March 20, 2020

"Doctors have reckoned with the need to allocate resources in the face of overwhelming demand long before coronavirus."

"[Lydia Dugdale, professor of medicine and director of the center for clinical medical ethics at Columbia University] points out that the New York department of health’s ventilator allocation guidelines, published in November 2015 to address the issue amid a flu epidemic, states that first-come first-serve, lottery, physician clinical judgment, and prioritizing certain patients such as health care workers were explored but found to be either too subjective or failed to save the most lives. Age was rejected as a criterion as it discriminates against the elderly, and there are plenty of cases in which an older person has better odds of survival than someone younger. So the decision was to 'utilize clinical factors only to evaluate a patient’s likelihood of survival and to determine the patient’s access to ventilator therapy.' In tie-breaking circumstances, though, they did approve treating children 17 and younger over an adult where both have an equal odds of surviving.... 'I would say that leaving some to die without treatment is NOT ethical, but it may be necessary as there are no good options,' David Chan, philosophy professor at the University of Alabama at Birmingham, writes. 'Saying that it is ethical ignores the tragic element, and it is better that physicians feel bad about making the best of a bad situation rather than being convinced that they have done the right thing.'"

From "Ethicists agree on who gets treated first when hospitals are overwhelmed by coronavirus" by Olivia Goldhill (Quartz).

Do you think it's right to take age into account only to benefit the super-young — those under 18? Would you choose between a 20 year old and a 70 year old solely on the basis of who is more likely to survive? I suspect the age factor is bundled into the assessment of who's more likely to survive, which would simply hide the disapproved-of discrimination against the elderly. By contrast:
Italy has prioritized treatment for those with “the best chance of success” but adds as a second criterion those “who have more potential years of life.”
Another thing I wonder about is the issue of surviving without the ventilator. What if, for example, X has an 80% chance of surviving without a ventilator and a 90% chance of surviving with it and Y has a 10% chance of surviving without a ventilator and a 60% chance of surviving with it? Does X, the more vigorous person, get the task of struggling to survive without the ventilator? And do you take into account how long a person will need the ventilator? Maybe you could save 2 of my Xs in the time it would take Y to get well or perish.

177 comments:

rhhardin said...

Ethics is usually done using lifeboats.

Ralph L said...

Are you going to take a failing 80 y.o. off the ventilator to save a 20 y.o. who needs it now?

Johnathan Birks said...

Eugenics By Other Means: A Love Story

James K said...

Another thing I wonder about is the issue of surviving without the ventilator. What if, for example, X has an 80% chance of surviving without a ventilator and a 90% chance of surviving with it and Y has a 10% chance of surviving without a ventilator and a 60% chance of surviving with it?

I learned from advanced stats courses in college and grad school that doctors are terrible at interpreting data. The profs gave examples of idiotic reasoning in the medical profession. Of course your question is exactly the right one, together with other issues like age. If Y was 85 years old and X was 25 I still might go with X, but the marginal impact of the ventilator is clearly the starting point.

Ignorance is Bliss said...

We should not factor in age directly, but should factor in remaining life expectancy. For most people, that is roughly equivalent.

I say this as someone diagnosed with cancer at age 52, with a life expectancy of less than 5 years, knowing this leaves me on the short end of the stick.

Bill Harshaw said...

The time spent gathering data and considering is costly. At some point you have to cut the theorizing and make a decision.

tim in vermont said...

Where is ARM to scold Americans for spending too much on health care when we need him?

JAORE said...

Could it be "Death Panels"?

Naw.... that's deplorable talk.

Greg Hlatky said...

A bioethicist is someone who provides a high-minded reason for killing you.

iowan2 said...

this is down to the debate about how many angles can dance on the head of the pin.

Your one example is flawed because nothing in medicine is 100%. Thus 80% this, and 10% that are close to 100% and 0% So the choice is clear. The 10% is made comfortable like Dr Obama taught us.

But in the end Medical staff make these decisions constantly. They can always be looked back on and judged. With little learned. Medicine is way more art, and faith, less science and math. YMMV

Ann Althouse said...

I tried to make the differences in percentages as hard as possible.

X is the stronger person, so do you give him the hard work of struggling to breathe or do you give him preference for the machine because you like the 90% chance of using it to produce a healed human being and not a dead person?

Y needs the machine more, though, but that's not the ethics that were worked out in 2015. It's not whose odds are most improved by the machine, but who's more likely to emerge from machine use alive. I think.

I could be misunderstanding the text I read and the text may be inaccurate in conveying what the policy is. In fact, the text must be wrong, because otherwise you'd be using the machine on a person with a 99% chance of living without the machine just to get a 99.1% chance of living with it, and that does not make sense.

Robert Cook said...

I'm annoyed the writer of the article wrote the phrase "first come, first served" as, incorrectly, "first come, first serve." This is the kind of stupid error that writers should not make, such as "...could care less" (for "...couldn't care less") or "beg the question" (for "raise the question").

DimWhit said...

Ethics is hard.

DimWhit said...

Ethics is hard.

Shouting Thomas said...

My thought as I read the summary was: "What if this panic never materializes? What if none of this happens?"

The panic and hysteria model of the media during the internet era has made me super skeptical.

Could it be that this article is just the work of ambitious writers and editors trying to capture eyeballs, and that it didn't need to be written?

tim in vermont said...

We knew our daughter had a pretty serious heart defect in utero, and we made the choice to bring her into this world. She has had a pretty good life, though she has been through a lot of surgery, and we have never regretted our choice, but this is terrifying to us, and as you can imagine, to her. She came by her heart problems honestly, as I have them, but less severe, so getting this is going to be like Russian roulette for me. I have a 3-4% chance of dying in any given year from heart issues already. I have learned to handle those odds, but I am going to be honest, this is terrifying. Not so much about me, though I am not happy about my prospects, but the idea of going through the pain of watching my daughter fight through this and possibly not make it is as much as I can bear.

I don’t know what kind of point I am trying to make, except please consider who is reading these comments as you share your “hot takes."

Left Bank of the Charles said...

Is it ageist and sexist to take young males over old females in a war-time draft? We don’t let the ethicists make these decisions.

Robert Cook said...

This seems to be the kind of difficult choice that can only really be made in the moment, on a case-by-case basis, by doctors using their experience and intuitive sense of who may survive with or without use of scarce resources. If the question is "should the young always be saved before the elderly?," this is a question with no correct answer. Medical providers will make this decision according to their own convictions, and most will probably not state those convictions outright.

Jim Gust said...

What is the efficacy of ventilators in this situation? Do we even know? In my very limited experience ventilators are essential and wonderful during surgery, but with chronic disease the question becomes "when do remove the ventilator to let the patient die"?

How much difference, at this point, will it make?

My advance health directive bars the use of ventilators on me, BTW. I would overrule that were I going in for surgery, but I think not if I get the WuFlu.

Krumhorn said...

This is reminiscent of the rationing of care in the UK by measuring the “quality adjusted life year” of the patient. If the blue pill treatment exceeds $47,000/yr,, they’ll dispense the red pill instead. This is what we have to look forward to with single payer medical with the lefties in charge.

-Krumhorn.

iowan2 said...

Are you going to take a failing 80 y.o. off the ventilator to save a 20 y.o. who needs it now?

Yes. With the sparse information you provided (the less information, the easier the decision)

The age you provided is extraneous information that has no bearing.

The question is, a patient that is already receiving respiratory therapy is continuing to fail, and a new patient is in need of therapy, that can only be provided by shifting resources. Yes shift the resources.

Filling the equation with names, and ages, education, etc. serves no purpose as to distribution of resources.

Ann Althouse said...

"Your one example is flawed because nothing in medicine is 100%."

It's a hypothetical involving informed estimates. I don't see this as a flaw. I've put it in a form where it can be thought about and discussed. Obviously, we never know the future and we're making estimates. We can still make assumptions for the purpose of discussion.

If you want to emphasize the difficulty of estimating odds, then do you want to embrace an argument for using first-come-first-served? Or is that one more thing in medicine that isn't 100% (who was "first"?)?

rcocean said...

Good grief is there anything more absurd then an "Ethicist"- oh wow, he has a title, lets listen to him! Obviously, there are black and white decisions and grey areas. 80 year old with 50% of survival vs. 19 year old with 80% is pretty easy. But what about a 60 year old with a 80% vs. a 25 y.o with 50%. I think survival rates - if they are accurate - should be the determining factor and then age up to a certain point. And then age in case the two people are both more or less equal.

