« Freakonomics Radio

413. Who Gets the Ventilator?

2020-04-16 | 🔗

Should a nurse or doctor who gets sick treating Covid-19 patients have priority access to a potentially life-saving healthcare device? Americans aren’t used to rationing in medicine, but it’s time to think about it. We consult a lung specialist, a bioethicist, and (of course) an economist.

This is an unofficial transcript meant for reference. Accuracy is not guaranteed.
Economics, radio, sponsored by the alliance for lifetime income, don't just plan to retire plan to live words to live by in retirement, and loss if he echoed by the alliance for lifetime income, which is committed to educating Americans on the importance of adding protected lifetime income from an annuity to their retirement portfolios. Annuities cover your essential monthly expenses, so that you have the freedom to pay. To those exciting things you ve always wanted to do in retirement, so protect your income with an annuity and plan to live, see how that protected, income that for freedom, for economics, radio sponsored by we all know, meetings struggling to pay attention file seem impossible to find and if your not in the room you're, not in the know. Well, come to the new way to work together, Microsoft teams rican contribute to me, Eating from anywhere chat with co workers,
never out of the loop and find all your files, even edit them in real time, in one convenient place when Europe the need to unleash the power of your team? Open teams learn more at Microsoft: DOT, com, slash teams, Here's a question for you, let's say: there's a pandemic fatal virus working its way around the world. There is no therapeutic treatment yet, but there is one piece of equipment that gives critically ill people, the least chance to survive Let's say the demand for this equipment outstrips the supply. There just aren't enough units for the number of people who need it. So how do you decide who gets priority? Should it be first come first served should be the very sickest people or perhaps the he's sick of the very six and now have a better shot at survival. Should it be older people who may be fragile or younger ones, with more life left to live in
theoretically more to contribute to society. Should wealthy and powerful have privileged access to this life, extending equipment, as they have system, most other resources, or should it be reversed with priority going to the poor, powerless. There's one more category: I'd like you to consider what about doctors, nurses and other health care since they are the ones treating the victims and putting themselves a higher risk of exposure. Should they moved to the front of the line if they get sick. How But you answer these questions probably says something about how you view the world generally give. For instance, you an economist, you think about the most efficient ways allocate scarce resources, but if you're a front line health care worker, you may think it's only fair to Alan's efficiency with some sense of reciprocity and how do you about this question. If you're this person, my name, is Parag pathway.
A professor of economics at MIT? Ok, that's the economy, part, but also so my wife, the physician and my sister is an emergency room doctor as it happens, Patrick's research, specialty is particularly suited to this sort of dilemma? It's called market design, so that is branch of Micro, economic that tries to devise practical themes for real life resource allocation problems like getting your kids. School or how can you increase your chances of getting a kidney, if you didn't have one, what I'm really excited about are situations where we have to be very precise about housing get rationed situation where supply and demand don't have the usual instruments for the market to clear. The use or instruments, meaning prices, so like a situation where there's no price, usually you know. If there's more demand then supply the price goes up. There is not enough demand. The price goes down, but
in light of the problems I've studied. We have to think about equilibrating the market in a different way, so does is still feel like economics to you or put you into the realm of ethics or phone ass a fee or something else were alive, the times when you can't use price. We have to ask the question why and that opens the doors exactly philosophy. Ethics. Consider issues that, I think, are a little difficult for economists to wrestle with, for instance, during this red nineteen epidemic? I started to look some other guidelines about? What do you do? there's not enough ventilators ventilator as you likely now is a piece of hospital equipment that can help keep alive someone with respiratory failure, Patrick in some key league started reading different states guidelines for how to prioritize ventilators in a potential shortage, and so there, interesting tidbits in the New York document that really got his thinking and one of the dead bits was
a statement in that guideline. That said in a we do not think that essential personnel or frontline health worker should be prioritized, and you know Here I am talking to my spouse, who is trying to find a way to get, and ninety five masks online the is looking at different face shields for welding from home depot before she goes into the emergency room and I asked him what do you think about this- and they both said this is crazy, but New York I was based on the idea that if we give essential personnel the highest priority. Then we could In a state where a hospital has twenty event, leaders and they only go to essential personnel that got me. Thinking got us thinking to today. On four radio will speak with a medical ethicists, about health care. Rationing. First comfort is the absolute worst principle you can think of
in this situation, man I'll on the need for better principle, fast hospitals those are bursting at the seams. I have friends, who are writing their wills and the economist the potential solution, I think, Most of these plans would like to prioritize frontline workers. They just don't know how to from stature and Gunnar productions. This is greek. Radio broadcasts explores the inside of everything. Here's your home Stephen governor there are so many unknowns about coded nineteen.
