe infection what 122 00:07:54,956 --> 00:07:59,156 Speaker 1: we might call sepsis, we often see a sequential failing 123 00:07:59,396 --> 00:08:02,956 Speaker 1: of these organs. And then we look at these triage 124 00:08:03,396 --> 00:08:06,036 Speaker 1: sort of allocation guidelines tend to look at the SOFA 125 00:08:06,036 --> 00:08:10,996 Speaker 1: score how it changes over time. So if a SOFA 126 00:08:11,036 --> 00:08:15,756 Speaker 1: score gets progressively worse day after day after day, that 127 00:08:15,836 --> 00:08:19,556 Speaker 1: trajectory tends to be only in one direction. Now, if 128 00:08:19,556 --> 00:08:22,876 Speaker 1: a SOFA score starts to show improvements, then we think 129 00:08:22,876 --> 00:08:25,676 Speaker 1: differently about an individual patient. So as you say, the 130 00:08:25,796 --> 00:08:29,916 Speaker 1: SOFA analysis doesn't mention age, it's not listed as a 131 00:08:29,956 --> 00:08:33,236 Speaker 1: consideration there. And I guess I have two questions about that. 132 00:08:33,316 --> 00:08:36,316 Speaker 1: One is if you had two identically placed patients with 133 00:08:36,356 --> 00:08:39,596 Speaker 1: respect to SOFA, but they were very disjunct with respect 134 00:08:39,636 --> 00:08:42,116 Speaker 1: to age. You know, one was I don't know, a 135 00:08:42,116 --> 00:08:44,836 Speaker 1: healthy eighteen year old and the other was a healthy 136 00:08:44,956 --> 00:08:48,276 Speaker 1: for their age. But you know, eighty year old under 137 00:08:48,436 --> 00:08:50,916 Speaker 1: current protocols, would that mean that you would not be 138 00:08:50,996 --> 00:08:54,396 Speaker 1: able to have a preference for the eighteen year old 139 00:08:54,436 --> 00:08:56,036 Speaker 1: over the seventy year old or the eighty year old 140 00:08:56,316 --> 00:08:58,716 Speaker 1: simply because it's not in the sofa score. Or do 141 00:08:58,796 --> 00:09:01,476 Speaker 1: you use the sofa score in a flexible way where 142 00:09:01,516 --> 00:09:03,116 Speaker 1: if sofas are equal, and then you have to make 143 00:09:03,156 --> 00:09:07,156 Speaker 1: an allocation decision, you could then consider other factors. The 144 00:09:07,236 --> 00:09:10,916 Speaker 1: New York State guidelines from twenty fifteen, the only look 145 00:09:10,956 --> 00:09:14,236 Speaker 1: to age as a tiebreaker if it's a child versus 146 00:09:14,236 --> 00:09:17,076 Speaker 1: an adult, that's the only time. And they do that. 147 00:09:17,116 --> 00:09:20,556 Speaker 1: They base those guidelines on our societal preference for caring 148 00:09:20,596 --> 00:09:24,476 Speaker 1: for children. If it's two adults with equal sofa scores 149 00:09:24,556 --> 00:09:26,836 Speaker 1: and equal need let's say, and let's say it's not 150 00:09:26,836 --> 00:09:30,236 Speaker 1: even removal, but it's just applying a ventilator and there's 151 00:09:30,276 --> 00:09:33,676 Speaker 1: only one ventilator left, then it's a lottery system according 152 00:09:33,676 --> 00:09:36,716 Speaker 1: to these New York State guidelines. Again, every hospital is 153 00:09:36,716 --> 00:09:39,356 Speaker 1: adapting these guidelines slightly differently. I think a lot of 154 00:09:39,356 --> 00:09:41,436 Speaker 1: the protocols are going to end up being quite similar, 155 00:09:41,476 --> 00:09:45,556 Speaker 1: and there are efforts underway to study these nationwide. But 156 00:09:45,676 --> 00:09:48,556 Speaker 1: I think most people are loath to sort of make 157 00:09:48,596 --> 00:09:51,356 Speaker 1: a strict age cut off and say or not even 158 00:09:51,356 --> 00:09:53,636 Speaker 1: a cutoff, but to just say the older person should 159 00:09:53,676 --> 00:09:56,276 Speaker 1: not get it and the younger person should get it. So, 160 00:09:56,316 --> 00:09:57,916 Speaker 1: like I said, a lot of the preference is often 161 00:09:57,916 --> 00:10:00,636 Speaker 1: given to children. Otherwise it tends to be a lottery system. 