But again, what is the survival rate? Its an estimate. And how good is it? Maybe we should place less weight, unless we know its pretty damn accurate.

Ron Winkleheimer said...

So the decision was to 'utilize clinical factors only to evaluate a patient’s likelihood of survival and to determine the patient’s access to ventilator therapy.

Age is a clinical factor.

Both of my parents, now deceased and who died under hospice care, drew up living wills specifying that they did not want "extraordinary measures" taken to revive them if they were dying, including intubation. What's being left out of this discussion is that elderly people in poor health are at risk of dying from all sorts of things. My mother-in-law caught a cold, ended up in the hospital, recovered after a few days, and then died in her sleep a week later. The conflict may not be a between a 40 yo with the Chinese coranavirus and a 75 yo with the Chinese coranavirus, but between a 40 yo with the virus and a 75 yo who tripped over their dog while walking it, broke their hip, and is suffering severe complications because they are elderly and in poor health. And yes, I saw that happen with a neighbor.

Finally, the following is one of the most stupid things I have ever read.

'Saying that it is ethical ignores the tragic element, and it is better that physicians feel bad about making the best of a bad situation rather than being convinced that they have done the right thing.'

rcocean said...

There's also a third factor. Bad taste. Anyone who likes Neil Diamond or Sedaka goes to the bottom of the list.

Fernandistein said...

David Chan, "...it is better that physicians feel bad about making the best of a bad situation"

David Chan should feel bad about making the best of his parasitical pseudo-profession.

rhhardin said...

Coleridge wrote that ethics puzzles serve to dull the moral sense.

Roger Sweeny said...

'I would say that leaving some to die without treatment is NOT ethical, but it may be necessary as there are no good options,' David Chan, philosophy professor at the University of Alabama at Birmingham, writes.

You, sir, are a Puritan asshole.

Eleanor said...

For the person who needs the ventilator to survive, the odds mean nothing. As a noted cancer specialist told me when he diagnosed my son, "For each individual patient, it's all or nothing." There are probably a lot of us who wander in and out of here who have had to make life or death decisions for other people. You do the best you can, and then you live with what happens. The same thing for doctors. They really don't try to quantify it. They want to save everybody, but they can't even under the best of circumstances. They make the best decisions they can, and then they live with it. Only actuaries and lawyers try to assign relative value to people's lives. The rest of us just want good outcomes for as many people as can be, and we know life is often a crapshoot.

tim in vermont said...

"My advance health directive bars the use of ventilators on me”

Advance directives don’t come into effect until you are mentally incapable of making a decision. My mother has one, but she is still sharp as a tack, despite her declining health and the fact that she is in hospice, so she decides what she gets and doesn’t get. But this is probably a good time to take care of one’s AD.

iowan2 said...

If you want to emphasize the difficulty of estimating odds, then do you want to embrace an argument for using first-come-first-served.

All I pointed out, a Doctor, or scientist, will never declare something 99% (100%). 80-95% leaves room for unknown, unknowns. Same on the other end of the scale.

These decisions or not about choosing which person to treat. The debate is how to triage the largest number of patients. Quantity of patients treated. Stop with the head to head matchups.

In the hypothetical, you are missing the probability of 2 dozen more patients showing up in 24 hours and how will you serve the largest number. In this case neither patient gets a respirator, one will live without treatment, and treatment will not help the other.

Lucid-Ideas said...

FYI, and for the good of the readers, do you own a CPAP machine?

If you do, they're classifying them 'as good as' ventilators for medical purposes. Obviously, they are not ventilators, however should you become ill anything that benefits respiration is a plus.

Keep this equipment in good working order.

tim in vermont said...

I think we should manufacture as many ventilators as we will possibly need and train up medical and nursing students to attend them, if that’s what’s needed, and deal with this like Americans.

The power over life and death of rationing during scarcity is a socialist’s game. They specialize in both, rationing and scarcity. Fuck them.

R2d2 said...

Perhaps we should assess who is most likely to harm/help society into that mix - a 70 yo veteran with a long work history of being productive or a 20 yo gangbanger with a rap sheet from here to there? This type of decision can be quite complicated and not easily answered. Do you save the firefighter or the arsonist, the rape victim or the rapist, the victim or the perpetrator? Given the uncertainty of the duration/severity of this pandemic, who do you want to be left standing? What will the world look like depending on the decisions one makes?

Oso Negro said...

I think here is how it goes:

1) The powerful, famous, and rich
2) Early cases from large urban centers
3) Health care workers and their families
4) Members of historically disadvantaged groups groups, because no one wants to be accused of racism or homophobia
5) Children
6) Everyone else

Leland said...

First of all, triage is nothing new for hospitals. They discuss how to prioritize cases all the time. You know who gets a treated before many others, someone with chest pains and shortness of breathe. If you are 10 year old sneezing with symptoms of a head cold, you are likely to wait a bit.

Second, why is this a discussion now? I know, coronavirus, but we aren't using up ventilators. Nobody is running out. There are studies that say it could happen, but those are 30 days out and based on not taking the measures we have taken. If we art still worried about running out of ventilators; then can we admit this halting of the economy isn't working?

iowan2 said...

Jim Gust makes a great observation. What is the recovery rate of COVID-19 patients that reach the level of respiratory therapy delivered by a ventilator? We have 205 deaths in the US so far. 10K world wide. Medicine should have good numbers as to the rate of recovery. If that recovery is only 20%, we are chasing invisible butterflies

Howard said...

I know what you mean, Auntie. My daughter is on immunosuppressants. Fortunately there are not a lot of other people working at her biotech startup and no-one went to the Boston biogen conference. She is able to do a combo of working from home and then goes into work to run experiments in the lab by herself.

bagoh20 said...

I would opt for first priority is determined by odds of survival times estimated years of survival. If life is the objective, then more life beats less life.

Josephbleau said...

The answer to all ethical questions seems clear to me. You make choices to maximize utility. The problem is, what utility standard should we use. Capitalism does this by proxy, by allowing people to pay more for scarce services and treatments, thus restricting demand to those with the highest desire for the good, excepting the fact that those with more money get more. If we define utility in the sense that “the good of the many outweighs the good of the few” we need a score for each person to include family interests and special abilities and future productivity, all weighted by the time you have left to exercise them. This could be worn on a bracelet giving you your value to humanity.

This is abhorrent because the raters have power over others lives and are not angels, so we have to throw all of that out, even if we try to be objective and make it about age or health or something allegedly objective, it will fall into bias. Imagine if a triage protocol was not statistically race neutral.

We have to forget all this ethics bs, and just quietly let Doctors muddle through making decisions sub rosa and not looking too closely. Using the marginal utility of a ventilator is good, but no one will let you rate that utility in practice.

I Have Misplaced My Pants said...

I don’t know what kind of point I am trying to make, except please consider who is reading these comments as you share your “hot takes."

In all sincerity, thank you for the reminder, and I'm so sorry for the vulnerability you and your family must be feeling right now.

Spiros said...

According to the South Koreans, the death rate for people under the age of 50 is between 0% and 0.1%. It is likely much lower since most asymptomatic people were not tested for Covid 19. It is insane to dedicate our healthcare to healthy men and women in this age group. They get Covid 19, they probably should just deal with it. In fact, there was an odd and massive spike in flu-like cases reported to the CDC in December, January and February (but there was NO odd spike in death rates). Hundreds of thousands of people thought they had the flu, but didn't. They recovered. You're hearing all sorts of anecdotal stories along these lines. So this disease has been around for a while, without much of a death toll...

BUT I am a bit concerned about how fat and unhealthy the kids are. Did you know that the hand grip strength of young men is plummeting (along with their IQ scores)?!! It is very strange. I've seen teenage boys struggle to open pop top cans. I hate to say it, but these kids are not only dumb, they're wimps and sissies. If the Deep State wants a war with China, it better take a long look at the potential pool of soldiers it has. The USA would get its butt whipped by China.

As a footnote, whatever the Italians are doing, they're doing it wrong. They're death rates from the flu and other contagious diseases are always double what they should be...

Ron Winkleheimer said...

Also, in an earlier thread someone asked what if the younger person is bad and the older person is good. The example given was murderer or rapist. That's exactly the sort of thing that doctors don't take into account when making medical decisions because whether someone is good or not is not a medical condition. If they start making moral decisions concerning peoples' character then they are playing God. Let me restate the example, what if the young person was a Republican and the old person was a Democrat?