It's hard not only to keep street what's known, but were constantly discovering that what we knew yesterday isn't quite so true today and by next week it may be totally and valid. One concern over the past couple months is many. People will need mechanical ventilators to keep them alive and that their aren't nearly enough ventilators go around keeping These numbers are changing all the time. Let's start with the current assumption. On ventilator demand and supply. The numbers! I've seen on this are aggregate numbers. That, again, is the aim. The economist, Parag PATH, EC, their full featured ventilators there is about seventy to eighty thousand of those, including attended twenty, from the strategic national stockpile and then there's a partial feature of it, later in there's about a hundred thousand of those and if you think, about the than Emerson ITALY about ten to twenty percent of those hospitalized require ventilator, so that takes us about two million at least, and even if those are spread out,
over three months. The hunter there are two hundred thousand number start to look pretty scary. It looks very scary, also just a minute in terms of the supply demand. Calculation- is a lot of them ventilators that we had in the United States were not just sitting idle. They were already being used for other types of elements in New York state, for instance, eighty five percent of ventilators are typically in use during normal conditions, which makes sense. Ventilator is inexpensive, piece of equipment hospital doesn't by ones that sit. I So a big share of those one or two hundred thousand existing ventilators were already in use, is also the two of whether the available ventilators are situated where there needed how those are split, States is a big open question. It's actually another area where economists have started to think if only we had a national registry. That said, you know, there's an excess supply ventilators in Idaho and there's a
bridge in New York City. Why don't we transport some of those Idaho ventilators to New York and a national registry does not exist, because why? I don't know, I think, in part, because medical services in the? U S are fairly decentralized. The purchase a of ventilators like most other expensive medical equipment, is often left to individual hospital systems. Capacity therefore varies from hospital. The hospital with coded nineteen, the overall capacity, is thought to be way too low, which is why the federal government and others have been frantically ramping up. Ventilator production. Will all those ventilators be needed? If needed? Will they be effective? Those questions are unanswerable for now in York it was predicted there would be a massive surge in ventilator demand and therefore a mass of shortage. Thankfully, that hasn't come to pass at least not yet. But if there are shortages
the issue of how to ration ventilator will be an incredibly difficult and important one. The idea of outright rationing medical resources Mason, the alien in the? U S, but that doesn't mean hasn't happened. We have had clear situate, since where we, the United States, has had to allocate resources an ration. That's the oncologist and bio ethicist Zeke you'll Emmanuel I am the vice provost global initiatives, a university professor and director of the healthcare transformation in situ at the inertia Pennsylvania Emmanuel was an architect of Obamacare he's now advising Joe Biden uncovered nineteen. He says urban. Three major instances of rationing in: U S, history, number one is insulin for diabetes was first discovered in nineteen twenty and before we figured out how to ass produce it and number two. A second
penicillin, which was discovered in the late nineteenth twenties, but could not be produced in large quantity until the war World WAR, to create a real and when they finally figured out how to produce it, but large quantities was not large enough for everyone who need- and so we the Russian who got it. First, the ring a war effort and even the vast majority. Ninety percent of it went to the military within the military wasn't enough for everyone who could benefit from it. So we had to Russian that and the most recent episode of rationing, a process to treat kidney failure in the early nineties, sixties figured out how to do long term. Chronic die and there was very substantial rationing, their picking the people, actual rationing, their picking the p who would get on long term dialysis and the people who wouldn't, who would end up dying that persisted until the federal government fully took over all the pain Four dialysis, which continues till today, while back kind
rationing is typically in the past a manual and his fellow bioethics is still have plenty to think about. You know: do you were shattered this patient. Do you call uncle pull the plug on this patient? How do you genetic tests, do we permit embryonic stem cells? us or only other kinds of matic stem cells. Do we use crisper analogy, but also there are still serious shortages in medicine, the shoulders of guinea's. We have a shortage of livers and you have to choose which patients get the organ that you have at any one time. There are rules that rules are not without their contention and those doctors probably a thought about it. More than the other the transplant in any other, set a doctor's. So how much discussion of rationing is there in medical schools? It's not really