162 00:10:01,436 --> 00:10:03,716 Speaker 1: Some of the state protocols, as reported and as they 163 00:10:03,756 --> 00:10:05,876 Speaker 1: appear to be written, and I'm thinking of the Alabamber 164 00:10:05,916 --> 00:10:10,596 Speaker 1: Procolling particular, seemed to say that people certain severe disabilities 165 00:10:10,996 --> 00:10:14,476 Speaker 1: would be lower on an allocation list. Where does that 166 00:10:14,516 --> 00:10:18,556 Speaker 1: fit within sort of standard good medical medical ethics. I 167 00:10:18,596 --> 00:10:22,156 Speaker 1: suppose I would have to know what you mean by disabilities. 168 00:10:22,756 --> 00:10:26,996 Speaker 1: So many of the protocols do have exclusion criteria. There 169 00:10:27,036 --> 00:10:32,996 Speaker 1: are particular illnesses that we specify, and if patients came 170 00:10:33,036 --> 00:10:36,116 Speaker 1: in with those illnesses, we would not allocate a ventilator 171 00:10:36,156 --> 00:10:40,956 Speaker 1: to them. But the exclusion criteria that most commonly are 172 00:10:41,036 --> 00:10:46,236 Speaker 1: discussed our exclusion that suggests that death is imminent. So, 173 00:10:46,316 --> 00:10:50,276 Speaker 1: for example, a person comes in with a severe bleed 174 00:10:50,396 --> 00:10:55,196 Speaker 1: in the brain that almost certainly will cause death, such 175 00:10:55,236 --> 00:10:57,796 Speaker 1: a person would not be given a ventilator according to 176 00:10:57,836 --> 00:11:03,036 Speaker 1: these allocation guidelines in crisis situations because death is imminent, 177 00:11:03,716 --> 00:11:06,716 Speaker 1: So the exclusion criteria that are most commonly used are 178 00:11:06,756 --> 00:11:10,036 Speaker 1: ones that really are quite close to the point of death. 179 00:11:10,316 --> 00:11:12,396 Speaker 1: So the language that they used, I'm quoting from the 180 00:11:12,396 --> 00:11:16,276 Speaker 1: Alabama protocol here. There are some patients for whom the 181 00:11:16,276 --> 00:11:20,036 Speaker 1: possible should not offer mechanical ventilator support, and those include 182 00:11:20,036 --> 00:11:22,956 Speaker 1: heart failure, respiratory failure, metastatic cancer. So that fits what 183 00:11:22,996 --> 00:11:26,396 Speaker 1: you're describing. And then it also says that quote persons 184 00:11:26,396 --> 00:11:31,076 Speaker 1: with severe mental rechardation, advanced dementia, or severe traumatic brain 185 00:11:31,156 --> 00:11:35,396 Speaker 1: injury may be poor candidates for ventilator support. So it's written, 186 00:11:35,716 --> 00:11:39,516 Speaker 1: you know, it's not written as mandatory. It's maybe poor candidates. 187 00:11:40,156 --> 00:11:43,276 Speaker 1: And maybe if you have advanced dementia, that's highly probable 188 00:11:43,276 --> 00:11:45,956 Speaker 1: that you will die sooner, and so perhaps that's an explanation, 189 00:11:45,996 --> 00:11:49,156 Speaker 1: and ditto for traumatic brain injury. I suppose the language 190 00:11:49,156 --> 00:11:52,636 Speaker 1: that motivated the disability rights advocates to bring a complaint 191 00:11:53,276 --> 00:11:57,996 Speaker 1: was the formulation that says persons with severe mental rechardation. Yeah, 192 00:11:58,036 --> 00:12:00,076 Speaker 1: I think many of us are very uncomfortable with that 193 00:12:00,196 --> 00:12:02,756 Speaker 1: sort of an assertion. The criteria of most hospitals with 194 00:12:02,796 --> 00:12:06,356 Speaker 1: which I'm familiar is not to look at specific aspects 195 00:12:06,436 --> 00:12:11,236 Speaker 1: of mental ability, cognitive ability and even know what you're 196 00:12:11,236 --> 00:12:13,716 Speaker 1: saying about dementia. Dementia is a disease that easily