Speaker 1: Pushkin from Pushkin Industries. This is Deep Background, the show
Speaker 1: where we explore the stories behind the stories in the news.
Speaker 1: I'm Noah Feldman. We're continuing our ongoing coverage of different
Speaker 1: aspects of the coronavirus pandemic. Today, our topic is medical
Speaker 1: ethics and how they apply in a crisis. There have
Speaker 1: been reports of doctors in some countries around the world
Speaker 1: having to ration care, including ventilators, for patients who are
Speaker 1: sick with the coronavirus because they don't have sufficient supplies
Speaker 1: to care for everyone. It looks at least possible that
Speaker 1: the same thing could be happening here in the United States.
Speaker 1: The situation is especially pressing in New York, where there
Speaker 1: is a shortage of ventilators and where the possibility of
Speaker 1: splitting ventilators has been considered by some hospitals. What happens
Speaker 1: when hospitals have to decide who gets a ventilator and
Speaker 1: who doesn't. What happens at the end of life, when
Speaker 1: we're trying to figure out what sort of heroic measures
Speaker 1: should be used to save people who are close to
Speaker 1: dying from the coronavirus. To discuss these issues, I'm joined
Speaker 1: today by doctor Lydia Dugdale. She's an Associate Professor of
Speaker 1: medicine and director of the Center for Clinical Medical Ethics
Speaker 1: at Columbia University. She's practicing medicine on the front lines
Speaker 1: of this pandemic, both in the hospital and in the
Speaker 1: temporary tent that Columbia University has set up in its
Speaker 1: own parking lot to deal with the overload of Corona cases.
Speaker 1: She's also the author of a forthcoming book, The Lost
Speaker 1: Art of Dying. Lydia, thank you so much for joining me.
Speaker 1: I wonder if we could begin by talking about something
Speaker 1: that I think the whole world is focusing on now,
Speaker 1: but that you do every day, and that is the
Speaker 1: fundamentals of medical ethics. How do you go about thinking
Speaker 1: in a systematic way about the rationing questions that may
Speaker 1: not have quite yet emerged in the United States, but
Speaker 1: which are on the edge of emerging, and which have
Speaker 1: already emerged in lots of other countries. Medical ethics typically
Speaker 1: focuses on the doctor patient relationship. That's really the core
Speaker 1: of what we do in non crisis times. As such,
Speaker 1: we tend to focus on principles of beneficence and non maleficence.
Speaker 1: Beneficence is doing good for patience, and non maleficence is
Speaker 1: not doing harm, So that's sort of that hippocratic It's
Speaker 1: typically called the hippocratic idea of first doing no harm
Speaker 1: to one's patience. So that's what we talk about in
Speaker 1: non crisis times in medicine. However, with this current coronavirus pandemic,
Speaker 1: we've shifted the current framing for medical ethics to more
Speaker 1: of a public health fix, which takes into account different
Speaker 1: principles and they're sort of a different framing for how
Speaker 1: we think about decisions, and we tend to focus more
Speaker 1: on a duty to care for everyone, so there's more
Speaker 1: of a community bent to things. There is a commitment
Speaker 1: to stewarding resources, this is what we've heard about a
Speaker 1: lot in the media, making sure we have enough equipment.
Speaker 1: There's certainly a duty to plan governments. Healthcare administrators are
Speaker 1: expected to anticipate foreseeable crises and sort of come up
Speaker 1: with a plan to respond to these. There's also a
Speaker 1: commitment to distribute of justice, making sure that we have
Speaker 1: allocation protocols in place that will meet the most needs
Speaker 1: possible in a way that is most fair. And then,
Speaker 1: of course transparency is fundamental to this. We want to
Speaker 1: make sure that the public knows what we're doing in
Speaker 1: these unique situations when everyone's already on edge. We want
Speaker 1: to do everything we can to sort of shore up
Speaker 1: public trust so that everyone knows that the healthcare system
Speaker 1: and the policymakers still have their back and will really
Speaker 1: work to prioritize their health and well being. Could we
Speaker 1: drill down to what you called allocation protocols, which I'd
Speaker 1: take it as a fancy way of saying who gets
Speaker 1: which medical supplies or medical technologies when and products? The
Speaker 1: allocation part and protocol implies that you'd have a kind
Speaker 1: of model or an algorithm that you would follow in
Speaker 1: individual instances. Now, those things are super tricky and they
Speaker 1: require sort of unveiling a lot of the values that
Speaker 1: you were talking about. So would you talk a little
Speaker 1: bit about how you think about allocation protocols. Let's use
Speaker 1: an example that's really concrete, the example of ventilators. So,
Speaker 1: hospitals all over the country right now and over the
Speaker 1: last few weeks have been debating how to handle the
Speaker 1: possibility of a ventilator shortage. It's worth pointing out, though,
Speaker 1: that perhaps more than an actual ventilator shortage. There's a
Speaker 1: concern that we would have a shortage of healthcare personnel,
Speaker 1: particularly respiratory therapists and critical care doctors who know how
Speaker 1: to manage these very complex and sophisticated devices. However, having
Speaker 1: said that, assuming that there is a ventilator shortage or
Speaker 1: that there will be one, hospitals are trying to figure
Speaker 1: out what is the best way to make sure that
Speaker 1: we save the most lives possible. That's really the driving
Speaker 1: question here. And even though there has been certainly a
Speaker 1: lot of concern expressed that these allocation principles are going
Speaker 1: to cut off the elderly or not serve those with disabilities,
Speaker 1: that's not at all the aim of these allocation protocols.
