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| Who Should Be Saved First? Experts Offer Ethical Guidance | Who Should Be Saved First? Experts Offer Ethical Guidance |
| (8 days later) | |
| How do doctors and hospitals decide who gets potentially lifesaving treatment and who doesn’t? | How do doctors and hospitals decide who gets potentially lifesaving treatment and who doesn’t? |
| A lot of thought has been given to just such a predicament, well before critical shortages from the coronavirus pandemic. | A lot of thought has been given to just such a predicament, well before critical shortages from the coronavirus pandemic. |
| “It would be irresponsible at this point not to get ready to make tragic decisions about who lives and who dies,” said Dr. Matthew Wynia, director of the Center for Bioethics and Humanities at the University of Colorado. | “It would be irresponsible at this point not to get ready to make tragic decisions about who lives and who dies,” said Dr. Matthew Wynia, director of the Center for Bioethics and Humanities at the University of Colorado. |
| Facing this dilemma recently — who gets a ventilator or a hospital bed — Italian doctors sought ethical counsel and were told to consider an approach that draws on utilitarian principles. | Facing this dilemma recently — who gets a ventilator or a hospital bed — Italian doctors sought ethical counsel and were told to consider an approach that draws on utilitarian principles. |
| In layman’s terms, a utilitarian approach would maximize overall health by directing care toward those most likely to benefit the most from it. If you had only one ventilator, it would go to someone more likely to survive instead of someone deemed unlikely to do so. It would not go to whichever patient was first admitted, and it would not be assigned via a lottery system. (If there are ties within classes of people, then a lottery — choosing at random — is what ethicists recommend.) | In layman’s terms, a utilitarian approach would maximize overall health by directing care toward those most likely to benefit the most from it. If you had only one ventilator, it would go to someone more likely to survive instead of someone deemed unlikely to do so. It would not go to whichever patient was first admitted, and it would not be assigned via a lottery system. (If there are ties within classes of people, then a lottery — choosing at random — is what ethicists recommend.) |
| In a paper in The New England Journal of Medicine published Monday, Dr. Ezekiel Emanuel, vice provost for global initiatives and chairman of the Department of Medical Ethics and Health Policy at the University of Pennsylvania, and colleagues offer ways to apply ethical principles to rationing in the coronavirus pandemic. These too are utilitarian, favoring those with the best prospects for the longest remaining life. | In a paper in The New England Journal of Medicine published Monday, Dr. Ezekiel Emanuel, vice provost for global initiatives and chairman of the Department of Medical Ethics and Health Policy at the University of Pennsylvania, and colleagues offer ways to apply ethical principles to rationing in the coronavirus pandemic. These too are utilitarian, favoring those with the best prospects for the longest remaining life. |
| In addition, they say prioritizing the health of front-line health care workers is necessary to maximize the number of lives saved. We may face a shortage of such workers, and some have already fallen ill. | In addition, they say prioritizing the health of front-line health care workers is necessary to maximize the number of lives saved. We may face a shortage of such workers, and some have already fallen ill. |
| In a recent article in The New York Times, a British researcher said, “There are arguments about valuing the young over the old that I am personally very uncomfortable with,” adding, “Is a 20-year-old really more valuable than a 50-year-old, or are 50-year-olds actually more useful for your economy, because they have experience and skills that 20-year-olds don’t have?” | In a recent article in The New York Times, a British researcher said, “There are arguments about valuing the young over the old that I am personally very uncomfortable with,” adding, “Is a 20-year-old really more valuable than a 50-year-old, or are 50-year-olds actually more useful for your economy, because they have experience and skills that 20-year-olds don’t have?” |
| Dr. Emanuel disagreed with that interpretation: “The 20-year-old has lived fewer years of life; they have been deprived of a full life. If they have roughly comparable prognoses, then the fact that the 20-year-old has not had a full life counts in their favor for getting scarce resources.” | Dr. Emanuel disagreed with that interpretation: “The 20-year-old has lived fewer years of life; they have been deprived of a full life. If they have roughly comparable prognoses, then the fact that the 20-year-old has not had a full life counts in their favor for getting scarce resources.” |
| Some organizations, states and federal agencies have anticipated challenges like these and developed resources and guides for hospitals and health systems. | Some organizations, states and federal agencies have anticipated challenges like these and developed resources and guides for hospitals and health systems. |