last 197 00:12:13,796 --> 00:12:16,796 Speaker 1: ten years, So we have to be careful about how 198 00:12:16,796 --> 00:12:20,476 Speaker 1: we use these terms. And that's why many hospitals are 199 00:12:20,516 --> 00:12:22,716 Speaker 1: most comfortable with when we know death is imminent. This 200 00:12:22,756 --> 00:12:25,236 Speaker 1: person is really going to die within hours. Those are 201 00:12:25,236 --> 00:12:28,796 Speaker 1: the people that in times of crisis, we would consider 202 00:12:28,836 --> 00:12:33,436 Speaker 1: withholding ventilators from if there were a ventilator shortage. We'll 203 00:12:33,476 --> 00:12:45,156 Speaker 1: be back in just a moment. May ask you the 204 00:12:45,516 --> 00:12:49,836 Speaker 1: difference from the standpoint of standard medical ethics between removing 205 00:12:49,956 --> 00:12:54,796 Speaker 1: someone from a ventilator in order to enable another person 206 00:12:54,836 --> 00:12:59,756 Speaker 1: to have that ventilator, as opposed to allocating that ventilator 207 00:12:59,836 --> 00:13:02,876 Speaker 1: in the first instance to somebody on the basis of 208 00:13:02,916 --> 00:13:05,716 Speaker 1: criteria that are in a protocol. Do you see those 209 00:13:05,716 --> 00:13:09,876 Speaker 1: two things typically as different in some important way or 210 00:13:09,916 --> 00:13:15,476 Speaker 1: do you think of them is basically equivalent ethically and morally. 211 00:13:15,916 --> 00:13:19,796 Speaker 1: The arguments that are typically used is that they are 212 00:13:19,836 --> 00:13:25,876 Speaker 1: the same emotionally, they are hugely different, and the idea 213 00:13:25,876 --> 00:13:29,116 Speaker 1: of removing a ventilator for both a patient's family and 214 00:13:29,236 --> 00:13:32,516 Speaker 1: for the treating team, the medical doctors. It takes an 215 00:13:32,636 --> 00:13:37,156 Speaker 1: enormous emotional toll, which is why most people right now 216 00:13:37,156 --> 00:13:39,756 Speaker 1: with this coronavirus pandemic want to try to avoid doing 217 00:13:39,796 --> 00:13:42,996 Speaker 1: that no matter what, because there's already enough moral distress. 218 00:13:43,596 --> 00:13:46,076 Speaker 1: It's already difficult enough. The last thing we want to 219 00:13:46,076 --> 00:13:49,156 Speaker 1: do is add to that by removing patients from ventilators. 220 00:13:49,356 --> 00:13:51,356 Speaker 1: So the sort of the better move is to try 221 00:13:51,356 --> 00:13:54,836 Speaker 1: to allocate them up front. Right, So, going back to 222 00:13:54,876 --> 00:13:57,756 Speaker 1: the sofa scores that we discussed earlier in this conversation, 223 00:13:58,596 --> 00:14:02,556 Speaker 1: the only sofa scores again, in many of these triage protocols, 224 00:14:02,556 --> 00:14:04,956 Speaker 1: I can't speak for all, the only sofa scores that 225 00:14:06,596 --> 00:14:11,036 Speaker 1: those having to allocate ventilator would rely upon. Our sofa 226 00:14:11,076 --> 00:14:15,436 Speaker 1: scores that show progressive worsening. Anyone who is sort of 227 00:14:15,636 --> 00:14:19,916 Speaker 1: holding his or her own or showing any evidence of improvement, 228 00:14:19,956 --> 00:14:22,676 Speaker 1: there would never be any consideration given to removing a 229 00:14:22,756 --> 00:14:25,476 Speaker 1: ventilator from that person. And if you push me further 230 00:14:25,516 --> 00:14:27,876 Speaker 1: and you say, well, still, what if what if we 231 00:14:27,916 --> 00:14:31,876 Speaker 1: get to the point where all ventilators are allocated, everyone 232 00:14:32,156 --> 00:14:35,516 Speaker 1: who is failing, you know, has died and the only 233 00:14:35,516 --> 00:14:37,916 Speaker 1: people left on ventilators are people who are sort of 234 00:14:37,916 --> 00:14:41,236 Speaker 1: holding their own or improving, and still someone comes in 235 00:14:41,316 --> 00:14:44,516 Speaker 1: who needs one, then it's probably going to revert to 236 00:14:44,556 --> 00:14:48,196 Speaker 1: a first come, first serve scenario because there's no other option. 