Bay Area Guy said...

"My thought as I read the summary was: "What if this panic never materializes? What if none of this happens?"

Fact 1: US has a population of 330 Million.

Fact 2: Last winter, there were 490,000 Hospitalizations for the flu (out of 35 Million cases)

Source

Tom T. said...

Lots of interesting possibilities here. You're down to the last ventilator -- do you save Ruth Bader Ginsburg, or PewDiePie? Pope Francis or Pope Benedict? Hand-sanitizer-hoarder or ice-cream-licker? Undocumented homeless addict, or your mother-in-law?

rehajm said...

Your future self-driving car is pre-programmed with a comparable ethics algorithm to decide who it will plow into in an unavoidable situation, though I'm not sure the math takes age, race or gender into account. Bet they're working on it though...

DavidUW said...

Journalists discover triage.
what's next? their little minds are blown daily.

Mark said...

I commented on this yesterday.

It is a policy of not only triaging/rationing care, it is a policy of taking ventilators away from people using them now in order to give them to others.

Sebastian said...

"I think survival rates - if they are accurate - should be the determining factor and then age up to a certain point."

No. Survival to what is the question, and for how long. QALYs, people.

But not factored into the hypos is the cost of decision-making. In a crisis, time is scarce. Estimates become bunk. Therefore, you need simpler decision rules. Regardless of your "ethics," in triage you will default to simple.

When demand outstrips supply, i.e., at the point of actual crisis, I propose rigorous age discrimination: no ventilators for anyone over 80, and only for 70-80 if they are free from underlying conditions and can expect to live another decade. Then we may have time to contemplate Althousian hypos for everyone else.

Freeman Hunt said...

Is it a good idea to turn these decisions into an algorithm?

Spiros said...

Sebastian, you're right! It is every man for himself on a sinking ship (women and children, and the elderly, be damned!). This attitude is reflected in the Italian approach to the Covid 19 crisis. The Italians have (essentially) stopped treating elderly coronavirus patients due to "socialized medicine." Nice.

But the results in Italy have been devastating. Especially, psychologically. I think the better response, as long as we're able, is to treat the most vulnerable first and those most likely to benefit from medical care. Thankfully, given the extremely low fatality rate (the data is rolling in now) of Covid 19, we are not going to be tested in this ugly manner.

narciso said...

the same medical ethicists, who pushed us into Obamacare, which surprise doesn't make dealing with this pandemic any easier,

chickelit said...

In the olden days we would save women and children first because men were genetically expendable. But these days with so many women choosing to go childless, that dynamic has changed. Chivalry went down with the Titanic.

narciso said...

and with Ezekiel Emmanuel, as part of biden's advisors, well wasn't the praxis he recommended,

Fritz said...

Spiros said...
Sebastian, you're right! It is every man for himself on a sinking ship (women and children, and the elderly, be damned!). This attitude is reflected in the Italian approach to the Covid 19 crisis. The Italians have (essentially) stopped treating elderly coronavirus patients due to "socialized medicine." Nice.

But the results in Italy have been devastating. Especially, psychologically. I think the better response, as long as we're able, is to treat the most vulnerable first and those most likely to benefit from medical care. Thankfully, given the extremely low fatality rate (the data is rolling in now) of Covid 19, we are not going to be tested in this ugly manner.


My sister in law got a letter from her relative in Italy yesterday:

A Letter from Italy

Drago said...

Freeman Hunt: "Is it a good idea to turn these decisions into an algorithm?"

No. But an 8 to 15 layer Deep Learning reinforcement-trained Neural Net just might be more effective than you can imagine...with that recommendation-predictor delivered at near immediate speed for human review.

Narayanan said...

Points to remember:
Ethicist always assume lifeboat situations not flotillas of empty cruise ships available for rescue.

All problems framed within socialized medical institutions and resources. No private sector to be included.

Spiros Pappas said...

Fritz, 65 million people live in Italy and 2,500 Italians die every day of something. Covid 19's death toll is ugly. The images are powerful and moving. But Covid 19 represents a tiny part of overall deaths. And I don't believe our response to this virus is rational.

rehajm said...

Is it a good idea to turn these decisions into an algorithm?

It's a deep question recognizing in this context they're really just automated decision trees or in the medical verbiage protocol - we're substituting judgement and nuance for blind mechanics.

Perhaps it's not a poor decision in the absence of good judgement?

Laslo Spatula said...

""Is it a good idea to turn these decisions into an algorithm?"

It depends on how well the algorithm responds to bribes and the celebrity factor, I guess.

I am Laslo.

RMc said...

Undocumented homeless addict, or your mother-in-law?

What if they're the same person?

The Cracker Emcee Refulgent said...

“Good grief is there anything more absurd then an "Ethicist"- oh wow, he has a title, lets listen to him! “

No kidding. I should hang out a shingle. I’ve noticed that I’m consistently more concerned about doing the right thing than those around me. I say that modestly, natch.

One thing I’ve noticed about KungFlu coverage is journalism’s consistent insistence on asking the wrong person for opinions. Are we running out of masks? Ask a doctor instead of a supply chain person. Do we have to let Granny die so Johnny can have the bed? Ask the chief of the medical staff instead of the charge nurse. I shudder when I read this stupid shit.

R2d2 said...

Ron said, “Also, in an earlier thread someone asked what if the younger person is bad and the older person is good. The example given was murderer or rapist. That's exactly the sort of thing that doctors don't take into account when making medical decisions because whether someone is good or not is not a medical condition. If they start making moral decisions concerning peoples' character then they are playing God.”

Yes I know they don’t. The point was perhaps they should. Given approximately 5 percent of the ppl perpetually prey on the other 95 percent, (recidivism), the world would be a kinder, gentler place without them. It may also work as a disincentive to future criminality - you reap what you sow type of thing, so don’t be a criminal. Just as doctors try to eradicate cancer cells and try to save other cells, some cells are better for the world than others.

BleachBit-and-Hammers said...

"The novel coronavirus is causing working-age people to worry about missing paychecks, caring for kids home from school, stockpiling groceries and canceling plans. But people in their 50s, 60s or older have bigger worries. Many are lying awake wondering if this is how they are going to die.

At its most severe, the coronavirus attacks the lungs, making it impossible to breathe without a ventilator. Landing in the hospital on a ventilator is bad. But worse is being told you can’t have one.

Hospitals in New York are running short. To his credit, Gov. Andrew Cuomo is doing his best, but he admits “you can’t find available ventilators no matter how much you’re willing to pay right now, because there is literally a global run on ventilators.”

It’s a little late. Several years ago, after learning that the Empire State’s stockpile of medical equipment had 16,000 fewer ventilators than the 18,000 New Yorkers would need in a severe pandemic, state public-health leaders came to a fork in the road."

More

tim in vermont said...

How to conjure scarcity out of plenty

.@NYCMayor: If Trump doesn’t nationalize medical supply companies “in the next few days,” then “thousands will die around the nation who did not need to die.”

traditionalguy said...

Jeremy Bentham would be proud of these new “ethicists.” Now let’s use that game theory on RBG. Oops, you didn’t really mean it. It’s just propaganda for the Masses.

Yancey Ward said...

There is no point in discussing percentages here, Althouse- the real world does not work like this. Here is the decision medical personnel will actually face- who got here first. Ralph L, with one of the early comments asked the right question- would you remove someone who you thought was sure to die to ventilate someone who you thought can still be saved.

Of course, one can ask certain critical patients what they want done, if they are conscious. The real world muddles through these ethical questions without counting angels.

tim in vermont said...

From BleachBit and Hammer’s link:

They could have chosen to buy more ventilators to back up the supplies hospitals maintain. ­Instead, the health commissioner, Howard Zucker, assembled a task force for rationing the ventilators they already had.

In 2015, that task force came up with rules that will be imposed when ventilators run short. ­Patients assigned a red code will have highest access, and other ­patients will be assigned green, yellow or blue (the worst), ­depending on a “triage officer’s” decision.

In truth, a death officer. Let’s not sugar-coat it. It won’t be up to your own doctor.

BleachBit-and-Hammers said...

"In Italy, the death rate from coronavirus is a staggering 8 percent, more than double what’s occurring in many other countries. That’s partly because almost a quarter of Italy’s population is over 65 and thus especially vulnerable.