Speaker 1: In New York State, for example, there was put forward
Speaker 1: in twenty fifteen by the New York State Department of
Speaker 1: Health allocation guidelines for ventilators in the event of a
Speaker 1: flu epidemic. New York was trying to anticipate how they
Speaker 1: would meet the needs of New Yorkers, particularly in this
Speaker 1: congested urban area, if flu were to sort of go haywire,
Speaker 1: and a lot of hospitals around the country currently have
Speaker 1: looked back to those twenty fifteen guidelines as a starting point,
Speaker 1: and there are other other similar guidelines out there, so
Speaker 1: we're sort of wrestling with these and then applying them
Speaker 1: to COVID. So, of course, coronavirus and the way it's
Speaker 1: playing out does not look exactly like influenza in a
Speaker 1: typical season, so we're having to adapt these guidelines. The
Speaker 1: formula that you used was the goal of saving the
Speaker 1: most lives possible, and I guess what I want to
Speaker 1: ask you about is if we really are committed to
Speaker 1: saving the most lives possible, then our protocol is presumably
Speaker 1: going to ask how likely is this person to survive
Speaker 1: if given the scarce ventilator, and if you're younger and healthier,
Speaker 1: that probably on the whole enhances your chances of surviving.
Speaker 1: What's your view about how we should think that through.
Speaker 1: So the score that a lot of us are looking at,
Speaker 1: or at least studying and considering, is something called the
Speaker 1: SOFA score. SOFA it stands for the Sequential organ Failure Assessment,
Speaker 1: and this is a score interestingly that doesn't take age
Speaker 1: into account, but it does take into account the health
Speaker 1: of six organ systems. So the SOFA score looks at
Speaker 1: the lungs, the heart, the kidneys, the liver, the brain,
Speaker 1: particularly with regard to mental status, how alert is an individual,
Speaker 1: and also blood clotting, so you know, doctors will call
Speaker 1: this the hematologic system. So the SOFA score takes into
Speaker 1: account that the healthy functioning or lack of health of
Speaker 1: these six organs, which in times of severe infection what
Speaker 1: we might call sepsis, we often see a sequential failing
Speaker 1: of these organs. And then we look at these triage
Speaker 1: sort of allocation guidelines tend to look at the SOFA
Speaker 1: score how it changes over time. So if a SOFA
Speaker 1: score gets progressively worse day after day after day, that
Speaker 1: trajectory tends to be only in one direction. Now, if
Speaker 1: a SOFA score starts to show improvements, then we think
Speaker 1: differently about an individual patient. So as you say, the
Speaker 1: SOFA analysis doesn't mention age, it's not listed as a
Speaker 1: consideration there. And I guess I have two questions about that.
Speaker 1: One is if you had two identically placed patients with
Speaker 1: respect to SOFA, but they were very disjunct with respect
Speaker 1: to age. You know, one was I don't know, a
Speaker 1: healthy eighteen year old and the other was a healthy
Speaker 1: for their age. But you know, eighty year old under
Speaker 1: current protocols, would that mean that you would not be
Speaker 1: able to have a preference for the eighteen year old
Speaker 1: over the seventy year old or the eighty year old
Speaker 1: simply because it's not in the sofa score. Or do
Speaker 1: you use the sofa score in a flexible way where
Speaker 1: if sofas are equal, and then you have to make
Speaker 1: an allocation decision, you could then consider other factors. The
Speaker 1: New York State guidelines from twenty fifteen, the only look
Speaker 1: to age as a tiebreaker if it's a child versus
Speaker 1: an adult, that's the only time. And they do that.