237 00:14:48,276 --> 00:14:51,116 Speaker 1: We're not going to cut short someone's life who is 238 00:14:51,116 --> 00:14:54,196 Speaker 1: a possibility of life in order to give someone else 239 00:14:54,236 --> 00:14:57,076 Speaker 1: a possibility of life. That just wouldn't That wouldn't be right, 240 00:14:57,076 --> 00:15:00,596 Speaker 1: and no one, no one would be comfortable with that. Again, 241 00:15:00,636 --> 00:15:02,836 Speaker 1: that the idea is to help as many people as 242 00:15:02,876 --> 00:15:05,556 Speaker 1: possible and to save as many lives as possible, not 243 00:15:05,796 --> 00:15:09,636 Speaker 1: in any way to jeopardize someone's life. That that's never 244 00:15:09,676 --> 00:15:12,836 Speaker 1: the goal. So the first in time rule, which is 245 00:15:12,876 --> 00:15:16,436 Speaker 1: really a luck rule, would then kick in as well, 246 00:15:16,476 --> 00:15:19,636 Speaker 1: because we don't have anything better to do at that point. Yeah, Frankly, 247 00:15:19,676 --> 00:15:22,276 Speaker 1: I don't know that you know the protocols get to 248 00:15:22,356 --> 00:15:24,476 Speaker 1: that level. I think you know there are so many 249 00:15:25,076 --> 00:15:28,516 Speaker 1: patients in any given hospital on any day that are 250 00:15:28,676 --> 00:15:32,516 Speaker 1: languishing on a ventilator that are not showing improvement, and 251 00:15:32,636 --> 00:15:37,836 Speaker 1: it's it's specifically because everyone holds out hope and frankly, 252 00:15:37,876 --> 00:15:41,396 Speaker 1: as I've written about, don't want to have to face 253 00:15:41,516 --> 00:15:44,476 Speaker 1: mortality that we often keep trying. We keep trying and 254 00:15:44,556 --> 00:15:48,076 Speaker 1: keep trying. That's sort of the way that we've all 255 00:15:48,116 --> 00:15:52,476 Speaker 1: been socialized, both physicians and Americans. Can I just ask 256 00:15:52,516 --> 00:15:56,636 Speaker 1: you about ventilator splitting, which you know we're not there yet, 257 00:15:56,676 --> 00:16:00,116 Speaker 1: but again, it seems like one of the possible responses 258 00:16:00,676 --> 00:16:04,276 Speaker 1: Leaving aside the technology of whether it's doable, does it 259 00:16:04,356 --> 00:16:08,636 Speaker 1: strike you as problematic from an ethical perspective? Where is 260 00:16:08,636 --> 00:16:11,596 Speaker 1: it simply a matter of the probabilities it's more likely 261 00:16:11,596 --> 00:16:13,556 Speaker 1: to help the people than just helping one of them, 262 00:16:13,876 --> 00:16:16,436 Speaker 1: We should take a crack at it. Sure. I mean, 263 00:16:16,516 --> 00:16:19,796 Speaker 1: it's been reported in the New York Times that Columbia 264 00:16:19,836 --> 00:16:26,396 Speaker 1: Presbyterian pioneered this, So it's definitely doable. It's enormously complex, 265 00:16:26,916 --> 00:16:29,596 Speaker 1: much more difficult cult than having a single patient on 266 00:16:29,716 --> 00:16:34,316 Speaker 1: event later, but it works and if it comes to 267 00:16:34,356 --> 00:16:38,076 Speaker 1: that we can do that. It's possible. It wouldn't automatically 268 00:16:38,076 --> 00:16:42,396 Speaker 1: double the number of ventilators that we have because patients 269 00:16:42,436 --> 00:16:46,516 Speaker 1: have to have similar needs, because they share single United 270 00:16:46,596 --> 00:16:50,956 Speaker 1: ventilator settings which are highly tailored to each individual patients. 