| The Hastings Center has curated a list of resources that health care institutions can use to prepare for responding to the coronavirus, including for shortages. In 2015, the New York Department of Health released a report on the logistical, ethical and legal issues of allocating ventilators during a pandemic-created shortage. This and many other states’ plans are modeled on guidance from the Ontario Ministry of Health on critical care during a pandemic. | The Hastings Center has curated a list of resources that health care institutions can use to prepare for responding to the coronavirus, including for shortages. In 2015, the New York Department of Health released a report on the logistical, ethical and legal issues of allocating ventilators during a pandemic-created shortage. This and many other states’ plans are modeled on guidance from the Ontario Ministry of Health on critical care during a pandemic. |
| Federal health agencies, including the Department of Veterans Affairs and the Department of Health and Human Services, have also published guidance that includes approaches for allocation of scarce resources during a pandemic. | Federal health agencies, including the Department of Veterans Affairs and the Department of Health and Human Services, have also published guidance that includes approaches for allocation of scarce resources during a pandemic. |
| A study in Chest in April 2019 imagined a 1918 flulike pandemic in which there weren’t enough I.C.U. beds and ventilators to meet demand. The authors engaged focus groups in Maryland about views on how to ration care. The preference of the focus groups? Direct resources to those with the greatest chance of survival and the longest remaining life spans — in other words, also the pragmatic utilitarian approach. This study stemmed from work for a Maryland report on allocating scarce medical resources during a public health emergency. | A study in Chest in April 2019 imagined a 1918 flulike pandemic in which there weren’t enough I.C.U. beds and ventilators to meet demand. The authors engaged focus groups in Maryland about views on how to ration care. The preference of the focus groups? Direct resources to those with the greatest chance of survival and the longest remaining life spans — in other words, also the pragmatic utilitarian approach. This study stemmed from work for a Maryland report on allocating scarce medical resources during a public health emergency. |
| “Key is to be transparent about the principles, save as many lives as possible, and ensure that there are no considerations such as money, race, ethnicity or political pull that go into allocation of lifesaving resources such as ventilators,” said Dr. Tom Frieden, president and C.E.O. of Resolve to Save Lives and former director of the Centers for Disease Control and Prevention. | “Key is to be transparent about the principles, save as many lives as possible, and ensure that there are no considerations such as money, race, ethnicity or political pull that go into allocation of lifesaving resources such as ventilators,” said Dr. Tom Frieden, president and C.E.O. of Resolve to Save Lives and former director of the Centers for Disease Control and Prevention. |
| Another principle recommended by medical ethicists is to take tough choices out of the hands of front-line clinicians. Instead, have dedicated triage officers decide. Also, decisions should be free of financial considerations or the social status of patients, something that seems to have been violated in the provision of scarce coronavirus tests to N.B.A. players, for example. | Another principle recommended by medical ethicists is to take tough choices out of the hands of front-line clinicians. Instead, have dedicated triage officers decide. Also, decisions should be free of financial considerations or the social status of patients, something that seems to have been violated in the provision of scarce coronavirus tests to N.B.A. players, for example. |
| “Ethically speaking, rationing by ability to pay is the worst way to allocate scarce medical resources in an emergency,” said Dr. Jerry La Forgia, chief technical officer of Aceso Global and former lead health specialist for the World Bank. | “Ethically speaking, rationing by ability to pay is the worst way to allocate scarce medical resources in an emergency,” said Dr. Jerry La Forgia, chief technical officer of Aceso Global and former lead health specialist for the World Bank. |
| Nevertheless, precisely this kind of rationing is commonplace in the U.S. health system during more normal times. | Nevertheless, precisely this kind of rationing is commonplace in the U.S. health system during more normal times. |
| Health economists have also thought deeply about how to allocate finite health care resources, in government budgets for instance. Often there are winners and losers in these calculations — some treatments covered and some not — but they’re not always individually identifiable. | Health economists have also thought deeply about how to allocate finite health care resources, in government budgets for instance. Often there are winners and losers in these calculations — some treatments covered and some not — but they’re not always individually identifiable. |
| Updated June 30, 2020 | |
| Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days. | |
| Scientists around the country have tried to identify everyday materials that do a good job of filtering microscopic particles. In recent tests, HEPA furnace filters scored high, as did vacuum cleaner bags, fabric similar to flannel pajamas and those of 600-count pillowcases. Other materials tested included layered coffee filters and scarves and bandannas. These scored lower, but still captured a small percentage of particles. | Scientists around the country have tried to identify everyday materials that do a good job of filtering microscopic particles. In recent tests, HEPA furnace filters scored high, as did vacuum cleaner bags, fabric similar to flannel pajamas and those of 600-count pillowcases. Other materials tested included layered coffee filters and scarves and bandannas. These scored lower, but still captured a small percentage of particles. |