The other reason is that ­Italy’s universal national health system promises free care but delivers stingy care. Italy has only around one-third as many intensive-care beds per capita as the United States does. Coronavirus patients are being turned away.

Expect the same dire results in the United Kingdom. The British National Health Service allocates about one-fifth as many intensive care beds per capita as American hospitals do. Bernie Sanders, are you watching? What’s happening in Italy and Britain is proof single-payer heath care is emphatically not the way to go."

More.

Ron Winkleheimer said...

First of all, triage is nothing new for hospitals.

Many years ago when I was in the Army I took a friend to the base hospital emergency room because she was feeling ill with nausea being her primary symptom. The hospital was on a Marine base and it happened to be a Friday night, so she was never seen and we ended up going back the next morning. Marines kept coming in that had been in fights and she kept getting bumped because "if it bleeds it has priority."

Yancey Ward said...

rcocean wrote:

"There's also a third factor. Bad taste. Anyone who likes Neil Diamond or Sedaka goes to the bottom of the list."

You can have my Neil Diamond CDs and my ventilator when you pry them from my cold, dead hands.

But you have a point about Sedaka.

BleachBit-and-Hammers said...

If democrats are to blame - they won't be to blame. Ever.

Because as usual, with the corrupt hack press - Trump is to blame for all things.

Nonapod said...

for example, X has an 80% chance of surviving without a ventilator and a 90% chance of surviving with it and Y has a 10% chance of surviving without a ventilator and a 60% chance of surviving with it? Does X, the more vigorous person, get the task of struggling to survive without the ventilator?

In a triage situation, in my own completely unprofessional opinion, yes. As horrible and inhuman as it might sound to reduce people to presumed percentages (which, lets face it, are ultimately just guesses anyway), you'd have to go with the option that theoretically saves the most people. As such, in this specific example you have 2 possible choices:

1. (90% and 10%) 90+10/2 = 50
2. (80% and 60%) 80+60/2 = 70

The desired outcome is both patients surviving so option 2 is the better choice.

Of course, as others have already pointed out, this example is unrealistically reductive. In reality you're not realing with just 2 patients in a vacuum like that. Rather, you're deal with dozens and you're making a sorts of guesses with head-math/napkin-math/back-of-the-envelope math.

Ron Winkleheimer said...

Yes I know they don’t. The point was perhaps they should. Given approximately 5 percent of the ppl perpetually prey on the other 95 percent, (recidivism), the world would be a kinder, gentler place without them. It may also work as a disincentive to future criminality - you reap what you sow type of thing, so don’t be a criminal. Just as doctors try to eradicate cancer cells and try to save other cells, some cells are better for the world than others.

The problem with that is that it will devolve into "that guy is a transphobe, or he is against gay marriage, or he's a Republican" pretty quickly.

Amexpat said...

Anyone who likes Neil Diamond or Sedaka goes to the bottom of the list.

Used to think that until I heard Neil Diamond's "Solitary Man" a few months ago. The song is borderline schmaltz, but it's a very good song.He should also get some credit for writing "I'm a Believer"

tim in vermont said...

"Italy has only around one-third as many intensive-care beds per capita as the United States does. “

Where is ARM to explain to us that our high spending on health care makes us uncompetitive and that the Democrats are going to cut that expense with clear eyed realism and ethical rationing.

Remember Zeke Emanuel? He is working with Biden. Low cost health care designed by Dr Kavorkian.

tim in vermont said...

Neil Diamond’s ealy stuff was good. Tap Root Manuscript was a great album. I think I will listen to it today in the car, if I leave the house, that is.

BleachBit-and-Hammers said...
This comment has been removed by the author.
BleachBit-and-Hammers said...

who makes ventilators?
where are they made?

China?
If so, that must change.

Where are the super-hero billionaires? Too busy making fancy Teslas or space-ships or running 500 million dollar presidential campaigns to no-where?

Drago said...

traditionalguy: "Jeremy Bentham would be proud of these new “ethicists.” Now let’s use that game theory on RBG. Oops, you didn’t really mean it. It’s just propaganda for the Masses."

If RBG were to succumb to the ravages of cancer or Commie Chinese Wuhan Virus it will take about 1.9 milliseconds for the dems to blame Trump with a not insignificant plurality of dems asserting Trump personally launched the virus to do just that.

I suspect House dems would then demand hearings due to the "seriousness of the accusation".

Curious George said...

"Laslo Spatula said...
""Is it a good idea to turn these decisions into an algorithm?"

It depends on how well the algorithm responds to bribes and the celebrity factor, I guess."

*Cough Steve Jobs cough*

Leland said...

.@NYCMayor: If Trump doesn’t nationalize medical supply companies “in the next few days,” then “thousands will die around the nation who did not need to die.”

Did he really say this? If so, the gig is up. This isn't about fighting a virus.

tim in vermont said...

Zeke Emanuel put in an exception for people of "high utility” like himself

Here, read it yourself. This is an advisor to Joe Biden and Obama Admin Obamacare guru https://philpapers.org/archive/PERPFA-2.pdf

tim in vermont said...

Yes, he said it.

https://twitter.com/NYCMayor/status/1240471907335536641

Ken B said...

Does partying at Ft Lauderdale instead of following medical advice matter?

exhelodrvr1 said...

Death panels!!

Ken B said...

I think we need to prioritize researchers, doctors, nurses. We need to get them the masks first, the drugs first, and the ventilators first. This is true whether they are 28 years old women or 72 year old men.

BleachBit-and-Hammers said...

Imagine if we had Cuban health care. Michael Moore health care.
We wait in line to die, while the propagandists and party leaders ... live large.

Karen said...

Why are we having this argument when we should be manufacturing ventilators 24/7?

Yancey Ward said...

"*Cough Steve Jobs cough*"

Is that a dry and unproductive cough?😜

Leland said...

So they are finally announcing the end game. We have to go full on authoritarian communism in order to fight the Chinese Coronavirus, because it worked so well for China. We have dictated that people stay home, the businesses for leisure are closed, we've restricted productivity, and now we must nationalize businesses by executive fiat. I'm thinking this we the plan from the beginning in terms of using this routine illness as a method to bring about political change.

Otto said...

Using polynomial order 4 regression, March 20th USA predictions:
85 new deaths
6,800 new cases
Will publish results tomorrow.

Nonapod said...

Is it a good idea to turn these decisions into an algorithm?

I'd argue yes, precisely because it's inhuman. Triage is the ultimate zero sum game where you have both finite resources and a clear, optimal outcome (saving as many lives as reasonably possible). In a triage situation, time is of the essence and health care workers can't afford to muse and philosophise about the ethics of each choice that's before them. Math reduces people and choices to numbers. On the surface that may seem monstrous. After all, reducing people to numbers has been used in the sort of arguments that've been made by the most vile eugenicist and authoritarian dictators. But I'd rather be accused of being a monster for saving more lives with math than making choices that ultimately cost more lives under some other thought process involving some notion of more humane behavior.

dbp said...

"X has an 80% chance of surviving without a ventilator and a 90% chance of surviving with it and Y has a 10% chance of surviving without a ventilator and a 60% chance of surviving with it?"

Let's say X is 25 years old and would expect to live to 75 if they survive this illness. Y is 70 years old and would expect to live to 80 if they survive the illness. (The values are made-up for this hypothetical).

The utility calculations would be as such:

X: 0.1 X (75-25) = 5 saved years
Y: 0.5 X (80-70) = 5 saved years

They are even values, perhaps our hostess planned it out this way!

In such a case, I would say the vent should stay with whoever had it first. In fact, I think it would be unethical to take away a vent unless the difference in utility was very very large.

Leland said...

Why are we having this argument when we should be manufacturing ventilators 24/7?

We are. Nobody needs them right now. Name the place in the United States that has run out of ventilators. If and when they do, are you getting training to operate them? Because we will run out of doctors and nurses to manage them before we run out of the machines. The limitation of trained staff is why triage has been in practice at medical facilities for centuries. That this is something new we need to consider is media hype. I had triage training when I signed up for my local Citizen Emergency Response Team (CERT) ten years ago.

Crazy Jane said...

Why not ask the patients?

If I were 75, healthy for my age and had led a satisfying life that included launching children who could take care of themselves, I like to think I'd say, "Sure, give that young parent the ventilator -- his children still need him."

narciso said...

it was the same betsy mcaughey, who found the flaws in Hillary care, and found the death panels, ipab, in the stimulus bill, that Bachmann and the huntress brought to public attention,

HT said...

