१ एप्रिल, २०२०

"We must first reject what often seems optimal in ordinary times, such as first-come, first-served, or even a lottery."

"These choices risk filling up ICU beds with patients unlikely to emerge alive, at the cost of the deaths of multitudes of patients who are likely to survive if given temporary care.... The save-the-most-lives strategy faces two plausible objections. The first questions how much survival counts, and whether a patient projected to survive a shorter period should have the same priority as one likely to live much longer. The second asks whether, on balance, younger patients should be favored over older ones.... In specific case... a pure save-the-most-lives rule could favor a 65-year-old over a more severely afflicted college-age patient. Many of us would root for the younger person, both because she might live longer if she pulls through and because the older patient has already enjoyed the decades of life that may be denied to the other. This modification of the save-the-most-lives strategy might be achieved by accepting a 'bias' in favor of the young, and not merely as tiebreakers. Ideally, this might be carried out without imposing formal age limits.... No preference is given to those most likely not merely to survive but also to enjoy the best health, let alone the highest quality of life. Nor does the strategy excuse abandonment of the disabled. Rather, it directs resources to providing the greatest assurance possible that each of us will achieve what we most value: our own survival and that of our loved ones and fellow citizens."

From "Here are rules doctors can follow when they decide who gets care and who dies/Ethicists like me have studied rationing for decades. In a few days, our guidelines will be needed" by Daniel Wikler, who is a Harvard Professor of Ethics and Population Health. He used to be in the Medical Ethics program here at the University of Wisconsin.

८५ टिप्पण्या:

David-2 म्हणाले...

Would it be ethical to shoot all the medical ethicists in the head? Because if it ever was a worthwhile field of study that could give us helpful insights into difficult problems, it hasn't been since at least Peter Singer, and yet they seem to have acquired some sort of influence in the halls of government.

pacwest म्हणाले...

Without going into the ethical weeds I can agree with most of that. I'm not sure we are going to reach that point except in very rare instances though.

Ken B म्हणाले...

I'd trust him more if sounded less gloaty.

Or maybe not. I don’t place much value on surveys about trolley cars.

rhhardin म्हणाले...

Ethics experts are always wrong and never know it.

rhhardin म्हणाले...

Richard Epstein does an analysis

https://www.hoover.org/research/grim-costs-total-lockdowns

The first proposition is that there are no acceptable market solutions on how best to allocate scarce social resources for dealing with the coronavirus crises....

Second, in ordinary times, these essential nonmarket institutions can operate effectively at a reasonable cost that does not threaten the operation of standard exchange mechanisms for ordinary goods and services that do trade in wealth, as measured in dollars or dollar equivalents. But in times of extreme stress, the constraints of scarcity not only remain, but also tighten....

So in approaching the two questions I posed earlier, the issue is not whether there should be a government response, but how it should best take place...

Rick म्हणाले...

The save-the-most-lives strategy faces two plausible objections. The first questions how much survival counts, and whether a patient projected to survive a shorter period should have the same priority as one likely to live much longer. The second asks whether, on balance, younger patients should be favored over older ones...

Call me crazy but these seem like the same objection. A better second objection is that we don't know the likelihood of survival - not even retroactively. Therefore using that as a basis is effectively impossible in all but the most hopeless cases.

Yancey Ward म्हणाले...

Ethicists can offer you ways to think about making decisions. What they can't do is relieve you of having to make them.

Rick म्हणाले...

Is this one of the five smart people we don't want making real world decisions?

The Bergall म्हणाले...

Harvard Professor of Ethics and Population Health

Speaks for it's self............

Yancey Ward म्हणाले...

First come, first served and lotteries are ways the ways we try to avoid responsibility. This why the trolley runs over the five people in most cases.

Kevin म्हणाले...

Henry Blake, Commanding Officer, MASH 4077: "There are certain rules about a war. Rule Number One is: Young men die. And Rule Number Two is: Doctors can't change Rule Number One."

Give the ventilators to the women.

It's best for society and puts a dose of reality back into our notions of "justice".

n.n म्हणाले...

Religion.

tcrosse म्हणाले...

Do ethicists chime in on how to decide who gets the placebo when they do their clinical trials?

n.n म्हणाले...

Give the ventilators to the women.

It's best for society and puts a dose of reality back into our notions of "justice".


It was always, with cause, women and children first. The in the 20th century the social progression diverged, monotonically. Around one million planned excess deaths annually in America alone.

Bob Smith म्हणाले...