Speaker 1: They base those guidelines on our societal preference for caring
Speaker 1: for children. If it's two adults with equal sofa scores
Speaker 1: and equal need let's say, and let's say it's not
Speaker 1: even removal, but it's just applying a ventilator and there's
Speaker 1: only one ventilator left, then it's a lottery system according
Speaker 1: to these New York State guidelines. Again, every hospital is
Speaker 1: adapting these guidelines slightly differently. I think a lot of
Speaker 1: the protocols are going to end up being quite similar,
Speaker 1: and there are efforts underway to study these nationwide. But
Speaker 1: I think most people are loath to sort of make
Speaker 1: a strict age cut off and say or not even
Speaker 1: a cutoff, but to just say the older person should
Speaker 1: not get it and the younger person should get it. So,
Speaker 1: like I said, a lot of the preference is often
Speaker 1: given to children. Otherwise it tends to be a lottery system.
Speaker 1: Some of the state protocols, as reported and as they
Speaker 1: appear to be written, and I'm thinking of the Alabamber
Speaker 1: Procolling particular, seemed to say that people certain severe disabilities
Speaker 1: would be lower on an allocation list. Where does that
Speaker 1: fit within sort of standard good medical medical ethics. I
Speaker 1: suppose I would have to know what you mean by disabilities.
Speaker 1: So many of the protocols do have exclusion criteria. There
Speaker 1: are particular illnesses that we specify, and if patients came
Speaker 1: in with those illnesses, we would not allocate a ventilator
Speaker 1: to them. But the exclusion criteria that most commonly are
Speaker 1: discussed our exclusion that suggests that death is imminent. So,
Speaker 1: for example, a person comes in with a severe bleed
Speaker 1: in the brain that almost certainly will cause death, such
Speaker 1: a person would not be given a ventilator according to
Speaker 1: these allocation guidelines in crisis situations because death is imminent,
Speaker 1: So the exclusion criteria that are most commonly used are
Speaker 1: ones that really are quite close to the point of death.
Speaker 1: So the language that they used, I'm quoting from the
Speaker 1: Alabama protocol here. There are some patients for whom the
Speaker 1: possible should not offer mechanical ventilator support, and those include
Speaker 1: heart failure, respiratory failure, metastatic cancer. So that fits what
Speaker 1: you're describing. And then it also says that quote persons
Speaker 1: with severe mental rechardation, advanced dementia, or severe traumatic brain
Speaker 1: injury may be poor candidates for ventilator support. So it's written,
Speaker 1: you know, it's not written as mandatory. It's maybe poor candidates.
Speaker 1: And maybe if you have advanced dementia, that's highly probable
Speaker 1: that you will die sooner, and so perhaps that's an explanation,
Speaker 1: and ditto for traumatic brain injury. I suppose the language
Speaker 1: that motivated the disability rights advocates to bring a complaint
Speaker 1: was the formulation that says persons with severe mental rechardation. Yeah,
Speaker 1: I think many of us are very uncomfortable with that
Speaker 1: sort of an assertion. The criteria of most hospitals with
Speaker 1: which I'm familiar is not to look at specific aspects
Speaker 1: of mental ability, cognitive ability and even know what you're
Speaker 1: saying about dementia. Dementia is a disease that easily last
Speaker 1: ten years, So we have to be careful about how
Speaker 1: we use these terms. And that's why many hospitals are
Speaker 1: most comfortable with when we know death is imminent. This
Speaker 1: person is really going to die within hours. Those are
Speaker 1: the people that in times of crisis, we would consider
Speaker 1: withholding ventilators from if there were a ventilator shortage. We'll
Speaker 1: be back in just a moment. May ask you the
Speaker 1: difference from the standpoint of standard medical ethics between removing
Speaker 1: someone from a ventilator in order to enable another person
Speaker 1: to have that ventilator, as opposed to allocating that ventilator
Speaker 1: in the first instance to somebody on the basis of
Speaker 1: criteria that are in a protocol. Do you see those
Speaker 1: two things typically as different in some important way or
Speaker 1: do you think of them is basically equivalent ethically and morally.