Ann you are approaching this issue like a lawyer. This is not how medical personnel think in the heat of the moment (see comment above about prioritization). But it's an interesting question for discussion.

I like it that you're thinking of the patients, esp older ones. But right now, medical personnel are being actively feared and inadequately protected. This helps no one, no matter how long anyone speculates they will live.

Jupiter said...

"Ralph L, with one of the early comments asked the right question- would you remove someone who you thought was sure to die to ventilate someone who you thought can still be saved."

Not quite. The right question is, would you take someone who was doing just fine off his ventilator, to give it to someone younger. That is where this logic leads.

tim in vermont said...

" are you getting training to operate them?”

Compromises will have to be made on qualifications. People who have survived it will have to volunteer. How long did it take them to train fighter pilots during WWII? How long does it take in peacetime?

I think that the crucible of this thing is hidden from most of us, in the IC wards of hospitals, nicely out of sight. It’s not like The Blitz where there is a public spectacle of the casualties. In a lot of ways, this pandemic is an abstraction, and abstractions are hard for a lot of people to process.

dbp said...

Operationally, I can think of a couple of ways that hospitals could operate:

1. As long as you have idle vents, give one to anyone you think might benefit. But you will only do this if you reserve the power to pull one away from a patient who hardly needs it and give it to a patient who really needs it badly.

2. Reserve vents to be used only for people who need them badly. The draw-back to this mode is that you are leaving resources underutilized.

Protocol 1 will save more lives than 2, but I would be willing to bet that most hospitals will choose 2, because it relieves them of difficult decisions.

exhelodrvr1 said...

"Imagine if we had Cuban health care. Michael Moore health care.
We wait in line to die, while the propagandists and party leaders ... live large."

But we would all be able to read much better!

tim in vermont said...

Incidentally, IRL, it seems like both my Democrat Trump hating friends and my Republican friends are in a kind of denial. The difference is that the Democrat friends give it lip service, up to the point where it affects their behavior, when they ignore it, and the Republicans behave exactly the same, but don’t lecture everybody on how they should behave.

HT said...

"the Republicans behave exactly the same, but don’t lecture everybody on how they should behave. "

You sound like you're in denial.

Ken B said...

“Imagine if we had Cuban health care. Michael Moore health care.
We wait in line to die, while the propagandists and party leaders ... live large.”

Or a Bernie Sanders pharma industry with no investment in research or development.

Or a Joe Biden medical system where al, our drugs came from China ...

tim in vermont said...

"You sound like you're in denial.”

I call ‘em like I see ‘em.

Mark said...

It's not just young against old.
It's the able-bodied against the disabled.

According to New York State Department of Health “Ventilator Allocation Guidelines”:

With their arrival at the hospital, [chronic care patients] are treated like any other patient who requires a ventilator and need to meet certain criteria to be eligible for ventilator therapy. While a policy to triage upon arrival may deter chronic care patients from going to an acute care facility for fear of losing access to their ventilator, it is unfair and in violation of the principles upon which this allocation scheme is based to allow them to remain on a ventilator without assessing their eligibility.

Distributive justice requires that all patients in need of a certain resource be treated equally; if chronic care patients were permitted to keep their ventilators rather than be triaged, the policy could be viewed as favoring this group over the general public.


Yes, they will rip that equipment from people who have been using it for months or years in order to give it to someone whose life is deemed to be more worthy of life.

tim in vermont said...

I was talking about real life, not on line.

wendybar said...

Traditionalguy said...
Jeremy Bentham would be proud of these new “ethicists.” Now let’s use that game theory on RBG. Oops, you didn’t really mean it. It’s just propaganda for the Masses.
3/20/20, 9:52 AM


Ding Ding Ding!!!

Ignatius Acton Chesterton OCD said...

Here is a story people seem to be missing about what is going on in Italy:
https://www.bloomberg.com/news/articles/2020-03-18/99-of-those-who-died-from-virus-had-other-illness-italy-says

We are well into the process of wrecking our economy. The WSJ had an excellent lead editorial recommending balance in our approach to Coronavirus.

What we are witnessing is a panic, driven by one-size-fits-all public health policy, driven by people who are choosing the safest path amidst uncertainty. Understandable early-on, but a picture is starting to develop. This confinement needs to end as soon as reliable testing is in place. And it needs to happen fast.

We need to segment our population based on vulnerability. We simply cannot endure 18 months of this. We'll be a Third World country by that point. Stay at home until July/August? That's poppycock. All this moralizing and hectoring about what might happen is bringing out the worst in everyone.

If vulnerable demographics can shelter in place, fine. Retirement allows for that kind of flexibility. If people can work from home, fine. Telecommuting may work for them. None of this is ideal. But there is little being written about this reality: blue collar people cannot work from home. Why should everyone have to halt their economic lives?

Again, balance is needed. This may be a nasty virus. We've seen these kinds of deadly viruses before. We've dealt with them in an altogether different way than we are now. This seems over-the-top, all-encompassing, zero tolerance. This is not the Bubonic Plague, which was bacterial. COVID-19 is a virus.

Zero tolerance = zero thought. What happens with COVID-20?

narciso said...

btw, boessert seems to auditioning for the Richard Clarke role, re the piece by former fusion trey recipients,

Unknown said...

Maybe we need to institute a social credit system. Those with the most social credit points win a respirator. (Yes, I'm being sarcastic.)

Bob Smith said...

If you are my age (80+) and you don’t know about triage you didn’t get out much. Just another consequence of trying to build a consequence free society.

Robert Cook said...

"...the same medical ethicists, who pushed us into Obamacare, which surprise doesn't make dealing with this pandemic any easier...."

"Us?" Were you pushed into Obamacare? I wasn't. I maintain my employer-funded group insurance policy that I have had for years. (Though premiums increase and what and how much is covered decreases each year, a dynamic that was always in place and is not particularly a consequence of Obamacare.)

If you had insurance that you paid for entirely yourself, was there a circumstance such that you could not keep it? Did you then obtain medical insurance via Obamacare? How does this make it more difficult for you or others to deal with this pandemic?

Levi Starks said...

I prefer the socialist approach,
If everyone can’t have a ventilator then no one gets one.
But seriously, choosing those under 18 vs. 18 and over values future utility over present utility.
It’s possible that in the end more under 18’s might be saved by saving those with knowledge/skill today. And I don just mean doctors.

Leland said...

1. As long as you have idle vents, give one to anyone you think might benefit. But you will only do this if you reserve the power to pull one away from a patient who hardly needs it and give it to a patient who really needs it badly.

That's the part that's unethical. If you put a patient on a ventilator, then you did so because 1) they needed it and 2) use of it meant they have a chance of survival with it. Therefore, if you take it away to give to another patient; then you have decided to allow the first patient to die. It's one thing if that patient has had a change in symptoms and the ventilator will no longer be enough. It's another if that initial patient is stable, and now you will put them in danger by removing the ventilator.

2. Reserve vents to be used only for people who need them badly. The draw-back to this mode is that you are leaving resources underutilized.

Practically, this is what is done via triage, at least initially. The assumptions is you have limited resources. You then prioritize your patients. You treat the most severe but likely to recover patients first within your capacity and resources. At that point, assuming you have the ventilator and resources to hook them up and monitor them, you start assigning them to the patients that need them and are likely to recover with them. Lots of variables come into play with age being on the very low end. For example, is the patient struggling with breathing, has low blood oxygen levels, yet is conscious and able to talk about symptoms? Or is the patient passed out, shows signs of breathing problems, and cannot communicate? Notice, age, sex, race are not part of the signs you are seeking.

If we get later into this, and there is one ventilator and the decision is who of the many gets it next; the same criteria will be used, but the nearest patient that's most likely to survive with the ventilator may get it over another simply because the more limiting resource is the time of the doctor and nurses in hooking up the patient. They don't need to be standing around framing the decision that needs to be made.

Levi Starks said...

One additional comment,
The very reasoning process shows how much doctors have taken on for themselves the roll of God.
Some deemed ventilator critical will survive, even in the absence of one.
While others in the same situation will still die even when provided with one.
Uncertainty is the real enemy,
And no matter how advanced we as a society become uncertainty will still exist.

Marc said...

You make choices to maximize utility.

I make a choice because it seems to me that it represents the closest approximation to the good that can be had at the moment. When I make a good choice, anyway.