271 00:16:50,996 --> 00:16:54,476 Speaker 1: So there are a lot of factors that would need 272 00:16:54,516 --> 00:16:57,076 Speaker 1: to be tailored. There but it would certainly increase our 273 00:16:57,156 --> 00:16:59,996 Speaker 1: ventilator capacity if it came to that. Can I ask 274 00:17:00,036 --> 00:17:02,796 Speaker 1: you what are you seeing? I mean, what are the 275 00:17:02,876 --> 00:17:06,596 Speaker 1: ethical issues that ethicis are most pressed about right now 276 00:17:06,636 --> 00:17:08,916 Speaker 1: that you are most pressed about right now? What are 277 00:17:08,916 --> 00:17:12,156 Speaker 1: the challenges that you've seen that are uncertain where it's 278 00:17:12,156 --> 00:17:13,636 Speaker 1: not so simple just to say, well, we know what 279 00:17:13,716 --> 00:17:15,676 Speaker 1: to think about this because we have a protocol in place. 280 00:17:16,436 --> 00:17:19,516 Speaker 1: The question of whether to resuscitate a particular patient is 281 00:17:19,556 --> 00:17:22,316 Speaker 1: really on a lot of people's minds. Some of the 282 00:17:22,396 --> 00:17:27,556 Speaker 1: arguments against that are that resuscitation is very, very messy, 283 00:17:28,076 --> 00:17:32,996 Speaker 1: and it leads to body fluids and aerosolization, which is 284 00:17:32,996 --> 00:17:35,476 Speaker 1: where the virus goes into the air and spreads everywhere, 285 00:17:35,836 --> 00:17:39,836 Speaker 1: and so it significantly increases the amount of virus that's 286 00:17:39,916 --> 00:17:44,636 Speaker 1: around and infectious and able to make the healthcare worker sick. 287 00:17:45,116 --> 00:17:49,156 Speaker 1: Any resuscitation attempt requires an enormous team size and a 288 00:17:49,156 --> 00:17:52,436 Speaker 1: lot of personal protective equipment. The so called ppe that 289 00:17:52,996 --> 00:17:56,036 Speaker 1: everyone has heard that there's been a shortage of so 290 00:17:56,396 --> 00:18:00,516 Speaker 1: between the risk and the danger of it, the fact 291 00:18:00,516 --> 00:18:02,836 Speaker 1: that we've already stopped doing a lot of procedures in 292 00:18:02,836 --> 00:18:05,196 Speaker 1: the hospital in this current moment that lead to this 293 00:18:05,276 --> 00:18:08,516 Speaker 1: aerosolization of the virus. A lot of people feel that 294 00:18:08,556 --> 00:18:13,236 Speaker 1: we should not be doing CPR. Some people feel that 295 00:18:13,396 --> 00:18:19,196 Speaker 1: no patient with coronavirus should have resuscitation. In my view 296 00:18:19,236 --> 00:18:21,796 Speaker 1: and in the view of many many ethicis that is 297 00:18:21,956 --> 00:18:26,036 Speaker 1: far too extreme. Certainly, we're having patients come in who 298 00:18:26,276 --> 00:18:31,276 Speaker 1: could easily be resuscitated with good outcomes, and so I 299 00:18:31,316 --> 00:18:36,476 Speaker 1: would be very uncomfortable with a blanket restriction on resuscitating 300 00:18:36,596 --> 00:18:40,036 Speaker 1: anyone who walks in with coronavirus. Having said that, it's 301 00:18:40,076 --> 00:18:45,716 Speaker 1: not uncommon for patients with coronavirus to have a cardiac arrest, 302 00:18:45,836 --> 00:18:49,836 Speaker 1: meaning their heart stops and they die for a successful 303 00:18:50,076 --> 00:18:54,396 Speaker 1: resuscitation attempt, and then for a repeat cardiac arrest, so 304 00:18:54,436 --> 00:18:56,996 Speaker 1: they die again. That's something we're seeing quite a bit. 305 00:18:57,636 --> 00:19:01,316 Speaker 1: And many people feel that if a patient is dying again, 306 00:19:02,156 --> 00:19:04,116 Speaker 1: even though we've tried to bring them back, but they 307 00:19:04,156 --> 00:19:07,196 Speaker 1: die again rather imminently, that this is someone who does 308 00:19:07,236 --> 00:19:12,356 Speaker 1: not show long term good odds for survival. This question 309 00:19:12,476 --> 00:19:15,916 Speaker 1: is probably more pressing right now for doctors on the 310 00:19:15,956 --> 00:19:19,476 Speaker 1: front lines than