really discussed and not a core part of the curriculum anywhere and I think prior took over ninety, despite some Evelyn no one really thought that this was critical, Emmanuel was one person who did think it was critical to think about rationing. I wrote my first paper in two thousand and six, which was basically an analysis of the Department of Health, human services plan for rationing vaccines and treatments. If we had a influenza pandemic, so the government had been thinking about it. Way back in two thousand and five and they came up with an initial plan, and I thought that plan was unethical, because that plan said our goal is to save the most lies and wait a minute. What's wrong with a plan for the goal is to save the most wives, the
She just plan made clear that older people were most likely to die in an influence outbreak and so on. We should save them. First than that just struck me is wrong because you emphasise saving the most lies and ignored saving the most life years, people who if you save them, live a long time. If you read a lot of papers, written by Bio, ethicists and health economists, theirs nationalism. You often run across Q, EL. Why you stands for quality adjusted life here. One quality adjusted life here means you live a year longer full health if you live a full year at only fifty percent of full health, that's only half of a quality adjusted life here, one of the things we know from the influenza pandemic, nineteen eighteen, it was people in the prime of
young kids up until young adults, were the most likely to die in that episode. And so, if you focusing on older people, you would end up quota Kojak, sacrificing younger people who had way more potential time to live, but the HIV plan, prioritized older people, so we wrote a paper criticising it and then it turned out. If you survey the public, they agreed with us that with a pandemic, you're safe young people and not just old people. So one of the things ended up doing is to think through one of the values that are really important. People in any kind of risk, situation. Here's one value that embraced by nearly all bio ethicists when it comes to Ashley Medical Services, things like race, ethnicity or socio economic factors should not come into play. This, of course, is not a universal com
Consider Saudi Arabia were several as members of the royal family are reported to have covered. Nineteen, the house where royals typically receive treatment was instructed to not only prioritize those vip patients but to remove non vip patients from the premises asap the. U S had its own brushes with privileged access, for instance, when many NBA players were given covert. Nineteen tests, despite showing symptoms, while countless civilians with symptoms were unable to get tested. When you hear this kind of storing. It may be natural to think that the fairest way to distribute medical care would say it's a ventilator would simply be Come first served first comfort, serve as the absolute worst principle you can think of in this situation.
Its biased and a number of ways, its biased, because people who live close to a health facility get priority. People who have traditionally been excluded from getting good Health care, whether their minorities or people in rural areas or others. They continue to get excluded because first come first served precisely those people who are well into the system. Third, you they have someone who has a worse prognosis, who happens to shop. First, that's a relevant criteria, but it's hardly determinative. We you know Someone with a better prognosis ought to get those resources. I recognise that if you say first comes doesn't have a role in someone who happened to be an event later, but someone else who is better prognosis, comes in, and you have no other rent, the labors, removing a patient from a ventilator to give it to someone else is psychologically traumatic, it's very hard to do, but I think it very important to do because it's the ethic
the thing to do before we go deeper, into ventilator. Rationing, Stick stepped back and learn exactly what a ventilator is. Gas at normal breathing. Does forests, that's MILAN Han, so the most important things that it does is get Milon Han, so gay most important things that it does is get oxygen in that helps ourselves and then get carbon accede out, which is the waste product. So when we think about Evanna. Later it has to do those two things: get the oxygen in and get the carbon dioxide out Hon is an M, and professor of pulmonary and critical care medicine at the University of Michigan Covert teen is fairly widespread in Michigan within the last few weeks. The greater area Detroit has been hit quite hard, my county was not hit quite so hard, but we
in trying to help by taking transfers from Detroit. The house those are bursting at the seams. They have opened up field hospitals. We are redeploying staff, but its incredibly stressful on everyone. We have health care workers now that are sick. I have friends who are writing their wills Hahn is a big deal in the field of permanent she's a journal editor. She sits on scientific advisory committees. In other words, she knows a lot about how we breathe or fair to a patient can end upon a ventilator for huge, a variety of reasons. Essentially any time the lungs are failing. To do one of its two key jobs that kid He do to pneumonia that could be due to heart. Failure in some cases ventilators are only used in intensive care units. It actually requires an incredible amount.