Speaker 1: The arguments that are typically used is that they are
Speaker 1: the same emotionally, they are hugely different, and the idea
Speaker 1: of removing a ventilator for both a patient's family and
Speaker 1: for the treating team, the medical doctors. It takes an
Speaker 1: enormous emotional toll, which is why most people right now
Speaker 1: with this coronavirus pandemic want to try to avoid doing
Speaker 1: that no matter what, because there's already enough moral distress.
Speaker 1: It's already difficult enough. The last thing we want to
Speaker 1: do is add to that by removing patients from ventilators.
Speaker 1: So the sort of the better move is to try
Speaker 1: to allocate them up front. Right, So, going back to
Speaker 1: the sofa scores that we discussed earlier in this conversation,
Speaker 1: the only sofa scores again, in many of these triage protocols,
Speaker 1: I can't speak for all, the only sofa scores that
Speaker 1: those having to allocate ventilator would rely upon. Our sofa
Speaker 1: scores that show progressive worsening. Anyone who is sort of
Speaker 1: holding his or her own or showing any evidence of improvement,
Speaker 1: there would never be any consideration given to removing a
Speaker 1: ventilator from that person. And if you push me further
Speaker 1: and you say, well, still, what if what if we
Speaker 1: get to the point where all ventilators are allocated, everyone
Speaker 1: who is failing, you know, has died and the only
Speaker 1: people left on ventilators are people who are sort of
Speaker 1: holding their own or improving, and still someone comes in
Speaker 1: who needs one, then it's probably going to revert to
Speaker 1: a first come, first serve scenario because there's no other option.
Speaker 1: We're not going to cut short someone's life who is
Speaker 1: a possibility of life in order to give someone else
Speaker 1: a possibility of life. That just wouldn't That wouldn't be right,
Speaker 1: and no one, no one would be comfortable with that. Again,
Speaker 1: that the idea is to help as many people as
Speaker 1: possible and to save as many lives as possible, not
Speaker 1: in any way to jeopardize someone's life. That that's never
Speaker 1: the goal. So the first in time rule, which is
Speaker 1: really a luck rule, would then kick in as well,
Speaker 1: because we don't have anything better to do at that point. Yeah, Frankly,
Speaker 1: I don't know that you know the protocols get to
Speaker 1: that level. I think you know there are so many
Speaker 1: patients in any given hospital on any day that are
Speaker 1: languishing on a ventilator that are not showing improvement, and
Speaker 1: it's it's specifically because everyone holds out hope and frankly,
Speaker 1: as I've written about, don't want to have to face
Speaker 1: mortality that we often keep trying. We keep trying and
Speaker 1: keep trying. That's sort of the way that we've all
Speaker 1: been socialized, both physicians and Americans. Can I just ask
Speaker 1: you about ventilator splitting, which you know we're not there yet,
Speaker 1: but again, it seems like one of the possible responses
Speaker 1: Leaving aside the technology of whether it's doable, does it
Speaker 1: strike you as problematic from an ethical perspective? Where is
Speaker 1: it simply a matter of the probabilities it's more likely
Speaker 1: to help the people than just helping one of them,
Speaker 1: We should take a crack at it. Sure. I mean,
Speaker 1: it's been reported in the New York Times that Columbia
Speaker 1: Presbyterian pioneered this, So it's definitely doable. It's enormously complex,
Speaker 1: much more difficult cult than having a single patient on
Speaker 1: event later, but it works and if it comes to
Speaker 1: that we can do that. It's possible. It wouldn't automatically
Speaker 1: double the number of ventilators that we have because patients
Speaker 1: have to have similar needs, because they share single United
Speaker 1: ventilator settings which are highly tailored to each individual patients.
Speaker 1: So there are a lot of factors that would need
Speaker 1: to be tailored. There but it would certainly increase our
Speaker 1: ventilator capacity if it came to that. Can I ask
Speaker 1: you what are you seeing? I mean, what are the
Speaker 1: ethical issues that ethicis are most pressed about right now
Speaker 1: that you are most pressed about right now? What are
Speaker 1: the challenges that you've seen that are uncertain where it's
Speaker 1: not so simple just to say, well, we know what
Speaker 1: to think about this because we have a protocol in place.
Speaker 1: The question of whether to resuscitate a particular patient is
Speaker 1: really on a lot of people's minds. Some of the
Speaker 1: arguments against that are that resuscitation is very, very messy,
Speaker 1: and it leads to body fluids and aerosolization, which is
Speaker 1: where the virus goes into the air and spreads everywhere,
Speaker 1: and so it significantly increases the amount of virus that's
Speaker 1: around and infectious and able to make the healthcare worker sick.