I already have a “no heroic measures” directive. If that doesn’t work my wife is going to put me in a wheelchair and roll me in the lake near our house.

narciso म्हणाले...

it does seem they aren't any good, there was another one, cate-house, who was cautioning against the hcq-zpak cocktail that saved david lat's life, another is dr. exekiel 'death panels' Emmanuel,

henry blake was much of the mindset of the writer of mash (not larry gelbart) Richard hooker, who understood these realities,

Yancey Ward म्हणाले...

"If that doesn’t work my wife is going to put me in a wheelchair and roll me in the lake near our house."

Nothing wrong with that last part, Bob, but make sure to get a second opinion.

Gahrie म्हणाले...

This never used to be a problem. It was simply assumed that women and children came first.

Thanks feminists.

Gahrie म्हणाले...

A horrifying number of people are contemplating the possibility that this disease will solve our social security problem for us.

dreams म्हणाले...

First thing to do is make sure the Professor of Ethics and Population Health is last on the list to get healthcare treatment.

Kai Akker म्हणाले...

"Rather, it directs resources to providing the greatest assurance possible that each of us will achieve what we most value: our own survival and that of our loved ones and fellow citizens." [bioethicist blabla]

Stunning self-deception or cynical pablum? This conclusion is entirely contradicted by what came before it. I'm with Rick, Rick, and especially David-2.

Jaq म्हणाले...

"First thing to do is make sure the Professor of Ethics and Population Health is last on the list to get healthcare treatment.”

It’s only right, I am sure he’d agree. His work is done, what further use is he to us?

TRISTRAM म्हणाले...

Why not treat more people? Do your best for every one with what you have available? At the same time, others can be adding supply.

LYNNDH म्हणाले...

So in other words "Death Panels". My wife and I are 73 so I guess we should just turn toes up.
Thank you very much.

Fernandinande म्हणाले...

A U.S. human life is worth about twice as much as an Australian life, 3 to 4 times as much as a life in New Zealand or Sweden, and maybe 126 times as much as a Russian life.

Charlie Currie म्हणाले...

Let's start pumping everyone who walks through the door with hydroxychlorquine and zinc before we start making life and death decisions. As a matter of fact, let's include a month's supply with those new car parts government stimulus checks.

Kai Akker म्हणाले...

Ask Sebastian for a QALY analysis, Lynndh. Others can evaluate your quality of life best.

Wa St Blogger म्हणाले...

This question is not new now, and has never been new, even when we are not dealing with a potential run on the hospitals. During disasters, doctors do triage, picking who they can save. In everyday medicine there are treatments that can help, but are too expensive. We always have a problem of unlimited demand and limited supply. COVID-19 is simply a more acute case of it.

When it comes down to it, everyone wants to be the one left in the life boat, and they have a rational argument why someone else gets tossed overboard. And barring that, they devolve into either first-come or lottery if the rational arguments do not favor them. We all want to live. I am glad I am not the one in the position to choose.

narciso म्हणाले...

there is a protocol, that the cocktail be provided as early as is practical,

Otto म्हणाले...

So if we had to choose between a 20 yr old sex offender or a 60 year old married man who sent two kids through college , the prof would choose the 20 year old.
No wait let's do it by IQ .After all then only those who survive will advance society.
I say we immediately reduce the salaries of all ethics profs and take away their 401K and pension plans and spend that money on building more hospitals and ventilators. In fact we should do it for all profs but to be fair only those profs that are over 60 years old.

tim maguire म्हणाले...

Health economics deals with these sorts of issues all the time. If lots of different factors need to be weighed, you use a point system--age has a point value, likelihood of survival gets a point value. Whatever factors you want to consider get point values. Then you add up all the points to see who wins.

cubanbob म्हणाले...

Hmm how about the Deborah Brix or a teen gangbanger? Anthony Fauci (79 years old) or a young meth head? Or the so-called ethicist from Harvard and a young welfare deadbeat? Besides why do we assuming that this guy is a nearly universally considered ethicist? Any half decent MBA graduate is also capable of making a mini-max calculation. Hell any ordinary person could do it. Simple? Yes. Easy? Not a chance.

CWJ म्हणाले...

"In specific case... a pure save-the-most-lives rule could favor a 65-year-old over a more severely afflicted college-age patient."

Yeah right. Soothing hypothesis to cover for the Stark reality that these Solomans don't exist. No one will risk picking the geezer over the young adult. Unless the geezer is richer or more politically connected. Otherwise bye bye geezer. Health "ethicists" are evil.

Big Mike म्हणाले...

People in your sixties and up, take a good, hard, look. Every country that has a single-payer healthcare system rations access to healthcare by age. Every. Single. One. In a moment of weakness Elizabeth Warren admitted that “Medicare for All” would do the same.