| A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico. | A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico. |
| The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth. | The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth. |
| The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave. | The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave. |
| So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement. | So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement. |
| Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks. | Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks. |
| A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study. | A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study. |
| The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April. | The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April. |
| If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.) | If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.) |
| If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others. | If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others. |
| During a pandemic, the winners and losers are both clearly identifiable. They’re right in front of the doctor at the same time. “This shifts the ethical and emotional burden from society or government to the clinician,” said Christopher McCabe, a health economist and executive director and C.E.O. of the Institute of Health Economics in Alberta, Canada. “There’s no perfect way to choose who gets lifesaving treatment. At times like these, society may be more forgiving of utilitarian decision making.” | During a pandemic, the winners and losers are both clearly identifiable. They’re right in front of the doctor at the same time. “This shifts the ethical and emotional burden from society or government to the clinician,” said Christopher McCabe, a health economist and executive director and C.E.O. of the Institute of Health Economics in Alberta, Canada. “There’s no perfect way to choose who gets lifesaving treatment. At times like these, society may be more forgiving of utilitarian decision making.” |
| History offers examples of competing values. During World War II, soldiers received penicillin before civilians. In Seattle in the 1960s, social worth was among the criteria used to ration dialysis machines. | History offers examples of competing values. During World War II, soldiers received penicillin before civilians. In Seattle in the 1960s, social worth was among the criteria used to ration dialysis machines. |
| In 2005, Hurricane Katrina caused acute shortages under emergency conditions in Louisiana health centers. “Health care workers were forced to make things up as they went along, amounting to life and death decisions,” Dr. Wynia said. “This was widely viewed as unfortunate for patients, doctors, and not what we want as a society.” | In 2005, Hurricane Katrina caused acute shortages under emergency conditions in Louisiana health centers. “Health care workers were forced to make things up as they went along, amounting to life and death decisions,” Dr. Wynia said. “This was widely viewed as unfortunate for patients, doctors, and not what we want as a society.” |
| Today, there is greater demand for some organs for transplants than supply can accommodate. The United Network for Organ Sharing is a system for prioritizing patients for transplants. It combines medical condition, waiting time and prognosis into a scoring system that varies by type of organ. | Today, there is greater demand for some organs for transplants than supply can accommodate. The United Network for Organ Sharing is a system for prioritizing patients for transplants. It combines medical condition, waiting time and prognosis into a scoring system that varies by type of organ. |
| “It has elements of utilitarianism,” said David Vanness, Professor of Health Policy and Administration at Penn State. “But it’s not designed for the urgency of a pandemic.” | “It has elements of utilitarianism,” said David Vanness, Professor of Health Policy and Administration at Penn State. “But it’s not designed for the urgency of a pandemic.” |
| In particular, society has had time to consider how to cover the care for patients needing transplants. The vast majority of end-stage kidney disease patients are eligible for Medicare at any age, for example. | In particular, society has had time to consider how to cover the care for patients needing transplants. The vast majority of end-stage kidney disease patients are eligible for Medicare at any age, for example. |
| When antivirals or vaccines become available, those too will initially be in short supply, and undoubtedly discussion will arise on who should get them first. | When antivirals or vaccines become available, those too will initially be in short supply, and undoubtedly discussion will arise on who should get them first. |
| Dr. Emanuel predicts we will soon see in the U.S. the kind of rationing happening in Italy, where there are too few ventilators and I.C.U. beds for all the patients who need them. Estimates by researchers at Harvard show that without drastic expansion of supply, many areas of the U.S. will have inadequate numbers of hospital beds. | Dr. Emanuel predicts we will soon see in the U.S. the kind of rationing happening in Italy, where there are too few ventilators and I.C.U. beds for all the patients who need them. Estimates by researchers at Harvard show that without drastic expansion of supply, many areas of the U.S. will have inadequate numbers of hospital beds. |
| “When you consider the shortage of coronavirus tests, we’re already seeing rationing,” he said. | “When you consider the shortage of coronavirus tests, we’re already seeing rationing,” he said. |