Who Should Be Saved First? Experts Offer Ethical Guidance - The New York Times

This is one of the issues that scares me most about this pandemic given how America has always discriminated against people of color. Can America change in a crisis? I seriously doubt it. Please prove me wrong.

"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.

“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.

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 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?”

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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.

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.

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.

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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.

Nevertheless, precisely this kind of rationing is commonplace in the U.S. health system during more normal times.

The Hardest Questions Doctors May Face: Who Will Be Saved? Who Won’t?March 21, 2020

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.

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.

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.

“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.

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.

“When you consider the shortage of coronavirus tests, we’re already seeing rationing,” he said.

Austin Frakt is director of the Partnered Evidence-Based Policy Resource Center at the V.A. Boston Healthcare System; associate professor with Boston University’s School of Public Health; and a senior research scientist with the Harvard T.H. Chan School of Public Health. He blogs at The Incidental Economist, and you can follow him on Twitter at @afrakt

Who Should Be Saved First? Experts Offer Ethical Guidance - The New York Times

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E.P.A., Citing Coronavirus, Drastically Relaxes Rules for Polluters - The New York Times

"WASHINGTON — The Environmental Protection Agency on Thursday announced a sweeping relaxation of environmental rules in response to the coronavirus pandemic, allowing power plants, factories and other facilities to determine for themselves if they are able to meet legal requirements on reporting air and water pollution.

The move comes amid an influx of requests from businesses for a relaxation of regulations as they face layoffs, personnel restrictions and other problems related to the coronavirus outbreak.

Issued by the E.P.A.’s top compliance official, Susan P. Bodine, the policy sets new guidelines for companies to monitor themselves for an undetermined period of time during the outbreak and says that the agency will not issue fines for violations of certain air, water and hazardous-waste-reporting requirements.

Companies are normally required to report when their factories discharge certain levels of pollution into the air or water.

“In general, the E.P.A. does not expect to seek penalties for violations of routine compliance monitoring, integrity testing, sampling, laboratory analysis, training, and reporting or certification obligations in situations where the E.P.A. agrees that Covid-19 was the cause of the noncompliance and the entity provides supporting documentation to the E.P.A. upon request,” the order states.

It said the agency’s focus during the outbreak would be “on situations that may create an acute risk or imminent threat to public health or the environment” and said it would exercise “discretion” in enforcing other environmental rules.

The order asks companies to “act responsibly” if they cannot currently comply with rules that require them to monitor or report the release of hazardous air pollution. Businesses, it said, should “minimize the effects and duration of any noncompliance” and keep records to report to the agency how Covid-19 restrictions prevented them from meeting pollution rules.

“E.P.A. is committed to protecting human health and the environment, but recognizes challenges resulting from efforts to protect workers and the public from Covid-19 may directly impact the ability of regulated facilities to meet all federal regulatory requirements,” Andrew R. Wheeler, the E.P.A. administrator, said in a statement.

Environmental groups and former Obama administration officials described the policy as an unprecedented relaxation of rules for petrochemical plants and other major polluters.

Gina McCarthy, who led the E.P.A. under the Obama administration and now serves as president of the Natural Resources Defense Council, called it “an open license to pollute.” She said that while individual companies might need flexibility, “this brazen directive is nothing short of an abject abdication of the E.P.A. mission to protect our well being.’’

Cynthia Giles, who headed the E.P.A. enforcement division during the Obama administration, said: “This is essentially a nationwide waiver of environmental rules. It is so far beyond any reasonable response I am just stunned.”

Other observers defended the move. Granta Nakayama, a partner at the law firm King & Spalding who served in the E.P.A.’s office of compliance under President George W. Bush, said the memo did not give companies a free pass to pollute, but rather provided guidance in a challenging situation where many industries are facing unique circumstances.

“It’s a very straightforward and sensible, in my view, guidance,” he said.

Agency officials said the new policy relaxes compliance for monitoring and reporting only so that facilities can concentrate on ensuring that their pollution-control equipment remains safe and operational.

“It is not a nationwide waiver of environmental rules,” said Andrea Woods, an E.P.A. spokeswoman. “For situations outside of routine monitoring and reporting, the agency has reserved its authorities and will take the pandemic into account on a case-by-case basis.”

The memo said the compliance changes were retroactive to March 13."

E.P.A., Citing Coronavirus, Drastically Relaxes Rules for Polluters - The New York Times

Trump touted an anti-malarial drug as a cure for Covid-19. Don't believe the hype | World news | The Guardian

"Faced with a global coronavirus pandemic that is increasingly centered upon the US, Donald Trump has touted several drugs that he claims can help tackle the outbreak.

The US president last week used a press conference to promote the use of hydroxychloroquine, a common anti-malaria drug, to treat Covid-19, saying: “I sure as hell think we ought to give it a try.”

He followed this with a tweet that claimed the use of the drug in combination with azithromycin, an antibiotic, could be “one of the biggest game changers in the history of medicine”.