Will be interested to read the National Catholic Bioethics Center analysis on this question of ventilator access triage when it becomes available.

Crazy Jane said...

Or do something practical instead. In China, 76 out of 100 patients given chloroquine survived while 10 out of 100 patients given placebos survived.

Another benefit of chloroquine was that it improved the health of a number of patients to such an extent that they could be taken off ventilators, which -- duh -- freed up some ventilators for other patients in worse shape.

This week, Bayer, the German company sent the U.S. millions of doses of chloroquine.

Meanwhile, our CDC is dithering about whether the lack of "large clinical trials" should restrict the release of chloroquine to very, very sick US patients.

Again, why not ask the patients? Would you like to try a drug that won't hurt you (i.e., passed the FDA's Phase One test long ago) but cured 76 out of 100 patients in China? Or would you rather stay on this ventilator until the wise bureaucrats at the (laughably named) Centers for DISEASE CONTROL give you permission?

Nichevo said...

Yes I know they don’t. The point was perhaps they should.


Curiously, Lebensunwertes Leben got a bad rep about eighty years ago for some reason. The Russian translation, of course, is Kto kovo? (Who, whom?)

I'm fine with decisions on such basis as long as I'm the decider.

Rick said...

the roll of God.

Def: toilet paper which self-replicates as it unwinds.

Achilles said...

It is a good thing we are not going to have a long term shortage of ventilators.

If you require a ventilator to live, you will pay well to have one made.

There will be someone there to supply it.

If we are allowed to that is. Regulations always seem to be relaxed for some reason in those situations. Feather bedding bureaucrats know when to hide from those with pitchforks and torches.

I think most would be surprised if there were a shortage of ventilators how quickly they would be produced given the right incentive.

The issue is that people read these stories written by journalists. Journalists are only more intelligent than 2 groups of people: Sports Journalists and Teachers.

WK said...

I would anticipate that if we get to the point of inability to provide treatment due to lack of resources - the federal govt will develop some type of “Coronavirus Victims Compensation Fund” for surviving family members. Some are already comparing this to 9/11 which resulted in benefits for those killed in the attack. Isn’t this being described as an assault that originated in China?

tim in vermont said...

"Uncertainty is the real enemy,”

It’s managed through probabilities based on long experience. Sure, it would be better if we had Barbara Streisand’s powers in “On a Clear Day” where her husband insured ships, and she knew which ones were going to sink on account of she had magic. That’s musical comedy, in the real world grown ups deal with probabilities and understand that they are not certainties. Anybody who can’t do that is still a child and certainly not a doctor.

tim in vermont said...

"Isn’t this being described as an assault that originated in China?”

The trial lawyers have found their angle! “I have a scheme."

hombre said...

Are the criteria set by “death panels.” Why yes, they are.

Tomcc said...

Somewhat on topic:
Our local news had a segment a couple of days ago where the crew visited a ventilator manufacturer based in WA. They are ramping up production, as one would expect. The question that I would have liked answered is "where do the components come from?"
According to that report, there are five manufacturers in the US.

TSH73 said...

Ann,
I think your hypo is interesting but slightly gets wrong the medical reality. If X and Y need the ventilator, they need it all or none. So putting the matter as this or that chance of surviving without it is the wrong way to put it. Try it this way:

X and Y are going into respiratory failure and need mechanical ventilation to survive. Both have pneumonia which has progressed to respiratory failure. X is 55 and has moderate underlying COPD. You judge him to have a decent chance of recovery but it will not be quick. Y is 45 and has no underlying illnesses. He is very sick but has “better protoplasm” than X and a better chance of quicker recovery with mechanical ventilation than X in your judgment as a clinician. Which do you intubate if there is only one ventilator?

With your hypo, I think it’s an intelligible intuition to favor giving the ventilator to the sicker patient who needs it more even if chance of recovery is less. With my hypo, I find it easier to think that you give the ventilator to the guy most likely to recover. But its not obvious that either choice is definitely the right one.

R2d2 said...

Nichevo - unfortunately there may a time where a critical decision as to who receives medical care. You are far too quick to deem the elderly, the “greatest generation” who battled for freedom into those “unworthy of life.” That generation gave life to others. Perhaps reciprocity is owed. Yes owed. In contrast you have those that maliciously destroy life or the quality of life for others. Everyone is worthy of life, but a harm/benefit analysis to society is at least, if not more, rational as pitting old vs young. And the decider has just as objective criteria as the age split. As for as slipper slopes go, where is the age cutoff? 80, then 70, then 60 ... hey, if it gets really bad, we’ll have 5 yo running things. Again, those is left standing will be the ones who rebuild - so who do you think it more likely to rebuild?

Inga said...
This comment has been removed by the author.
n.n said...

"Ethicists" ponder their religion. That said, ageism is not a novel Choice.

n.n said...

Are the criteria set by “death panels.” Why yes, they are.

Single/central/dictatorial vs distributed/organic/democratic. In a society with an established Pro-Choice religion, the latter tamps down the curve.

Leland said...

The question that I would have liked answered is "where do the components come from?"

The report on CBSNews had the spokesperson from such company clearly stating they have no issues, none, with their supply chain. I don't recall if they clarified where their supply chain extends, but I thought they only pertinent news was they had checked their supply chain and they weren't worried, as they pump out 150 ventilators a month.

Sebastian said...

"What we are witnessing is a panic, driven by one-size-fits-all public health policy, driven by people who are choosing the safest path amidst uncertainty."

At this point, the panic has become a political CYA operation.

The politicos want to be seen as "saving lives," valuing "each of our lives," being fair and nice and compassionate. That includes Trump.

But nice is not nice. CYA is politically rational but economically disastrous. It has to stop. It will, cuz it can't go on.

Megaera said...

Several points should be made re vents -- I made some of these before, but they may bear repeating. First, even if you had 500000 vents available, with all the connection sets (multiple sets for each pt over any space of time), unless you have 500000 teams of respiratory techs to go with them, your ability to deploy is constrained by staff available, who can handle only so many pts at a time and cannot, reasonably be assumed to be capable of working 24/7 before collapsing and dying themselves. So, good luck with that. NY should have bought those 16000 vents when they had the chance in 2015, but elected to spend the money on valuable stuff like midnight basketball programs, not on training and staffing and equipment.

The decision to put someone on a vent is not made lightly or casually -- it's usually, that or this person dies/sustains permanent brain damage. And once ON a vent, you can't just
"take the pt off" and give it to someone you somehow deem "a better candidate" -- or rather, sure you can do that, and you will kill the vent user. Understand, this machine has been doing all the patient's breathing for him, in out in out, 24/7, constantly monitored and adjusted for every machine-measurable parameter - dc that process, and you are going to kill the patient. Half of a RT's work is weaning patients off vents, even off remedial 02, because otherwise they die. Glad you're so willing to turn your squads of RTs and techs into murderers just because somebody decided a 20-something tattooed MS thug has a better chance on a vent than the 70 yo teacher who paid into the system all his/her life . Geeze, you guys.

CPAP and BIPAP are NOT the same as vents and not in any way a usable substitute.

I keep seeing this assurances that we can train up squadrons of RTs and vent techs overnight -- good luck with that. Who's doing the training? All your working techs are, well, working -- and schools won't accomodate a vast influx of the trainee pool you envision -- and if you think hospitals will accredit them and turn them loose, um, think again; For pity's sake, the FDA is blocking use of a proven medical therapy in time of pandemic emergency because they're whimpering about running clinical trials and crap like that, like every bureaucrat in every time and age, protecting his turf at everyone else's expense. Neither the FDA nor hospitals nor staff will have any protection against the plaintiff's bar, and the rest of their effective lives will be spent litigating whether it was a clever decision to turn an unlicensed, untrained medical student loose on a machine that can suck your lungs out or overinflate them to the bursting point if you screw up on a setting.

Sorry this sounds cranky, my shoulder's broken and it hurts to keyboard.

Ralph L said...

The techs don't sit there and monitor a single patient 24/7, do they?

West Texas Intermediate Crude said...
This comment has been removed by the author.
West Texas Intermediate Crude said...

What Megaera said. And I hope his shoulder gets better.
Then add trained ICU nurses and pulmonary/critical care physicians to the mix. All 3 in short supply at baseline. No way to generate these folks quickly, unless you want to accept Insta-Docs and Insta-nurses who will make mistakes and some people will die. The Instas will not exist unless the medmal system is suspended. Like that's gonna happen.
Or, the hydroxychloroquine and remdesivir will work, and the onset of warm weather will slow the virus, and the CFR will be <0.1%. It could happen.

