Tents are now strewn across Manhattan’s Central Park—a field hospitals in the literal sense—that resemble the convalescence wards of the 1918 flu pandemic. They sit a stone’s throw from some of the world’s most expensive real estate. Not to mention some of the world’s most luxurious brick-and-mortar hospitals.
In these tents, on the cots that sit less than six feet apart, it is expected that millionaires will lie beside people without a penny to their names. Care will be allocated based on where it can be the most useful and do the most good.
This is not a type of health care that most Americans are accustomed to. But already, rationing is upon us.
If you are one of the 7.6 million people in New York City, you are advised by city officials to stay home until you become short of breath. Typically, this is a sign of being on the brink of a critical illness. It means a respiratory infection has spread into the lower airways, and it could quickly progress to the point of needing supplemental oxygen or intubation and mechanical ventilation. But, at this point, medical care—prior to the point of becoming short of breath—must be rationed. Clinics and emergency departments cannot currently handle being filled with people who, sick as they may be, do not yet clearly require hospitalization.
New York, like other states, does not yet have enough hospital beds, masks, or diagnostic tests for the coronavirus to accommodate all who might need one. Certain rationing decisions are already being made, including which surgeries can be considered “elective” and canceled, and which cannot.
Perhaps most ominously to the thousands of New Yorkers at home wondering just how short of breath is “short of breath,” we also do not have enough ventilators. By Governor Andrew Cuomo’s estimate, the state will need around 30,000 in coming months. We have about 5,000. Some new ventilators are being made, but this cannot happen quickly enough to meet that sort of demand.
And so, ethics boards at various hospitals are writing guidelines for how to manage allocation of life-saving resources like ventilators. These groups will deliberate and model various hypothetical scenarios, and then issue directives about what sort of decisions should be made. At a certain point, the calculus of American doctors will switch from the default of preferentially caring for the person who appears sickest to caring for the person with the greatest chance of benefiting from care—and with the greatest potential for years of life ahead.
These decision trees are guided by the four basic principles of medical ethics: personal autonomy, beneficence, non-maleficence (“do no harm”), and justice. In a fast-moving pandemic like this, these principles may look different in execution, but are no less important. A patient’s personal autonomy becomes limited based on, say, availability of resources. You may want a ventilator, and a doctor may agree that it’s necessary, and yet it may not be possible. The call to do no harm, likewise, can become a call to do as little harm as possible—or to do maximal good.
The question of who gets a ventilator and who does not, when two people are both in real need, is a question of justice of the sort doctors are not trained to adjudicate. But others are, and this is the moment they’ve been training for. (...)
James Hamblin: There was discussion over the weekend about making sure that there not be discrimination against elderly people, against chronically ill people. There is that tension, which is similar with organ donation, where you have to think about the utility of how many “quality life years” does a person have if they receive an organ.
So it seems like there is discrimination against elderly and chronically ill people built into so many rationing decisions. How do you navigate that in a way that if, say, if it comes to ventilators, is as nondiscriminatory as possible—while making decisions that are, by definition, discriminating who gets what?
Caplan: When I look at policies, including my own institution’s, the first thing you have to commit to is that you won't discriminate. I'm looking for a statement that says everyone will be considered. That includes elderly people, the chronically ill, the disabled, and also would include no discrimination by gender or race or culture. We're trying to lead with the principle, and this is what I would call fairness, that everybody has a shot. Everybody has an opportunity.
That's somewhat true in transplant rationing, and it's somewhat true with emergency medicine rationing. You begin by saying in order to get support for rationing, you have to make people know that the squeaky wheels won't have an advantage, the rich won't shove aside the poor, the disabled just won't be killed. We're not going to have hard and fast age boundaries.
You then move on to justice. And your question, James, is what about biological and physiological differences? The answer to that is, that's the first consideration. Try to maximize the chance of saving a life. I do think that the moral principle that has emerged is that first you try to save the most lives.
That does put people who have underlying chronic illnesses involving their respiratory system—chronic obstructive lung disease damage from vaping, smoking—that could put you down lower than somebody else. I wouldn't start with an age cutoff because we've seen healthy 70 year olds and very, very sick, compromised 20 year olds. But it would be fair to say if you can't sort them out by biology and physiology, then you go to age because age is somewhat of a predictor of who's going to do well.
Young people just do better than older people. It's not like 40 versus 30, it's more like 20 versus 70. I think Americans also want kids first. We haven't seen many kids get infected here, but most of the policies that I've had input to, we try to see children first, too.
Hamblin: We don't want the wealthy and powerful people to have unfair access. At the same time, there are questions of a person's utility in a specific scenario, like if you are the head of emergency medicine or ICU care at a hospital and your health ends up subsequently meaning many more people could be kept healthy. Do people in positions like that get priorities over people who ... who are of less ... I don't even know how to use these words appropriately without being offensive.
Caplan: Significance to trying to save more lives. I know where you're going. So the answer is yes. But I think you apply the physiology test first. So a very, very sick, dying head of an ICU [who] is not probably going to do well on a ventilator and they're gonna get excluded. Where I believe we should take into account health-care worker status is a tiebreaker. So after you get by physiology, after you get by age as a predictor, then you probably are going to say we got to get people back to work if we can, and they will save more lives that way, and we'll be prepared for the next wave of this virus if it bounces back. Which it could.