even the question of ventilater allocation. That's 311 00:19:19,516 --> 00:19:21,716 Speaker 1: completely fascinating, and I will say I think it's almost 312 00:19:21,756 --> 00:19:24,756 Speaker 1: completely underreported. You said that you think it's too extreme 313 00:19:24,916 --> 00:19:30,596 Speaker 1: to say, given those risks, we shouldn't resuscitate people who 314 00:19:30,596 --> 00:19:34,116 Speaker 1: have cardiac arrest on corona the first time at least why. 315 00:19:34,196 --> 00:19:36,236 Speaker 1: I mean, the risk is not only to the people 316 00:19:36,276 --> 00:19:39,116 Speaker 1: in the room, that's the healthcare workers, but it's also 317 00:19:39,116 --> 00:19:41,676 Speaker 1: to everybody else in the hospital, because once i'm these aerosolis, 318 00:19:41,716 --> 00:19:44,356 Speaker 1: you don't have a perfect seal around the hospital rooms. 319 00:19:44,516 --> 00:19:47,836 Speaker 1: I mean, it's you're creating a huge externalized risk for 320 00:19:47,916 --> 00:19:51,996 Speaker 1: everybody else. And if resuscitation has a high probability of 321 00:19:51,996 --> 00:19:54,756 Speaker 1: working in the individual case, and yet we know that 322 00:19:54,836 --> 00:19:57,836 Speaker 1: it often doesn't last in other words, that people then 323 00:19:57,916 --> 00:20:00,996 Speaker 1: have to they die again, it seems like a perfect 324 00:20:00,996 --> 00:20:03,996 Speaker 1: case to say, well, gee, we're just not going to 325 00:20:04,036 --> 00:20:06,876 Speaker 1: do it under these circumstances. What am I missing there? 326 00:20:07,676 --> 00:20:09,996 Speaker 1: So you're missing the forty year old who comes in 327 00:20:09,996 --> 00:20:13,236 Speaker 1: with a heart attack, which still happens, and hospitals are 328 00:20:13,276 --> 00:20:15,356 Speaker 1: testing patients as they walk in the door, and he's 329 00:20:15,396 --> 00:20:18,436 Speaker 1: COVID positive and he has a cardiac arrest in the 330 00:20:18,516 --> 00:20:23,116 Speaker 1: emergency room. Do you not resuscitate him because he's not 331 00:20:23,196 --> 00:20:25,676 Speaker 1: dying of the coronavirus. He's dying of a heart attack, 332 00:20:25,876 --> 00:20:27,716 Speaker 1: that's right. What we don't want to do is get 333 00:20:27,716 --> 00:20:30,876 Speaker 1: the black X on people's names because they have coronavirus 334 00:20:30,956 --> 00:20:34,316 Speaker 1: when they would be so easy to resuscitate them. I see. 335 00:20:34,316 --> 00:20:36,796 Speaker 1: So what you're really describing is maybe there should be 336 00:20:37,596 --> 00:20:40,436 Speaker 1: pulling back on resuscitating people who are dying of the 337 00:20:40,476 --> 00:20:45,916 Speaker 1: coronavirus and are probably going to die again after being resuscitated. 338 00:20:46,076 --> 00:20:47,556 Speaker 1: I don't know that I'd want to go on record 339 00:20:47,596 --> 00:20:50,316 Speaker 1: as saying I'm advocating for it, but I will definitely 340 00:20:50,356 --> 00:20:51,916 Speaker 1: go on record as saying this is something people are 341 00:20:51,956 --> 00:20:54,276 Speaker 1: very concerned about right now. It's one of the top 342 00:20:54,316 --> 00:20:58,876 Speaker 1: ethical issues we're debating in a book. You actually opened 343 00:20:58,916 --> 00:21:01,676 Speaker 1: your book with a kind of a graphic, if I 344 00:21:01,716 --> 00:21:04,956 Speaker 1: may say so, a description of a resuscitation in a 345 00:21:04,956 --> 00:21:08,396 Speaker 1: pretty standard case. This is not a coronavirus situation, And 346 00:21:08,556 --> 00:21:11,436 Speaker 1: the strong takeaway for the reader is that we do 347 00:21:11,516 --> 00:21:15,556 Speaker 1: this much, much too much. Anyway, Does that affect you're 348 00:21:15,596 --> 00:21:18,676 Speaker 1: thinking about this situation at all. The whole way