Of resource utilization from a human perspective to keep the peace an event in later years. We have physician tee consider going around in doing constant tweaking of the ventilators the later, is meant to help the lungs do their job, but it doesn't work that way. Lungs work advance later actually induced to something we call positive pressure breathing the air is essential being blown into you, if you think about how you normally breeze and normal your diaphragm fires. The lungs expand, actually air, Russia's in because of the negative Sure generated so it's very different and actually uncomfortable for patients to go from their normal negative pressure, breathing two positive pressure breathing. If you can imagine what it would all of a sudden feel like to have someone just lasting you with air and that's how you're supposed to breathe. So one of the reasons why we
I have two sedate patients in the icy you and in some cases we actually have to paralyse them, because otherwise you get significant de synchrony in the patient, trying to fire their own diaphragm to breathe, and the ventilator trying to deliver press. That's one of the things. I think a lot of people don't realize you do just put a patient on a valid and walk away. Things could be good one SEC and you get a call from the respiratory therapist her the nurse at all the sudden. The settings that were working fifteen twenty minutes ago or no longer working, so it requires really close. Tension to detail a lotta tweaking an expert contagion to really optimize each patient when appear comes the emergency room in respiratory distress. Let's say it's a covert. Nineteen patient eventually there is not necessarily the first step. Often they have low
both of action. So the first thing to do, if it's not life critically low, would be too the patients on some kind of supplemental action, there are a few options, this has actually been an area difficult debate among the medical community, but one These options is something called high: flown easel, canny alarm, that's administered through a thin, clear tube into the patient's knows, but for the most serious cases supplemental oxygen, won't be enough when we look at just x, we look at that and see tee some whose we call it white out. So when that is the one being nice in black, which is the color of air ANA radiographic image. All of a sudden. We just see these these white infiltrate everywhere the booth point: a patient is often put on a ventilator They are likely to be suffering from a r d s, acute respiratory distress syndrome and prior to covet, nineteen
we ve done tons of research studies on how best to treat a already ass, regardless of the cause, and so there are certain protocols that we have in place like keeping the size of the breath that we deliver on the ventilator low one of the things that people do not realise is that oxygen itself is toxic and high levels. The other thing four may not realise is that the amount of air that we push into the lungs beyond a certain point. It actually harmful. And it can actually cause lung injury, because cabinet team is a new disease doctor around the world are frantically trying to work out how to best use ventilators against it. You know there's no time for a randomized trial of how to ventilate patients. Everyone is just doing their best. There are a few different views. One camp of thought is that we should be
treating covered nineteen just like any other areas that we ve seen and followed the same protective protocols that we would normally follow. There is this other camp, a thought that may be. This isn't really like air DS, and maybe we should be using larger lung. Ions. Some researchers suspect that carbonate it is attacking the lungs of some patience in a manner more similar to high altitude, Pulmonary Edina, where the problem to do more with how the lungs blood vessels regulate blood flow. This would mean that ventilator uncovered nineteen patients in the weights used to treat They are the yes may be sub optimal at best, maybe the normal rules, I don't apply, There certainly do seem to be certain aspects of the patient physiology that seem a little bit strange. One thing: the dog here is the world are noticing the way
Ventilators have been used today uncovered. Teen patients isn't working very well rough least. Sixty seven percent of patients in one: U K database that received chemical ventilation still died in New York City. More than Eighty per cent of corona virus patients who were put on ventilators still died now keep in mind if need a ventilator you're already in very bad shape. In fact, roughly half of all patients with severe respiratory. Dress, who go on ventilator in normal times, will die. Sir How does MILAN Hon see the role of the ventilator in fighting covered? Nineteen? It's not gonna, be the panacea necessarily to get us all through, but for the patients that our severe it is our only hope.
All timidly. If we're going to beat this, we are going to need better proven treatments. The Van electors are our life sustaining, but, honestly, that's while we wait for either drugs to work or for the patient to heal themselves, but said to later can keep a covert nineteen patient alive. It can potentially help them recover, which means there will be competition for the yesterday I was chatting with a friend of mine who is a banal just in New York, and he told me that they were dead on two six ventilators and had twenty p who needed them. So it is definitely a crisis in some hospitals and how does it after, like Hon, think about handling a shortage like that. No one physician, no one nurse, no one respiratory therapists months to be the one to say: well, patient a get something patient be doesn't
We certainly have our own way of thinking about the likelihood of benefit. And while we don't usually like to think about that in prescribing a treatment. We are now forced to think about that. But I think what most healthcare teams that I've been working with really want. Are ethics boards from the hospital to come in and use ethical principles, but team based approach to try to decide if it comes down to it? whether this lifesaving treatment should be given to patient a or patient b, coming up after the break. What hospital ethics boards in their state overseers have come up with what those guidelines say and don't say and too really different ways of looking at the very same patient, that's coming up, and after this.