Jaq म्हणाले...

Rule should be that if you got it doing something stupid that had been forbidden during the pandemic, you are on your own.

campy म्हणाले...

We need to make sure we don't waste scarce beds and ventilators on deplorables.

Jaq म्हणाले...

"Why not treat more people? Do your best for every one with what you have available? At the same time, others can be adding supply.”

What are you? A capitalist?

narciso म्हणाले...

I see a guinea pig

LA_Bob म्हणाले...

He just needs to swallow his hydroxychloroquine / azithromycin / zinc sulfate cocktail and shut up.

WK म्हणाले...

Maybe someone will develop an app for deciding.

Jaq म्हणाले...

There should be wards for the voluntarily infected, who get treatment, but not the ventilators, if they are the scarce items. You get a card, you are allowed to open your business, frequent restaurants, everything else, and if draw the short straw and get not only sick, but need hospitalization? Well we will do our best, and here is some morphine. I think a lot of people would take that deal.

bagoh20 म्हणाले...

In these questions I never see any weight given to who has earned more consideration. It's always relative future potential alone. We have a culture steeped in the idea that if you do the right thing, you will be rewarded, or for some Karma. Yet, we throw it all out the window when we are deciding who should live. Maybe we should rethink that. Mike Lindell, man who turned his life around, created jobs for thousands, and cured neck pain for millions, vs some younger, healthier pickpocket with nice hair.

carrie म्हणाले...

Should weight be given to whether a person was socially responsible and followed the social distancing rules? Should young people who disregarded the rules and intentionally put themselves into situations where they were likely to get the virus be given priority over those who were cautious?

Jaq म्हणाले...

" Yet, we throw it all out the window when we are deciding who should live. “

It’s almost like somebody who spent 40 years working and saving and planning for retirement is enjoying some kind of unearned privilege lately, isn’t it?

Leland म्हणाले...

It doesn't seem ethical to tell the first patient that arrives they won't receive care while you wait for a more deserving patient. If the 5 trolley patients arrive together, they'll be triaged and treated according to resources available as was the process a year ago.

Jaq म्हणाले...

"Out of the way grandpa, you’re taking up oxygen and we want your stuff”

If I had known these were the rules, I would have lived my life a lot differently.

Jaq म्हणाले...

"It doesn't seem ethical to tell the first patient that arrives they won't receive care while you wait for a more deserving patient.”

It’s sort of like a datacom queueing problem. You have to take into account service time on the ventilator and arrival rate and have a buffer going. It could work if you had a large enough operation going on.

Michael K म्हणाले...

Medical "Ethicists" are a recent innovation that sort of corresponded to the rationing of DRGs and then Obamacare.

Zeke Emmanuel is only the loudest,.

Sheridan म्हणाले...

Athenian Democracy! As exemplified by the voting technique on "Dancing With the Stars"!! Forget ethics, have people vote electronically in real time as to who should be saved. Young, old, smart, stupid - it doesn't matter. Just impress those millions of judges with your worthiness and you will be saved! Just one caveat. As in Athens, though you may be saved today you may well be down-voted tomorrow. It beats getting selected for death by some Harvard wunderkind who wasn't good at medicine but really clever at medical "ethics".

Big Mike म्हणाले...

It seems to me that a proper sense of ethics would include an assessment of how they came by the disease. Young person who defies good advice to go off on Spring Break, then comes home with case of mild sunburn — and COVID-19. Versus an older healthcare practitioner who has pulled 14 and 16 hour shifts taking care of patients on ventilators and who caught the disease because the cheap masks and other protective equipment that the hospital bought was defective. If there’s one ventilator left, which one would you would you choose?

Dead last would be the hospital administrator who saved a few dollars buying inadequate protective equipment and/or ordered inadequate supplies ahead of the pandemic despite indications that the pandemic was coming. Or maybe next to last, just ahead of medical ethicists.

Rabel म्हणाले...

"Would it be ethical to shoot all the medical ethicists in the head?"

Yes, but you must shoot the oldest ones first.

Professor Wikler is 73.

Jaq म्हणाले...

If anybody is interested in seeing the perfect embodiment of an optimal queueing theory solution, have the delicious pancakes or waffles at The Paramount on Charles Street in Boston and just watch how they run their operation. I think that computer science students ought to be taken there on field trips.

Edmund म्हणाले...

The civil rights office of HHS has already warned that triage decisions based on age or disability will be considered civil rights violations.

Jaq म्हणाले...

It it’s still open after this mess has cleared, I guess.

Josephbleau म्हणाले...