that 349 00:21:18,716 --> 00:21:22,556 Speaker 1: the coronavirus pandemic has been discussed has been a focus 350 00:21:22,636 --> 00:21:28,876 Speaker 1: on delaying death, and there's been very little reported about 351 00:21:28,876 --> 00:21:32,316 Speaker 1: how we should actually use this as an opportunity to 352 00:21:32,356 --> 00:21:35,556 Speaker 1: think about our mortality and start to get our advanced 353 00:21:35,596 --> 00:21:37,756 Speaker 1: directives in order, and not to mention all the other 354 00:21:37,796 --> 00:21:41,596 Speaker 1: documents and share our passwords with our significant others. Things 355 00:21:41,596 --> 00:21:43,636 Speaker 1: like that. That's not so much a part of the 356 00:21:43,636 --> 00:21:47,236 Speaker 1: conversation right now. So, yes, I've reflected on my book 357 00:21:47,356 --> 00:21:51,836 Speaker 1: a lot. I do think people would die much better 358 00:21:51,916 --> 00:21:54,556 Speaker 1: deaths if they had a lot more preparation and if 359 00:21:54,556 --> 00:21:59,356 Speaker 1: they started preparing now rather than waiting until they're sitting 360 00:21:59,396 --> 00:22:03,156 Speaker 1: in the emergency room with coronavirus or whatever other disease. 361 00:22:03,916 --> 00:22:07,156 Speaker 1: Because this coronavirus pandemic too shall pass, but there will 362 00:22:07,196 --> 00:22:10,636 Speaker 1: be something else for all of us. Moves us to 363 00:22:10,676 --> 00:22:14,036 Speaker 1: think about these things now and to plan for them. 364 00:22:15,436 --> 00:22:19,876 Speaker 1: One last question about their resuscitation issue. If a decision 365 00:22:19,916 --> 00:22:24,076 Speaker 1: were taken on, for example, not resuscitating some people who 366 00:22:24,076 --> 00:22:27,276 Speaker 1: are close to dying from coronavirus, would that be a 367 00:22:27,276 --> 00:22:30,196 Speaker 1: decision that was taken at individual hospital levels, would it 368 00:22:30,196 --> 00:22:33,676 Speaker 1: be taken at statewide levels? Would it be a federal decision? 369 00:22:33,756 --> 00:22:38,236 Speaker 1: How do the mechanics of implementing an ethical intuition like 370 00:22:38,316 --> 00:22:41,436 Speaker 1: that work themselves out in the real world, most of 371 00:22:41,476 --> 00:22:44,516 Speaker 1: them are at hospital levels. I was on a call 372 00:22:44,596 --> 00:22:47,556 Speaker 1: with an ethesis from California, and it sounds to me 373 00:22:47,676 --> 00:22:50,716 Speaker 1: that the u SEE system in California is coming up 374 00:22:50,716 --> 00:22:53,796 Speaker 1: with the guidelines that they expect many other hospitals in 375 00:22:53,836 --> 00:22:57,116 Speaker 1: California to adopt. But at the end of the day, 376 00:22:57,156 --> 00:23:00,236 Speaker 1: it's going to be an individual hospitals legal counsel who's 377 00:23:00,276 --> 00:23:06,156 Speaker 1: comfortable with supporting and individual hospitals clinicians and practitioners through 378 00:23:06,316 --> 00:23:10,596 Speaker 1: this time. Having said that Governor Cuomo in New York 379 00:23:10,596 --> 00:23:15,676 Speaker 1: State where I practice, granted civil and criminal immunity to 380 00:23:16,036 --> 00:23:20,876 Speaker 1: healthcare practitioners on Friday, backdated to March seventh, to give 381 00:23:20,916 --> 00:23:25,516 Speaker 1: protections obviously not for anything that was ill intentioned, but 382 00:23:25,836 --> 00:23:28,996 Speaker 1: to give protections for anything that may result during this 383 00:23:29,076 --> 00:23:31,036 Speaker 1: time when we are working as hard as we can 384 00:23:31,076 --> 00:23:33,516 Speaker 1: to save lives. Yeah, and that which was advocated for 385 00:23:33,516 --> 00:23:35,396 Speaker 1: were very strongly by two of my colleagues at Harvard 386 00:23:35,436 --> 00:23:38,836 Speaker 1: Law