For radio sponsored by the GM by Power card from capital, one, let's be real. No one likes spending money on the small stuff, but you need things like gas to get to work in sometimes in early afternoon cup of coffee there's something else: this podcast can teach you the little things you buy. Every day can put you on the road to earning back on something huge, a new ride, the GM by Power card. You get closer to a new shiver, lay Buick, geomancy or cadillac, with everything you by even the small stuff, find out more at five Howard card that car slash for economics. That's be you! Why power card that gum? Slash for economics. For economic radio is sponsored by better help. Is something venting you from achieving your goals is work relates stress or insomnia, slowing it down better help online counselling securely connected
with the professional licence. Therapist login Your account any time too easily schedule a video or phone sessions plus securely exe change, unlimited messages with your counselor, its therapy to point out better health. For support wherever you are, whenever it's convenient and for economics. Radio listeners get ten percent off your first month with the code for economics start now go to better help that calm flash economics, that's better health, dotcom, flash for economics. Freedom with radio sponsored by Paddy hidden in each cubic yard of air or thousands of I allergens- you can't see them, but your surround. Your eyes each nonstop, You rub them all day, but now relief is just one drop away. Paddy once daily relief contains the number one prescribed I allergy, it relief ingredient, one drop.
Once a day works fast and lasts all day turn Europe Did she allergy idea into a payday now available without a prescription everywhere before covert. Nineteen. Many states had formulated guidelines for hospitals to follow if they were faced with a shortage of ventilators. It was those guidelines that got the MIT economist, Parag Patrick interested in this subject, so so the ventilator protocols we come across our based on a points system where you know gladly citizen, different stakeholders, doctor There is a legal scholars, basically take ethical principles and map them. Two numbers, for instance, There is a thing called a sofa. A sofa score stands for the sea, organ failure, assessment and
or organs, are more likely to fail. Then you get a higher score. If it's less likely to fail, you get a lower score, so they too and they summon up with another ethical criteria, which is why, save the most number of years of life, not the most number of lives. With a number of years wives and there again they take categories like DSL I called morbidity. Sir, do you have few commodities assign a number? And when all is said and done, they just some everything up and whoever has got the lowest score gets ventilator first, this is a pretty standard. Hey of prioritizing scarce medical resources like organs. Both for transplant mean One thing I do do is lung transplant mail. On Hon again from the University of Michigan, some very familiar with the allocation systems for long transplants, and they used to be based,
on how long you been on the list? And there was no prayers cessation of persons, but they realize. Then that means that the Sick patients are all getting dressed like a silly ones, living long enough to go transplant, so they changed that system to it being risk based on your day notice, but then they added to it. The patients numbers. This massive calculation and the patient gets a score. How does this kind of calculation work for ventilators? We s path to walk, is through the New York City, guidelines which were written into doesn't fifteen. So the highest priority. Patients are those who are most likely to recover with a ventilator. They call those patients red next come patients who are very sick and whose prognosis is a bit uncertain, so their likelihood of survival with ventilator is in the intermediate range so they're yellow then come blue patients
Those are patients who have a low likelihood of survival was ventilators and fight really you have green patients. These are green means go. These are patients, you dont need ventilator support, so even if we have ventilator. We wouldn't give those patients ventilator this priority point system is similar to what most states recommend that member states can do, here is what are the ethical principles at their entertain and so some of the principles. Are you know things like saving lives are saving life years again, that's the notion of quality adjusted life years that we mentioned earlier. Other principles food reciprocity. As someone who has put them so set risk should get priority that might include ambulance and fire department and grocery workers. As I was doctors, nurses and other frontline healthcare workers, there's also a concept of instrumental value, which is, if we don't have enough
members of society of this particular type, say doctors or respiratory therapists we're in trouble, so they need to be. Prioritized, meaning they are the stringent. A doctor in this case would be the instrument that would create value down. The line is that the correct interpretation that phrase that's absolutely right, so there is just direct Bennett. Instrumental value? They call it for having enough medical personnel, because if we didn't, then they occur. This is just going to get worse, so you could see how a given state might consider the reciprocity idea and the instrumental valuation idea and conclude that dog There's a nurses should be given priority ranking if they get sick and need a ventilator and that's exactly what some states have done mission for instance, where mail on Hon practices, medicine but other states as Patrick found, dont prioritized healthcare workers, including New York.