In a simpler America the braves took the old big chief out for a brisk walk on a chilly night and left him sitting on a rock. After a point there was no longer any percentage in surviving a battle.

But I think we had this ethics conversation last week so on the subject, “further deponent sayeth not.”

IgnatzEsq म्हणाले...

Don't worry, I'm sure that vague standards that rely on unknowable information will be both workable and not subject to abuse.

Then again, if I'm wrong and the standards are not vague and the information is knowable, he's calling for death panels.

chuck म्हणाले...

Triage is a thing, but AFAICT, the main job of ethicists is to invent reasons to kill people. I'd rather leave it do the medical doctors, and bless them if they need to make the decision. It can't be easy.

n.n म्हणाले...

The civil rights office of HHS has already warned that triage decisions based on age or disability will be considered civil rights violations.

Fetal-Americans... Geriatric-Americans. that too shall progress. Ethics is a relativistic religion ("Pro-Choice").

Then again, if I'm wrong and the standards are not vague and the information is knowable, he's calling for death panels.

They need to mitigate the spread of social contagion that is a first-order forcing of climate change and resource mismanagement. Baby steps.

JML म्हणाले...

Blogger campy said...
We need to make sure we don't waste scarce beds and ventilators on deplorables.

One of the commenters said just that - if wearing a MAGA hat, they should be left to die.

Marc in Eugene म्हणाले...

The National Catholic Bioethics Center issued "Points to Consider: Triage in the Perspective of Catholic Bioethics", about the current plague and the issues of triage and rationing, a week ago. Some might find it a useful read.

jimbino म्हणाले...

Of all the options, only the market option gives the price signalling needed to incentivize curing of the problem.

Sebastian म्हणाले...
ही टिप्पणी लेखकाना हलविली आहे.
Sebastian म्हणाले...

"a pure save-the-most-lives rule could favor a 65-year-old over a more severely afflicted college-age patient"

Except that the evidence thus far shows a high likelihood that the "severely afflicted" young person will survive.

"This modification of the save-the-most-lives strategy might be achieved by accepting a 'bias' in favor of the young, and not merely as tiebreakers."

Well, yeah.

"No preference is given to those most likely not merely to survive but also to enjoy the best health, let alone the highest quality of life."

Why not?

"Nor does the strategy excuse abandonment of the disabled."

They are not abandoned. In fact, right now, a whole country is sacrificing for them and the sick and the old.

"Rather, it directs resources to providing the greatest assurance possible that each of us will achieve what we most value: our own survival and that of our loved ones and fellow citizens."

This is a platitude. Not all of us value our own survival above all. Many old people don't. Nor do all of us want to put ailing 88-year old grandpa through weeks of intubation.

Some triage is inevitable. But the meta-triage is the key issue: what price do we pay, what devastation do we suffer to prevent that 88-year old from losing out on a ventilator? Right now, we appear to be edging toward tens of millions per life supposedly saved, not counting the cost of the havoc caused in the lives of younger people and the downstream harm to millions of people. That is unreasonable and unfair.

bagoh20 म्हणाले...

It sounds to me like a lot of people would prefer to save the most fearful and trusting of authority. Man, how the boomers have aged. This system would find the highest value in germaphobes, hypochondriacs, and loyalists. Not exactly survival of the fittest, nor a recipe for a strong population of free people.

bagoh20 म्हणाले...

It seems pretty obvious to me that if you want a happy peaceful society, you first save the richest men and the hottest women.

bagoh20 म्हणाले...
ही टिप्पणी लेखकाना हलविली आहे.
bagoh20 म्हणाले...

What if you just put a 24 hour waiting period in place and treat whoever still wants it. Since guns save millions of lives every year, semiautomatic ventilators should have a 10-day waiting period.

Jupiter म्हणाले...

"I'd rather leave it do the medical doctors, and bless them if they need to make the decision. It can't be easy."

Nah, they do it all day, they get used to it. They were going to just let my Mom die, until my sister and I told them we would prefer they save her. Then they kind of shrugged and said "OK. Whatevs."

Michael K म्हणाले...

Nah, they do it all day, they get used to it. They were going to just let my Mom die, until my sister and I told them we would prefer they save her. Then they kind of shrugged and said "OK. Whatevs."

Got to be more of a story there. That is rare as you describe it. I've got 50 years of stories, many in my books, but that sounds odd.

wildswan म्हणाले...

Should we try to save Ruth Bader Ginsburg if she gets sick? What would save the most lives?


Bob Loblaw म्हणाले...

In specific case... a pure save-the-most-lives rule could favor a 65-year-old over a more severely afflicted college-age patient. Many of us would root for the younger person, both because she might live longer if she pulls through and because the older patient has already enjoyed the decades of life that may be denied to the other.