School, Glen Cohen and Andrew Crispo, as part of 387 00:23:38,836 --> 00:23:42,356 Speaker 1: a broader team, is aimed at just making sure that 388 00:23:42,396 --> 00:23:44,276 Speaker 1: of all the worries that you the physicians have, you 389 00:23:44,316 --> 00:23:47,156 Speaker 1: don't also have the worry about being suitor being prosecuted. Well, 390 00:23:47,196 --> 00:23:49,436 Speaker 1: thanks to your colleagues for that. Thank you so much 391 00:23:49,516 --> 00:23:52,716 Speaker 1: for talking through these really, really hard questions with us. 392 00:23:53,156 --> 00:23:55,436 Speaker 1: I think it's super useful for me and for listeners 393 00:23:55,876 --> 00:23:57,196 Speaker 1: to get a sense of what it's like on the 394 00:23:57,236 --> 00:23:59,156 Speaker 1: front lines, and what are the issues you're struggling with, 395 00:23:59,556 --> 00:24:01,676 Speaker 1: and also how you're thinking about the big picture issues 396 00:24:01,716 --> 00:24:04,476 Speaker 1: that we hope you won't have to confront, but you know, 397 00:24:04,476 --> 00:24:06,356 Speaker 1: if we're not lucky, you may indeed have to. Thank 398 00:24:06,356 --> 00:24:09,996 Speaker 1: you so much for your time. Thank you. Speaking to 399 00:24:10,036 --> 00:24:13,956 Speaker 1: doctor Lydia Dugdale really brings home the difficulties that are 400 00:24:13,996 --> 00:24:17,756 Speaker 1: facing medical ethicists as they try to make extremely challenging 401 00:24:17,836 --> 00:24:22,636 Speaker 1: decisions under circumstances of genuine shortage. On the one hand, 402 00:24:22,756 --> 00:24:26,396 Speaker 1: we have some pre existing protocols to analyze under what 403 00:24:26,476 --> 00:24:30,396 Speaker 1: circumstances care should be allocated. Those are tricky and subtle 404 00:24:30,556 --> 00:24:33,236 Speaker 1: and have to be handled with great delicacy, but at 405 00:24:33,316 --> 00:24:36,396 Speaker 1: least they're already in place and enjoy a certain degree 406 00:24:36,436 --> 00:24:40,076 Speaker 1: of consensus for medical ethicists. Then there are the brand 407 00:24:40,156 --> 00:24:43,996 Speaker 1: new questions, like the end of life questions associated with 408 00:24:44,036 --> 00:24:48,956 Speaker 1: the resuscitation of coronavirus patients on those issues. The jury 409 00:24:49,036 --> 00:24:52,876 Speaker 1: is very much still out and new circumstances are demanding 410 00:24:53,156 --> 00:24:56,916 Speaker 1: new kinds of ethical wanging. We're fortunate to have serious 411 00:24:56,916 --> 00:25:00,716 Speaker 1: people like doctor Dugdale thinking about these questions until I 412 00:25:00,716 --> 00:25:03,396 Speaker 1: speak to you the next time. Be careful, be safe, 413 00:25:03,556 --> 00:25:08,796 Speaker 1: and be well. Deep Background is brought to you by 414 00:25:08,796 --> 00:25:12,836 Speaker 1: Push Industries. Our producer is Lydia gene Coott, with research 415 00:25:12,876 --> 00:25:16,436 Speaker 1: help from Zoie Edwyn. Mastering is by Jason Gambrell and 416 00:25:16,476 --> 00:25:20,436 Speaker 1: Martin Gonzalez. Our showrunner is Sophie mckibbon. Our theme music 417 00:25:20,556 --> 00:25:23,876 Speaker 1: is composed by Luis Gara. Special thanks to the Pushkin Brass, 418 00:25:24,156 --> 00:25:28,076 Speaker 1: Malcolm Gladwell, Jacob Weisberg, and Mia Lobel. I'm Noah Feldman. 419 00:25:28,516 --> 00:25:31,236 Speaker 1: I also write a regular column for Bloomberg Opinion, which 420 00:25:31,276 --> 00:25:34,556 Speaker 1: you can find at Bloomberg dot com slash Feldman. To 421 00:25:34,596 --> 00:25:38,156 Speaker 1: discover Bloomberg's original slate of podcasts, go to Bloomberg dot 422 00:25:38,236 --> 00:25:41,916 Speaker 1: com slash Podcamists. You can follow me on Twitter at 423 00:25:41,996 --> 00:25:45,116 Speaker 1: Noah R. Feldman. This is Deep Background.