So, if I compare New York to Michigan in Michigan, they say we want to prioritize essential personnel and they give rationale based on reciprocity. There take on a high risk saving others we ve seen with covered nineteen. A large fraction of those who got sick are actually these frontline health. Workers Minnesota. On the other hand, they ve said like New York, we should not treat frontline health workers and differently than any other patient, and how many states do prioritize essential points No, we don't know the answer to that. So Michigan is a state that does a Massachusetts just released their standard yesterday and today have the same priority point system the to ethical criteria. They have saving the most lives and saving the most life years, and then they have a kind of footnote paragraph below their table saying, and we think that a central point, How should get heighten priority and its a bit interesting? Because
this table is very concrete and mathematical. It's taking you know these debates that the great philosophers have had and putting them on the numeric scale and then You know, there's this comment, oh yeah, and by the way these guys should get heightened priority without explaining. Does that mean there? granted the line or other at the end of the line right. So it's math, math, math, math and then be no do what you think makes sense. Yes, and that strikes you is woefully inadequate. It sounds or any. What's the point of passive your values in the super concrete way and then say it's an adequate like we need to protect our front line workers. We should note that we interviewed Pathak on Friday April. Tenth by Monday, the 13th doctors in Massachusetts were pushed back against the states murky ruling saying they should be given priority access to ventilators if needed. In any case, some states have designed
to give doctors and nurses priority, while others have decided not to. I asked path to play. The role of disinterested scholar and explain the logic behind each position? First: states like New York in Minnesota, where Healthcare workers don't get priority, so I'm not an emphasis, but I can try to guess what the other this were were saying at Cora principle is a non discrimination idea, so everyone they treated equally, that's our collective values as society and if we pray, hurt I summoned based on their occupation. There's two issues. One is why one occupy Conversely, the other. So if I say frontline of care workers, are taking on greater risks. We could also say that there are certain types of jobs that are more valuable to society. That should be priorities as well. Second than is actually defining whether frontline health worker is
Is that a respiratory therapists? Is I e our doc? What about a dermatologists? Do they count and it's possible that that category gets very large their worried about is that the key workers would use. Oliver supply up and that's gonna? Do DR all of the other groups, people like you and me Stephen from getting access, and now? Let's hear you Argue- let's say the Michigan side. What are the good reasons why healthcare workers should be prioritized healthcare workers are heroes in this situation there putting their lives on the line. If you dont prior ties them. You know you could create some problems, things like sick out, absenteeism, if I'm putting my life on the line and I could get exposed to cover nineteen trying to help someone else, may decide not to show up or another thing could be. Ethical dilemmas that healthcare workers themselves faces, if they have decide. Should I give the ventilator to my colleague, whose health care worker or another in whose not what do I do so right
then forced them to make this trade off? We should prioritize healthcare workers first, so that's perfect laying the disinterested observer? What Zeke Emmanuel the medical, ethicists think of the New York position versus the Michigan position, I think The Ark is wrong in Michigan Right, a man, oh and several Co. Authors recently made their position clear in a New England Journal of Medicine article. I think the logic is pretty. In Poland, pretty widely and door in the sense that, in an emergency like a pandemic, where health system is working flat out to care for people. You want the health care providers who are providing back here to get the first street and keep them alone. Because they can save additional people. So one phrase: it has been used or force small suppliers. You know one doktor, a nurse one? Respiratory therapists can care for many other potential patients,
and so you want to save them. First, here's what Parag path it came to think about. The states like New York but dont priority care workers, you know my feeling about this. Actually, Stephen is, I think most of these plans would like to prioritize frontline workers. They just don't know how to, and so panic and three fellow economists set out to help they applied some of the principles of market design that have proven hopeful in allocating kidneys for donation in matching medical residents to hospitals in distributing visas to immigrant workers. They quickly row and academic paper. It's called tree. This protocol design for ventilator rationing in a pandemic, integrating multiple ethical values through reserves. And the key Their reserves are proposed. Here is to think about it in enhanced priority point system? Where you take it
