Who deserves treatment in COVID-19 coronavirus pandemic? Ethics and bias in therapy decisions. (5)

Well, it is quite apparent that the most vulnerable groups for a serious and sometimes fatal cause for COVID-19 Coronavirus are the older adults and patients with chronic medical problems who could be quite young. Dr. David S. Jones, MD. We already see that the ageism and ableism are being essential quote-unquote unleashed by necessity. This quote is from Rabbi Elliot Kukla, who wrote a very poignant opinion in the New York Times called “My life is more disposable during this pandemic”. Shouldn’t public health measures be sharply and very early focused on the most vulnerable populations first and foremost, to protect them, rather than being belatedly applied in a very blanket fashion on the entire society? Dr. Anton Titov, MD. It is what we see now. It is a very important question. There are two issues that are playing out in that. One is, what strategies should we use and focus on in terms of prevention? Dr. Anton Titov, MD. Then what do we Do once prevention, prevention has failed. There are actual cases in the community. So certainly in terms of prevention, there is enthusiasm for patients doing what they can to protect the most vulnerable, especially elderly populations. So you’ll see grocery stores now will have special hours that are only for patients of above a certain age, trying to protect them from exposure to younger patients. Part of the reason that schools were closed wasn’t to save the children from being exposed for their own sake. But it was to decrease the amount of spread in the community, for fear that those children would then infect, older patients who are more vulnerable. Certainly, I have many friends and colleagues who have young children who are being very wary about exposing their children to their grandparents, because no one wants the grandchild To me. This person gives their grandmother or grandfather, this virus and so in terms of her Prevention. Everyone is on board with trying to do reasonable precautions, born of an awareness that certain patients are more at risk than others. The challenge comes up when you get to questions of scarce resources. What we should do with patients who are sick few questions have preoccupied bioethicists more than this question of how to allocate scarce resources in a crisis. So you’ll find many classic teaching cases if you are a battlefield surgeon and you have five patients in triage. You can only save one how do you choose. This one to solve? Dr. Anton Titov, MD. Those kinds of scenarios are bread and butter of any medical ethics course for medical students for bioethics for undergraduates? Dr. Anton Titov, MD. Fixation on this question has done useful work. Medical second opinion is important. Over the past, probably 40 years, 50 years, bioethicists have done a lot of sophisticated thought about this question of how to ration in the justest way. There are very well described approaches to that. Now one method is to figure out how do you save the most lives in the short term. If you do that, then you would give the resources to the patients who are sickest, hoping that those lives will be saved. Other patients will say, well, you need to have an eye on the long term picture. Don’t save the patients who are sick, save the patients who are most likely to have the longest life expectancy in the aftermath of Yes. There are other patients who would say, well, we should focus on the most valuable, we should see what contributions Could someone make to society and make sure that they are the ones who are getting the resources. Dr. Anton Titov, MD. You know. The one area that is usually well-tolerated is there is a good sense that you need to provide resources to the healthcare providers. They are the ones who are putting themselves at risk. They are the ones who we will all rely on if they get sick. Medical second opinion is important. It does make sense to prioritize health care providers if we have immunizations or if they become sick. Then some patients will say, well, all of those schemes are making value judgments. They are saying that some patients are more valuable than others. Dr. David S. Jones, MD. That is just not fair. Dr. David S. Jones, MD. We should do it in the fairest way possible. This is simply to have a lottery. Dr. David S. Jones, MD. That way, everyone has an equal chance to receive a resource. Now you can find many, many ethicists who will be making arguments for different positions of those choices. There hasn’t been a very clear consensus about the best way to answer that question. Dr. David S. Jones, MD. We know what the options are. But how to choose is a question of values and other beliefs. So if you look at all these, these rationing schemes that had been suggested, one group is often targeted. This is older patients. Dr. David S. Jones, MD. That happens for several different reasons. Sometimes your value is the utilitarian answer of doing the greatest good for the most patients and producing the patients who will have the longest survivor survival after the intervention that is going to direct resources to younger patients away from older patients, some philosophers have this notion that Everyone has should have some sense of fair innings. This is a metaphor taken from cricket. Medical second opinion is important. It is not useful for most American audiences. But there is this notion that, everyone should have some fair crack at life. So if you have someone who’s 80 years old, they’ve had a long life, they’ve had their chance to live and enjoy it. So they are the ones who should be sacrificed. Medical second opinion is important. Dr. David S. Jones, MD. That if you have a choice of giving a ventilator to someone who’s at or someone who’s 15, well. Dr. David S. Jones, MD. That 15 years old hasn’t had their fair ending, they deserve their chance at life. So there are several different kinds of rationing schemes that would all converge on the decision to withhold these resources for older patients. Now it is possible that that is both rational and deeply ageist and ablest and everything else. There is a lot of discomfort with the fact that patients are trying to figure out well, is it truly rational, or are we simply rationalizing long-standing bias? Dr. Anton Titov, MD. Dr. David S. Jones, MD. We have older patients. Again. This goes back hundreds of years, it is possible that policies are both defensible. Also, stigmatizing and biasing at the same time is very uncomfortable to sit with that. One point that patients have been making is how crude age is as a threshold for making medical decisions. Sometimes you were to look at 28-year-olds, they might be in radically different health status. There are some extremely healthy 80-year-olds on this world whose physical health is probably better than many patients who are much younger than themselves. There are also are plenty of 18-year-olds who are living at death’s door. Medical second opinion is important. If you were going to take something like age into consideration, you wouldn’t want to do it in a purely bureaucratic way and have a fixed cutoff because that would completely ignore the incredible variety that exists within the population of older patients. That is certainly true for many, many medical conditions. Medical second opinion is important. we will speak With a lot of. In cardio surgery in cancer treatment, there is a certain bias in certain parts and certain hospitals and medical systems against just the number whereas,. The practitioners say it is not the biological number that matters. It is the functional state at any given age. Medical second opinion is important. What you say is certainly parallels what we hear in multiple discussions in the ordinary times but with serious diseases. Part of the challenge there is as you try to offer a more nuanced assessment that physicians want to do. Dr. Anton Titov, MD. You then just open the door wider and wider to judgment. Physicians will say, Well. There are many factors that need to be taken into consideration. Dr. Anton Titov, MD. You should trust my clinical judgment, my expertise that I am making the correct complex assessment correctly. Dr. David S. Jones, MD. That may often be true. But the wider you an open door. The door to individual judgment. The more likely you are to have decisions that are affected by others. Kinds of bias that exists amongst all individuals. There have been proposals that what we need to do is have good ethics council committees, to take the decision out of the hands of an individual clinician. Give them advice that could work very well. But it depends on how severe their crisis is. Sometimes a hospital is making this decision once a day, then you can certainly get a committee to come in, God forbid if the horrendous crisis strikes like somehow forecast. Physicians are making these rationing decisions right and left; it’d be very hard to imagine a bureaucratic process that would allow thoughtful deliberation case by case by case. If that happens, then patients will fall back to simple rules. They’ll say above an age, we can’t help you. Dr. David S. Jones, MD. I hope I don’t think I hope we won’t we will ever get to that point. Well, unfortunately. Dr. David S. Jones, MD. That hasn’t been seen in Italy, were the first the cutoff was for intubation in eight years of age than 75. Dr. David S. Jones, MD. That is it. Medical second opinion is important. But obviously, all the public health measures are now directed as at escaping that for the worst scenarios.