Speaker 1: Any resuscitation attempt requires an enormous team size and a
Speaker 1: lot of personal protective equipment. The so called ppe that
Speaker 1: everyone has heard that there's been a shortage of so
Speaker 1: between the risk and the danger of it, the fact
Speaker 1: that we've already stopped doing a lot of procedures in
Speaker 1: the hospital in this current moment that lead to this
Speaker 1: aerosolization of the virus. A lot of people feel that
Speaker 1: we should not be doing CPR. Some people feel that
Speaker 1: no patient with coronavirus should have resuscitation. In my view
Speaker 1: and in the view of many many ethicis that is
Speaker 1: far too extreme. Certainly, we're having patients come in who
Speaker 1: could easily be resuscitated with good outcomes, and so I
Speaker 1: would be very uncomfortable with a blanket restriction on resuscitating
Speaker 1: anyone who walks in with coronavirus. Having said that, it's
Speaker 1: not uncommon for patients with coronavirus to have a cardiac arrest,
Speaker 1: meaning their heart stops and they die for a successful
Speaker 1: resuscitation attempt, and then for a repeat cardiac arrest, so
Speaker 1: they die again. That's something we're seeing quite a bit.
Speaker 1: And many people feel that if a patient is dying again,
Speaker 1: even though we've tried to bring them back, but they
Speaker 1: die again rather imminently, that this is someone who does
Speaker 1: not show long term good odds for survival. This question
Speaker 1: is probably more pressing right now for doctors on the
Speaker 1: front lines than even the question of ventilater allocation. That's
Speaker 1: completely fascinating, and I will say I think it's almost
Speaker 1: completely underreported. You said that you think it's too extreme
Speaker 1: to say, given those risks, we shouldn't resuscitate people who
Speaker 1: have cardiac arrest on corona the first time at least why.
Speaker 1: I mean, the risk is not only to the people
Speaker 1: in the room, that's the healthcare workers, but it's also
Speaker 1: to everybody else in the hospital, because once i'm these aerosolis,
Speaker 1: you don't have a perfect seal around the hospital rooms.
Speaker 1: I mean, it's you're creating a huge externalized risk for
Speaker 1: everybody else. And if resuscitation has a high probability of
Speaker 1: working in the individual case, and yet we know that
Speaker 1: it often doesn't last in other words, that people then
Speaker 1: have to they die again, it seems like a perfect
Speaker 1: case to say, well, gee, we're just not going to
Speaker 1: do it under these circumstances. What am I missing there?
Speaker 1: So you're missing the forty year old who comes in
Speaker 1: with a heart attack, which still happens, and hospitals are
Speaker 1: testing patients as they walk in the door, and he's
Speaker 1: COVID positive and he has a cardiac arrest in the
Speaker 1: emergency room. Do you not resuscitate him because he's not
Speaker 1: dying of the coronavirus. He's dying of a heart attack,
Speaker 1: that's right. What we don't want to do is get
Speaker 1: the black X on people's names because they have coronavirus
Speaker 1: when they would be so easy to resuscitate them. I see.
Speaker 1: So what you're really describing is maybe there should be
Speaker 1: pulling back on resuscitating people who are dying of the
Speaker 1: coronavirus and are probably going to die again after being resuscitated.
Speaker 1: I don't know that I'd want to go on record
Speaker 1: as saying I'm advocating for it, but I will definitely
Speaker 1: go on record as saying this is something people are
Speaker 1: very concerned about right now. It's one of the top
Speaker 1: ethical issues we're debating in a book. You actually opened
Speaker 1: your book with a kind of a graphic, if I
Speaker 1: may say so, a description of a resuscitation in a
Speaker 1: pretty standard case. This is not a coronavirus situation, And
Speaker 1: the strong takeaway for the reader is that we do
Speaker 1: this much, much too much. Anyway, Does that affect you're
Speaker 1: thinking about this situation at all. The whole way that
Speaker 1: the coronavirus pandemic has been discussed has been a focus
Speaker 1: on delaying death, and there's been very little reported about
Speaker 1: how we should actually use this as an opportunity to
Speaker 1: think about our mortality and start to get our advanced
Speaker 1: directives in order, and not to mention all the other
Speaker 1: documents and share our passwords with our significant others. Things
Speaker 1: like that. That's not so much a part of the
Speaker 1: conversation right now. So, yes, I've reflected on my book
Speaker 1: a lot. I do think people would die much better
Speaker 1: deaths if they had a lot more preparation and if
Speaker 1: they started preparing now rather than waiting until they're sitting
Speaker 1: in the emergency room with coronavirus or whatever other disease.