Megaera said...

Was that sarcasm? The minutiae of hospital staffing is way, way beyond my remit, but surely you can grasp that hospitals have minimum 3 shifts/24 hr and there are minimum numbers of staff per vent pt (they have to be fed, bathed, turned, connections maintained/changedl treat,emt details logged) and so on FOR EACH PATIENT...it's not some lazy orderly sitting looking at a screen every eight hours or so. These pts DIE if they are not managed, and it is a intense process. Which may be why there are not huge numbers of RTs jamming the doors of hospital personnel departments. What do you do when you suddenly have 20 vent patients, needing all that care and more: When that number blows up to 40? 60? And it becomes impossible to deal with? And your connection sets are all used up with no replacements available? Hope you're never a pt under those circumstances. But see: Italy.

Nichevo said...

R2d2 said...
Nichevo - unfortunately there may a time where a critical decision as to who receives medical care. You are far too quick to deem the elderly, the “greatest generation” who battled for freedom into those “unworthy of life.” That generation gave life to others. Perhaps reciprocity is owed. Yes owed.


Hi r2d2,

I say this without anger as perhaps it was I who was unclear-please don't put words in my mouth.

Number one, this is not, yet, the lifeboat, this is not Omaha Beach or the second trench at Stalingrad. At this point I think existing processes can decide individual cases on the merits. For three thousand years physicians taking the Hippocratic oath have been dealing with these issues. I'm not sure some Princeton philosophe is needed here to tell them what to think.

Second, I don't believe I said what you seem to imply that I said. I may have said that I disagreed with the reverse.

Third, as I've said elsewhere, I would expect that *within families,* the doctor wouldn't have to choose between Grandparent and Grandchild, surely at least the preponderance of the elders would say No, save the wee one. On that basis, if we are playing Princeton rules, certainly Grandpa Smith would defer to Grandson Jones on the basis that Grandpa Jones should defer to Grandson Smith.

I think the ethics of organ donation would be the closest analogy. Mostly oldsters and the unhealthiest will be the ones getting the other end of the stick. Nothing to do with "worthiness." I don't think we have to reinvent the wheel.

Nichevo said...

I think the ventilators is not the big deal, didn't someone devise some kind of hydra head attachment allowing one machine to serve nine patients? The limit will be people. I wouldn't know whether you can make an acceptable shake-and-bake respiratory tech. As for the pool of applicants, at present there are a buncha people not working.

Bob Loblaw said...

'I would say that leaving some to die without treatment is NOT ethical, but it may be necessary as there are no good options,' David Chan, philosophy professor at the University of Alabama at Birmingham, writes. 'Saying that it is ethical ignores the tragic element, and it is better that physicians feel bad about making the best of a bad situation rather than being convinced that they have done the right thing.'

The idea we can say something isn't ethical because people should feel bad when they make a hard decision is nonsense on stilts. Universities have become day care centers for elderly children.

Nichevo said...

My personal opinion is that *some* of you oldsters are clinging too tenaciously to life, but that's every man's own choice to make for himself, not mine.

Bob Loblaw said...
This comment has been removed by the author.
Bob Loblaw said...

I think the ventilators is not the big deal, didn't someone devise some kind of hydra head attachment allowing one machine to serve nine patients? The limit will be people. I wouldn't know whether you can make an acceptable shake-and-bake respiratory tech. As for the pool of applicants, at present there are a buncha people not working.

Ventilators are not that complex. What makes them expensive and hard to source is the plethora of regulation meant to ensure they work 99.9% of the time, say, and not 98% of the time. We could absolutely increase the number of vents by a large margin.

As you say, the limit is people. We can't magically double the number of ICU teams necessary to make the equipment useful.

Nichevo said...

Megaera, sorry about your shoulder, wishing you complete and speedy healing. If you choose to rely on voice to text, I'm sure people will cut you slack on typos.

Nichevo said...

As for people-I've been thinking for some time we need a (crash or not) program to increase the number of medical people. More or larger med schools, I guess. Can't hurt in any case. I doubt we've scraped the bottom of the talent pool.

Skeptical Voter said...

Difficult choices when resources are short get made all the time-and not just in medicine.

But one of the areas where a lot of very difficult choices have to be made is in organ transplants. Who gets the new heart (I've had one friend who waited three years before his slot came up). Who gets the new liver (a friend's son waited four years--and died before he got it).

Consider also the case of an 18 year old Armenian girl at UCLA three or four years ago. She had a series of conditions which meant she would inevitably die within less than two years. There was a possibility that an experimental operation which would cost several hundred thousand dollars might--I say might--extend her life by three months. The medical insurers turned her down. There was a mighty hoohah about the racist nature of the denial, lawsuits were threatened and the insurers caved. I think the girl also needed a kidney transplant. Do you give a rare transplanted kidney to someone who is going to die within less than a year--or do you save it for another patient, otherwise healthy who would live for 45 years with the transplanted kidney? You guessed it--UCLA gave the 18 year old the kidney--and she died within four months of having the transplant.

Call it bio ethics--or call it allocation of scarce resources (say the number of trained respiratory therapists to manage someone on a ventilator)--hard choices are made every day. Get used to it, because that's the real world.

R2d2 said...

Nichevo - sorry, didn’t mean to put words in your mouth. And certainly, within families, grandparents would give their heart to the grandchildren. But that is not the choice we may face.

The choice is either to save some tatted banger who terrorizes anyone in a 50 mile radius or the guy who stormed the beaches and now needs our help to live his life with dignity. The choice is who will make this a better world. And yes, who “deserves.”

Known Unknown said...

""In Italy, the death rate from coronavirus is a staggering 8 percent, more than double what’s occurring in many other countries."

That's confirmed cases only. I'd imagine in a country of 65m people, there's probably at minimum 500k who have been infected. Even if you accept the Diamond Princess infection rate of 19%, that's 12.4 million infections. So the effective death rate (I guess we will call it) is currently lower than 8 percent. At 8% death rate at the current infection rate (assumed, so grain of salt time) that would mean 988,000 deaths in Italy.





Known Unknown said...

"The choice is either to save some tatted banger who terrorizes anyone in a 50 mile radius or the guy who stormed the beaches and now needs our help to live his life with dignity. The choice is who will make this a better world. And yes, who “deserves.”

Doctors almost never choose based on those parameters.

R2d2 said...

Known unknown - yes, I know doctors don’t factor these externalities NOW.

But, given the path this virus may take, we need a new paradigm. What worked yesterday may not be applicable today. If this virus ravages the world, who will rebuild? Not the tatted banger for dang sure. And yes, the old guy that stormed the beach has more to offer the rebuild than the banger who preys on innocents.

When you go to amputate a limb, you don’t give equal weight to the gangrene limb as you do the healthy limb. You choose to make the person, or maybe in this case the world, survive and thrive. Who will make the world thrive?

Morkoth4682 said...

What I want to know is what the hell have the CDC, DHS, FEMA and all the other alphabet agencies been doing with the hundreds of billions of $$$ we give them every year??? Isn't part of there mandate to stockpile HUGE emergency reserves of EVERYTHING for just these kid of scenarios? Masks, ventilators, reagents, fucking isopropyl rubbing alcohol... Why are we scrambling in the 11th hour to back-fill our emergency supply chain with stuff that should have already been taken care of?!?!?!

Iman said...

My Corona


My Corona
My Corona
Ooh, my little sneaky one, sneaky one
When you gonna give me a (break, Corona?)
Ooh, you make my nostrils run, my nostrils run
Turning red from having to (wipe, Corona)
It’s never gonna stop, I’m givin’ up, wipin’ my behind
Put one in my head, behind an ear, if you’d be so kind
My, my, my, ay, ay, woah!
M-m-m-my Corona
M-m-m-my Corona

stlcdr said...

Are there any places that have actually had to apply these ethical decisions?

n.n said...

Ethics or relativistic religion practiced in a secular crisis withing a society that has normalized wicked solutions. Caveat emptor.

Josephbleau said...

"Ventilators are not that complex. What makes them expensive and hard to source is the plethora of regulation meant to ensure they work 99.9% of the time, say, and not 98% of the time. We could absolutely increase the number of vents by a large margin"

What makes them really expensive is the judgements paid by ventilator companies to the plaintiffs bar by soft headed juries in product liability suits.

