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

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