Speaker 1: Because this coronavirus pandemic too shall pass, but there will
Speaker 1: be something else for all of us. Moves us to
Speaker 1: think about these things now and to plan for them.
Speaker 1: One last question about their resuscitation issue. If a decision
Speaker 1: were taken on, for example, not resuscitating some people who
Speaker 1: are close to dying from coronavirus, would that be a
Speaker 1: decision that was taken at individual hospital levels, would it
Speaker 1: be taken at statewide levels? Would it be a federal decision?
Speaker 1: How do the mechanics of implementing an ethical intuition like
Speaker 1: that work themselves out in the real world, most of
Speaker 1: them are at hospital levels. I was on a call
Speaker 1: with an ethesis from California, and it sounds to me
Speaker 1: that the u SEE system in California is coming up
Speaker 1: with the guidelines that they expect many other hospitals in
Speaker 1: California to adopt. But at the end of the day,
Speaker 1: it's going to be an individual hospitals legal counsel who's
Speaker 1: comfortable with supporting and individual hospitals clinicians and practitioners through
Speaker 1: this time. Having said that Governor Cuomo in New York
Speaker 1: State where I practice, granted civil and criminal immunity to
Speaker 1: healthcare practitioners on Friday, backdated to March seventh, to give
Speaker 1: protections obviously not for anything that was ill intentioned, but
Speaker 1: to give protections for anything that may result during this
Speaker 1: time when we are working as hard as we can
Speaker 1: to save lives. Yeah, and that which was advocated for
Speaker 1: were very strongly by two of my colleagues at Harvard
Speaker 1: Law School, Glen Cohen and Andrew Crispo, as part of
Speaker 1: a broader team, is aimed at just making sure that
Speaker 1: of all the worries that you the physicians have, you
Speaker 1: don't also have the worry about being suitor being prosecuted. Well,
Speaker 1: thanks to your colleagues for that. Thank you so much
Speaker 1: for talking through these really, really hard questions with us.
Speaker 1: I think it's super useful for me and for listeners
Speaker 1: to get a sense of what it's like on the
Speaker 1: front lines, and what are the issues you're struggling with,
Speaker 1: and also how you're thinking about the big picture issues
Speaker 1: that we hope you won't have to confront, but you know,
Speaker 1: if we're not lucky, you may indeed have to. Thank
Speaker 1: you so much for your time. Thank you. Speaking to
Speaker 1: doctor Lydia Dugdale really brings home the difficulties that are
Speaker 1: facing medical ethicists as they try to make extremely challenging
Speaker 1: decisions under circumstances of genuine shortage. On the one hand,
Speaker 1: we have some pre existing protocols to analyze under what
Speaker 1: circumstances care should be allocated. Those are tricky and subtle
Speaker 1: and have to be handled with great delicacy, but at
Speaker 1: least they're already in place and enjoy a certain degree
Speaker 1: of consensus for medical ethicists. Then there are the brand
Speaker 1: new questions, like the end of life questions associated with
Speaker 1: the resuscitation of coronavirus patients on those issues. The jury
Speaker 1: is very much still out and new circumstances are demanding
Speaker 1: new kinds of ethical wanging. We're fortunate to have serious
Speaker 1: people like doctor Dugdale thinking about these questions until I
Speaker 1: speak to you the next time. Be careful, be safe,
Speaker 1: and be well. Deep Background is brought to you by
Speaker 1: Push Industries. Our producer is Lydia gene Coott, with research
Speaker 1: help from Zoie Edwyn. Mastering is by Jason Gambrell and
Speaker 1: Martin Gonzalez. Our showrunner is Sophie mckibbon. Our theme music
Speaker 1: is composed by Luis Gara. Special thanks to the Pushkin Brass,
Speaker 1: Malcolm Gladwell, Jacob Weisberg, and Mia Lobel. I'm Noah Feldman.
Speaker 1: I also write a regular column for Bloomberg Opinion, which
Speaker 1: you can find at Bloomberg dot com slash Feldman. To
Speaker 1: discover Bloomberg's original slate of podcasts, go to Bloomberg dot
Speaker 1: com slash Podcamists. You can follow me on Twitter at
Speaker 1: Noah R. Feldman. This is Deep Background.