In these tents, on the cots that sit less than six feet apart, it is expected that millionaires will lie beside people without a penny to their names. Care will be allocated based on where it can be the most useful and do the most good.
This is not a type of health care that most Americans are accustomed to. But already, rationing is upon us.
If you are one of the 7.6 million people in New York City, you are advised by city officials to stay home until you become short of breath. Typically, this is a sign of being on the brink of a critical illness. It means a respiratory infection has spread into the lower airways, and it could quickly progress to the point of needing supplemental oxygen or intubation and mechanical ventilation. But, at this point, medical care—prior to the point of becoming short of breath—must be rationed. Clinics and emergency departments cannot currently handle being filled with people who, sick as they may be, do not yet clearly require hospitalization.New York, like other states, does not yet have enough hospital beds, masks, or diagnostic tests for the coronavirus to accommodate all who might need one. Certain rationing decisions are already being made, including which surgeries can be considered “elective” and canceled, and which cannot.
Perhaps most ominously to the thousands of New Yorkers at home wondering just how short of breath is “short of breath,” we also do not have enough ventilators. By Governor Andrew Cuomo’s estimate, the state will need around 30,000 in coming months. We have about 5,000. Some new ventilators are being made, but this cannot happen quickly enough to meet that sort of demand.
And so, ethics boards at various hospitals are writing guidelines for how to manage allocation of life-saving resources like ventilators. These groups will deliberate and model various hypothetical scenarios, and then issue directives about what sort of decisions should be made. At a certain point, the calculus of American doctors will switch from the default of preferentially caring for the person who appears sickest to caring for the person with the greatest chance of benefiting from care—and with the greatest potential for years of life ahead.
These decision trees are guided by the four basic principles of medical ethics: personal autonomy, beneficence, non-maleficence (“do no harm”), and justice. In a fast-moving pandemic like this, these principles may look different in execution, but are no less important. A patient’s personal autonomy becomes limited based on, say, availability of resources. You may want a ventilator, and a doctor may agree that it’s necessary, and yet it may not be possible. The call to do no harm, likewise, can become a call to do as little harm as possible—or to do maximal good.
The question of who gets a ventilator and who does not, when two people are both in real need, is a question of justice of the sort doctors are not trained to adjudicate. But others are, and this is the moment they’ve been training for. (...)
James Hamblin: There was discussion over the weekend about making sure that there not be discrimination against elderly people, against chronically ill people. There is that tension, which is similar with organ donation, where you have to think about the utility of how many “quality life years” does a person have if they receive an organ.
So it seems like there is discrimination against elderly and chronically ill people built into so many rationing decisions. How do you navigate that in a way that if, say, if it comes to ventilators, is as nondiscriminatory as possible—while making decisions that are, by definition, discriminating who gets what?
Caplan: When I look at policies, including my own institution’s, the first thing you have to commit to is that you won't discriminate. I'm looking for a statement that says everyone will be considered. That includes elderly people, the chronically ill, the disabled, and also would include no discrimination by gender or race or culture. We're trying to lead with the principle, and this is what I would call fairness, that everybody has a shot. Everybody has an opportunity.
That's somewhat true in transplant rationing, and it's somewhat true with emergency medicine rationing. You begin by saying in order to get support for rationing, you have to make people know that the squeaky wheels won't have an advantage, the rich won't shove aside the poor, the disabled just won't be killed. We're not going to have hard and fast age boundaries.
You then move on to justice. And your question, James, is what about biological and physiological differences? The answer to that is, that's the first consideration. Try to maximize the chance of saving a life. I do think that the moral principle that has emerged is that first you try to save the most lives.
That does put people who have underlying chronic illnesses involving their respiratory system—chronic obstructive lung disease damage from vaping, smoking—that could put you down lower than somebody else. I wouldn't start with an age cutoff because we've seen healthy 70 year olds and very, very sick, compromised 20 year olds. But it would be fair to say if you can't sort them out by biology and physiology, then you go to age because age is somewhat of a predictor of who's going to do well.
Young people just do better than older people. It's not like 40 versus 30, it's more like 20 versus 70. I think Americans also want kids first. We haven't seen many kids get infected here, but most of the policies that I've had input to, we try to see children first, too.
Hamblin: We don't want the wealthy and powerful people to have unfair access. At the same time, there are questions of a person's utility in a specific scenario, like if you are the head of emergency medicine or ICU care at a hospital and your health ends up subsequently meaning many more people could be kept healthy. Do people in positions like that get priorities over people who ... who are of less ... I don't even know how to use these words appropriately without being offensive.
Caplan: Significance to trying to save more lives. I know where you're going. So the answer is yes. But I think you apply the physiology test first. So a very, very sick, dying head of an ICU [who] is not probably going to do well on a ventilator and they're gonna get excluded. Where I believe we should take into account health-care worker status is a tiebreaker. So after you get by physiology, after you get by age as a predictor, then you probably are going to say we got to get people back to work if we can, and they will save more lives that way, and we'll be prepared for the next wave of this virus if it bounces back. Which it could.
by James Hamblin, The Atlantic | Read more:
Image: Aleksandra Michalska/Reuters 