ventilators in you split them into categories or what we call reserves were a free, China. Reserves can have one priority order, their remaining venture this can use another priority order. Imagine, for instance, we're talking about one hospital. Let's have a hundred fifty bad hospital. And they have twenty ventilators our proposal is the following right: take the twenty ventilators put them into two categories: ok, five of them are gonna, be ventilators at are gonna prioritize, essential personnel fifteen, of the ventilators are just going to take the ethical principles of. Saving the most lies in the most number of life years? We have these two groups, forty eight hours in his twenty patients ventilators imagine we have thirty patients show up who are frontline medical workers who need a ventilator. Ok, and there are an additional sixty patients who are not frontline medical personnel. What we need to do is take the thirty doctors or
Respiratory therapists or nurse who were on the front line and try to allocate them a ventilator, that's reserve for their group, let's backup for second, you said that fifteen ventilators from the general pool are being used and the five from the reserve pool are also being used. Are we to assume that all five of those reserve ventilators are being used by frontline medical personnel. It need not be Stephen action, suppose only three essential personnel had showed up so then the remaining two would go to the general community. Let's say I'm a doctor that comes in and I am qualified for the reserve pool of ventilators, and There are two people on those five van later is at a reserve for the reserve pool who are not from the reserve pool their from the general population. What happens? Did they need to get booted off their ventilator to accommodate me that could be passed?
We would potentially boot them access to the New York standard, actually talks a bit about moving people off. Until waiters. That's typically done when some status changes so if two of those people at their sofa Laurent deteriorates, then One of the ventilators becomes free That would be the case in which you would potentially be booted off. It could be possible that the patient, who would get displaced by the frontline medical worker would then after qualify for the general pool, in which case they would to be booted off, but what they would do. Displace a general poor person who maybe deteriorated and freeze up noble ventilator, so principle number one, no ventilators unused, ok key principle number to the categories can overlap so a frontline medical personnel? He could qualify for the first bite at the apple or we could call
Why? For the general pool right, so he is. Priority may be high enough that he gets a general ventilator just having two separate, These are three or, however many you wish for different, categories of ventilators, partitioning all ventilators into these groups and using a different priority order for those ventilators Might it not say well, let's talk about instrumental value on a much larger canvas, so there's one doktor who might be able to tree over the course of the next month on a no to three five hundred people, but what about a cancer researcher whose work might affect millions of people. What about an entrepreneur whose inventions by defect billions of people, so I undertook and why it resonates on an obvious dimension? Why healthcare workers should be given priority? I'm I'm not disputing that, but doesn't it feel like a fairly slippery slope and if
so? Can you persuade me that you're, not starting us on the slope primarily because you are married to a doctor. Let me give you another instrumental category that I think is important and that is a you sign up for a clinical trial on a covert treatment, so we need, it to do that if we ever gonna find a treatment for this. If we don't know patients who do this, then in other pandemic, might last longer amount of time, so they should also have some kind of consideration. You could call that the good samaritan category. I that say, however, that all of the instrumental evaluations should trump these other considerations, because that's what I'm worried about. I mean I don't think we can say that the person is delivering groceries folks, Hauser running the subway system of the bus system. There also keeping society going right. So you're, absolutely right, there's a slippery slope. So that's
exactly the reason why we should not have a bang bang is what we say in economics as one type solution which have some satisfied that respects instrumental value or reciprocity and some satisfied that has non discrimination, I think the main reason our proposal improves the current situation is we can accommodate frontline person and we can also accommodate nondiscrimination, what we offer is a mid point. There is really no right answer here. Right. It's about equity, it's about distributive justice, it's about! What's the appropriate! normative standard that we want to have you know what about a flip side? What about a stick? Instead of a carrot? Should people who get caught You know violating social distancing standards get demerits so that they don't have the right to a ventilator. I know that's that's upon. Ability? Stephen, I think, there's gonna be a lot of implementation challenges. There. I will say, however, I think a lot of front on medical personnel are annoyed when they see people not