I hate this kind of thinking. The weeds are endless when you start trying to play God like this. We're gonna bump a guy who didn't run to Canada and served in Vietnam, paid taxes for an entire career, raised a family without leaning on the rest of us, volunteered his Sundays at the food kitchen, etc, etc, with an illegal alien gangbanger just because the later is younger?

First come, first served is the only fair way to do this.

Bob Loblaw म्हणाले...

Should we try to save Ruth Bader Ginsburg if she gets sick? What would save the most lives?

You don't really believe the rich and powerful are going to be in the same line as the rest of us, do you? One thing I noticed about the organ transplant system, also infested with "ethicists", is politicians, celebrities, and rich people always get organs when they need 'em, which is pretty close to being mathematically impossible if the system really works the way they pretend.

Gahrie म्हणाले...

Every time I start to worry if I'm getting too cynical, I come here and read some of bagoh20's comments and feel better about myself.

Buckwheathikes म्हणाले...

Soooo ... death panels.

As predicted.

SGT Ted म्हणाले...

Why do "ethicists" so often talk like eugenicists and Nazis?

Moneyrunner म्हणाले...

How about everyone gets the best treatment available until they die or get better? Is Medical Ethicist an oxymoron?

Moneyrunner म्हणाले...

This is the sort of analysis that confirms the worst beliefs about academia. A round of applause for Ann for having lived and taught at Madison and retired before becoming a moral monster.

SGT Ted म्हणाले...

It isn't "ethics" if it's divorced from a moral framework that values life in general.

Bitter Clinger म्हणाले...

@Gahrie, is it the fault of feminism or the endless narcissism of Boomers? I'm amazed everytime I read comments on this topic that anyone even finds this controversial. Does a 90 y.o. get a vent instead of a 20 yo if both are in good health for their age? Does anyone think that 50 years ago this is a question that would even have to be asked?

Guess what Boomers, you're getting old, just like your parents and grand parents. The future is for the young, which you aren't. Get over it. It's bad enough that Boomers plan to suck the blood of this country by demanding their SS and Medicare when those systems are clearly going bankrupt. Now they're insisting they get the vents instead of younger people.

Paul Snively म्हणाले...

Why any of this is controversial is completely beyond me. Let's just all acknowledge that it sucks when you have to utilize your life insurance before death, and the mathematics of bioethics and of insurance are the same.

Smerdyakov म्हणाले...

This guy really thinks the people who make those decisions are gonna come to him for guidance.

Just think about NBA players and celebrities getting tests before anyone else. That should give us a clue as to how this will work out.

mikee म्हणाले...

Why do I get the strong impression that the left will be severely disappointed if less than 100,000 people die from this virus, and that the left will be absolutely devastated if any of the treatments actually work to reduce the severity, duration, and morbidity of this virus?

Jupiter म्हणाले...

"Got to be more of a story there. That is rare as you describe it. I've got 50 years of stories, many in my books, but that sounds odd."

Basically, she was old. Past 90. Good and old. She got sick (back in 2007), and her GP hospitalized her, and they put her in the ICU and intubated her. But they said her chances were poor, and they wanted to pull the plug. My view is that the fact that my sister and I were present and concerned validated her for them. Which makes a good deal of practical sense. How much value are you adding to the World if you prolong the physical existence of a person who is old, unconscious, of interest to no one and, in your opinion, unlikely to recover? She only lived another week, but she regained consciousness, lucidity even, and we took her home to die.

But anyway, there was very much a "We do this every day" vibe among the staff doctors. I don't blame them. Hospitals are full of people who are dying. Frankly, I don't see how they could do what they do if they couldn't achieve emotional distance. I think her GP took it harder than we did. I sent her a thank-you card. "Thanks for your courage".

Bob Loblaw म्हणाले...

But anyway, there was very much a "We do this every day" vibe among the staff doctors. I don't blame them. Hospitals are full of people who are dying. Frankly, I don't see how they could do what they do if they couldn't achieve emotional distance.

People can end up stuck in a half-living state for weeks or even months, with no chance of regaining consciousness. I'm not surprised they get that call wrong on occasion.

Bob Loblaw म्हणाले...

The future is for the young, which you aren't. Get over it. It's bad enough that Boomers plan to suck the blood of this country by demanding their SS and Medicare when those systems are clearly going bankrupt. Now they're insisting they get the vents instead of younger people.

Why do you assume your values are universal? They're not. Personally I'd rather see an older person who contributed to society get one over a younger person who hasn't.