Josephbleau said...

the lawyer gets a third of the multi million dollar prize.

Nichevo said...

Iman said...


M-m-m-my Corona
M-m-m-my Corona

3/20/20, 6:18 PM


Thanks Iman! I was actually going to do that but you saved me thw trouble.

Now, could you rework Roy Orbison's "Pretty Woman" the same way?

The refrain:
"Ohhhh, ohhh, coronavirus"

Josephbleau said...

"Olivia Goldhill (Quartz)."

In it's day, there was a lot of quartz vein mined in Gold Hill Nevada. Mark Twain, in Roughing It, noted Gold Hill as the richest gold producer in Nevada. I don't think Olivia is concerned with stamp batteries with mercury amalgamation sumps, but the juxtaposition of history was too much to resist.

Freeman Hunt said...

"But I'd rather be accused of being a monster for saving more lives with math than making choices that ultimately cost more lives under some other thought process involving some notion of more humane behavior."

More lives as utmost value is already involving some notion of more humane behavior. I bet a lot of young guys in prison for murder and molestation have better chances of COVID-19 survival than boring middle-aged guys at home with families.

Making it an algorithm forces us to spell out exactly what outcomes we would prefer. But it is doubtful that we are really willing to do that, so the algorithm will lock people into making whatever choices some bureaucratic committee deems politically acceptable.

I think Josephbleau might be right:

"We have to forget all this ethics bs, and just quietly let Doctors muddle through making decisions sub rosa and not looking too closely. Using the marginal utility of a ventilator is good, but no one will let you rate that utility in practice."

Nichevo said...

The choice is either to save some tatted banger who terrorizes anyone in a 50 mile radius or the guy who stormed the beaches and now needs our help to live his life with dignity. The choice is who will make this a better world. And yes, who “deserves.”


Yes, I understand, I have no particular sympathy for the gangbanger per se, and probably it would have been for the best if the cop or the other gangbanger had been a better shot.

But anyone can tell a story.

Maybe that gangbanger is the grandson of a member of the Red Ball Express, who ran gas and guns and beans and bullets to keep Patton's Third Army moving, maybe throwing C-rats out the windows to hungry French kids on the way back, until a Teller mine under his deuce-and-a-half blew him to glory.

Maybe that Omaha Beach vet (my grandfather was at Omaha Beach; the world owes me nothing for it, nor would I ask, unless perhaps I could have back the service weapons and other memorabilia my grandmother threw out after his death, alas; my mother did reorder his decorations) was childless.

Maybe besides his valor, he was otherwise a problematic person, a war criminal perhaps, a rapist.

Or he may have been a super guy, and maybe that gangbanger if he survives is going to rape some girl-and knock her up and their child will grow up to cure cancer.

You can never know the whole story.

You're not God. Don't play at it.

Freeman Hunt said...

"You're not God. Don't play at it. "

It can't be avoided. You have to make choices. Choosing one way is not less "playing God" than choosing some other way. The question is: What sort of God do you want to play?

R2d2 said...

Nichevo- not playing God. But someone may very well have to make these choices. Just saying what criteria should be used. I think age is arbitrary and not productive.

Hope there are no choices, but if there are - we have to be adults and make the difficult choice. It has to be rational, fact based. If I had to choose ppl to repopulate a world, that tatted guy is not making it on my boat.

jeremyabrams said...

If I were 80 years old right now, I'd feel heartened that other Americans are self-isolating essentially for me. This week is proof of America's greatness.

mockturtle said...

A man in Maricopa County, AZ, died today and was in his 50's.

Nichevo said...

You are presupposing perfect information. If you're a surgeon or triage nurse and your GSW, MI, COVID-19, whatever, patient has tattoos, then starts coding, are you really going to wait to crack his or her chest until someone's Google Lens image search tells you whether that snake or bird or whatever is a Marine or Navy insignia, or a Crips or MS-13 icon?

-Oh, she's got a dove tattooed on her cheek.

-Image search says Mexican gang sign, pull the plug.

-(reads further) Wait wait of course it's a gang sign, the gangs do that to their rape victims! No, start compressions again!

-deeeeeeeeeeeeeeeeeeee (flatline SFX)

-D'oh!

...Or he's an undercover cop. Or a reformed thug who now does good.


My cousin the neuro (he started as a neurologist then went the whole route to recertify as a neurosurgeon) has told us countless stories of thugs and victims he has saved at places like Harlem Hospital. That's part of the game.

Otherwise eventually you end up with e.g. a Korean surgeon who will not operate on a Japanese patient, because WWII.

Plus, if you slack off on a patient even for the best of reasons - he attacked you, he killed your best friend, your family - and he does, you can still go to jail. (See Homicide: Life On The Street, S04E11, I've Got a Secret)

R2d2 said...

Nichevo - if only there was someway to quickly identify those with violent criminal histories. You know, like a fingerprint and a database. Oh wait, we can do that. Not every hospitalization requires instantaneous decisions. They not routinely cracking chests as the wheel ppl in.


Your slippery slope is off base, prioritizing those who have no criminal history is not at all like personal animus - straw man. And irrespective of a tv show, we can legislate/regulate criteria. This is a new world, and it may, of necessity, require new, more pragmatic rules.

Nichevo said...

R2d2, you bid fair to start a decent SF dystopia, but that is not the world we now live in.

And mixing medicine and the justice system? See Isaiah 64:6

Et facti sumus ut immundus omnes nos, et quasi pannus menstruatæ universæ justitiæ nostræ; et cecidimus quasi folium universi, et iniquitates nostræ quasi ventus abstulerunt nos.

Which all the English translations bowdlerize, even the Hebrew one:



JPS Tanakh 1917
And we are all become as one that is unclean, And all our righteousnesses are as a polluted garment; And we all do fade as a leaf, And our iniquities, like the wind, take us away.


"Polluted garment" is nice. Google up "quasi pannus menstruatæ" sometime when you're not eating.

No, the duty of the surgeon is to save the criminal, if only that he not escape justice.



And the justice system can tag the ones who got caught. The one who was clever enough to kill the witnesses and burn the evidence gets on your boat. The one who molested his sister till she hanged herself in the attic, and found the note before his parents got home? Come on board.

Who knows what evil lurks in the hearts of men?

You'd really be more efficient running razzias into the neighborhoods where the "bad people" live.


I appeal to any medical people here (assume you are not one, r2d2). Mike K? Inga? Is that how you operate? Is that how you want to operate?

R2d2 said...

Nichevo - you’re right, we’re not there yet. But think back 2 months ago - did you think we would be here?

Unfortunately, I think many hard decisions may need to be made. Whether it’s push granny off the cliff, or deny care to a gangbanger. There will be (is) no perfect system - neither the justice system or in medicine. But perfection is the enemy of good (I think that’s the saying) and doing nothing or making no choice (is itself a choice) is not perfect either. They’re is no easy answer, no right answer, no decision that will bring peace of mind. But imperfect or not, circumstance may well force a decision. You and I obviously fall on different sides of that choice.


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Nichevo said...

R2d2, the choice may have to be made, but not, I think, at the doctors' level. In a dystopian SF novel I was working on there were Black Medics, trained in knowledge as doctors are trained, but with a very different creed. Executions, interrogation and torture, elective and forced abortions with fetal tissue harvesting, genetic experiments to make Dolly and the CRISPR twins look like Lego models. Oh and biowarfare of course.

We have something that's worth keeping. The banger is not worth throwing that away. You want summary executions, that's the cops' job.

Bob Loblaw said...

But I'd rather be accused of being a monster for saving more lives with math than making choices that ultimately cost more lives under some other thought process involving some notion of more humane behavior.

The latter is exactly what happens with kidney transplants. People die on the transplant waiting list every day, and that could be fixed overnight if we allowed people to sell a kidney. But the optics aren't good, so it isn't allowed. And people die as a result.

tim in vermont said...

"What makes them really expensive is the judgements paid by ventilator companies to the plaintiffs bar by soft headed juries in product liability suits.”

Obama made it clear that he wasn’t going to piss off his big contributing trial lawyers in Obamacare, and he came through for them.

Freeman Hunt said...

Nichevo, this isn't about murdering people. You have two guys and one ventilator. Who gets it? This kind of choice may have to be made by doctors soon.

Nichevo said...

Two guys, one kidney. They make these choices right now. I don't know that it's done on a morals or income or social credit basis.

Not here. Not yet.