the guidelines. So I could see some sentiment in favour of that, but that's a tricky one Patrick and his co author I have already had one fruitful conversation with a bio ethicist who was involved in setting up the Massachusetts standard for prioritizing ventilators. They plainly hope to influence. General conversation to that and it may be helpful to point to some other scenarios that use a reserve system, as one the system that we studied recently as they each one be immigration visa system. So each we ve says, are visas for highly skilled employees. This year, H The visa are located in the following way: that's typhoon son, one of path, co, authors, There are sixty five thousand each one: babies us which are open to all qualified candidates and then
twenty thousand, additional visas, richer exe also the reserve for holders of adverse degrees. American universities, so situation where someone who's got in advance to weaken qualify for more than one type of slot at Tuskegee holders correspond to essential personnel in no way, because they are the ones who have these reserves. But there's one crucial difference between the each one be visa reserves and the medical personnel reserves. The economists propose in their new paper. In the paper we distinguish between two gazes hot chaps. Soft caps saw The ventilator application is what beautiful, as a soft cap saw. Preferential treatment is given, but otherwise everybody's eligible for all units, whereas H won't be. Visa application is an example of heart chops, a heart
cap, because members of the general population, do not have access to the reserve slots. We are now talking to doctors. Romantic lettuces lawyers and their very much interest and this idea, but they are a little bit, worried about the reserve terminology. The phrase reserve might give people the wrong idea. These are soft deserves no unit is ever left unused. So as we speak, there is some evidence that the car nineteen curve is flattening in New York state which has been you know the epicenter. So let's say God willing, Trend continues and repeats itself elsewhere, the U S and around the world and lets say that the leaders will not be as scarce resource as predicted. What kind of- value will you were model.
Or idea still have We all hope that we don't need to ration and we get you know out in front of this. The curve is flattened, but I think there is on value here and thinking about what we as a society think about. National and whose more deserving so, as I read the documents that exist from two thousand fifteen I mean you could have asked the same question back then why did they write those documents? There was? influenza pandemic and two thousand fifteen it was. Anticipating the future, and if our d, Can I say certain groups are excluded or there's no priority for blue take risks. I think that's a dangerous situation. You could Imagine that cuban nineteen itself will present further rationing necessities. We're not gonna be able to get back to clone court, normal We have actually much about eighteen months from now that again, Zika manual, they're, all doubtlessly
be vaccine rationing and maybe even therapeutic rationing, depending upon which therapeutic seem to be effective against scolded nineteen Thinking about rationing is a form of preparation that is in short supply. We then prepare fur obviously search capacity. Weeding prepare for how do we rapidly developing distribute a test? We didn't prepare for the idea of contact, seeing and working with the tech companies to develop it. Robust system for tech enabled contact racing. Obviously we then prepare for enough authentic. We were woefully under prepared MILAN, Hon Han again turns out, our national stockpile was not adequate. It turns out that even, for instance, some of the equipment, the stockpile, the ventilators were not working and really We don't have a centralized system to get
needed medical supplies and equipment distributed evenly across the country, and what we are now left with- is each state sort of fighting for itself. Each house system fighting for itself each house, care worker fighting for their own personal protective equipment and to me just Team such a waste- and such a shame that a nation with the resources that we have can't figure out how to use and mobilise resources it's just like us, ventilators- are really concrete, but that principles that were her to collecting apply to any, I think indivisible resource, that's in short supply. So, let's imagine we have a vaccine for covered nineteen there's still a who gets the vaccine. So
we have a rationing problem yet again and we need to think carefully about who's, gonna get it and how it's gonna be allocated thanks for listening, we'll be back next week in the meantime, take care of yourself and someone else too. If he can economics He was produced by stature and w productions. This episode is produced by Zack Le Pen, ski our staff also includes Allison, Craig Low Gregg Ribbon met Hickey, Daphne Chan, Harry Huggins and Cornwallis in turn is Isabel, o Brien, and we had hoped meat from James Foster. Our theme song is MR fortune by the hitchhikers. All the other music was composed by Lewis Carroll. You can get for economics, radio on any podcast act. If you want the entire back catalogue, used sticker app or go to free,
nah mix that com, or we also publish transcripts and show notes we can be found on social media, or you can write to us directly at radio free can almost outcome for economics. Radio also plays on many an pr stations, so please check your local listing. teacher.
Transcript generated on 2020-04-17.