Trump was immediately contradicted by public health experts including his own top infectious diseases adviser, Dr Anthony Fauci, who warned that there was only “anecdotal evidence” that the drugs could be helpful.

Confronted with this disparity Trump, who has repeatedly made false and misleading assertions throughout the coronavirus crisis and indeed his entire presidency, responded by telling reporters that “I’m a smart guy” and “I’ve been right a lot.” The Fox News hosts Laura Ingraham and Sean Hannity seem to be satisfied by this assurance and have been promoting hydroxychloroquine on their shows.

But with some Americans turning to unconventional, and potentially deadly, treatments for coronavirus, medical experts have called for considered, accurate information to avoid exacerbating the pandemic.

Last week, an Arizona man died and his wife was left in critical condition after the couple took chloroquine phosphate, an additive used to clean fish tanks that is also found in the anti-malaria treatment promoted by Trump.

“Trump kept saying it was basically pretty much a cure,” the woman told NBC, before advising: “Don’t take anything. Don’t believe anything. Don’t believe anything that the president says and his people … call your doctor.”

Here are the key things to know:

What is hydroxychloroquine?

Hydroxychloroquine, also known by its brand name Plaquenil, is a drug used to treat malaria. It is a less toxic version of chloroquine, another malaria drug, which itself is related to quinine, an ingredient in tonic water.

It is also readily available to Americans – already approved as a malaria and anti-inflammation treatment by the Food and Drug Administration – where it is an off-the-shelf drug with various low-cost generic versions.

Why is Trump touting it?

Trump was influenced by a widely publicized study in France where 40 coronavirus patients were given hydroxychloroquine, with more than half experiencing the clearing of their airways within three to six days. This apparent improvement is important as it would curtail the timeframe in which infected people could spread Covid-19 to others.

However, experts have warned that the study is small and lacks sufficient rigor to be classed as evidence of a potential treatment. The French health ministry has warned against the use of hydroxychloroquine for Covid-19, with Olivier Véran, France’s health minister, saying that it shouldn’t be used by anyone with the exception of “serious forms of hospitalization and on the collegial decision of doctors and under strict medical supervision”.

What does the evidence show?

The French study followed work by Chinese researchers which suggested that hydroxychloroquine can slow infections from Sars-CoV-2, the virus behind Covid-19, by blocking it from entering cells in the body. But more recent, albeit small-scale, research from China has shown that patients who were treated with the drugs fought off coronavirus no more quickly than those who didn’t get it. Indeed, one patient given hydroxychloroquine severely worsened in condition while four patients on the medicine developed signs of liver damage and experienced diarrhea.

Regardless of these findings, any drug being used for a certain purpose before full clinical trials are completed is, by definition, untested and unproven. It’s too early to say if hydroxychloroquine can have a major benefit or not.

Are there any downsides to this drug being in demand?

Like many drugs, hydroxychloroquine comes with a number of potential side-effects. These include headaches, dizziness, stomach pain, weight loss and mood changes.

Worse, a sudden surge in demand for hydroxychloroquine risks shortages of the drug for those who need it most. Hydroxychloroquine is able to keep lupus, a chronic autoimmune disease, in check but some people with the condition have complained they are now unable to find Plaquenil. Trump’s pushing of the treatment has caused many Americans, whether they need it or not, to stock up on the drug.

What should people do instead?

The latest Chinese research suggests that using hydroxychloroquine is no better than more conventional coronavirus treatments, such as bed rest, anti-viral drugs and oxygen inhalation. There are about 40 different research efforts around the world to find a vaccine, which may take a year or more, while scientists rummaging around in the existing medical cabinet have identified some other drugs that may be repurposed to tackle Covid-19. But this work, too, will take time.

Conclusion?

There is no magic cure for this pandemic, no matter what Trump says."

Trump touted an anti-malarial drug as a cure for Covid-19. Don't believe the hype | World news | The Guardian

‘This all comes down to ventilators:’ Gov. Cuomo on the fight against coronavirus

‘This all comes down to ventilators:’ Gov. Cuomo on the fight against coronavirus

Stacey Abrams on how coronavirus stimulus package shortchanges election funding

Stacey Abrams on how coronavirus stimulus package shortchanges election funding

Opinion | Trump Chooses Disaster as His Re-Election Strategy - The New York Times

By Charlie Warzel

March 27, 2020

It’s a massive bet that political polarization is a more powerful force than the virus’s body count.

Tom Brenner/Getty Images

Donald Trump’s re-election strategy had two potential paths this week. The first path would save millions of jobs, turn Trump into a populist hero for many and perhaps prevent another depression. The second path would court chaos, playing up the partisan divide, deflecting all blame for the coronavirus pandemic onto the media, China and the Obama White House, and praying that it ends up being enough to obscure his administration’s disastrous lack of preparation.

It’s a testament to Mr. Trump’s callousness that at this decisive moment, he chose the second path.

Already we see the carnage. Last week, more than three million Americans filed for unemployment benefits, in part because of a sclerotic government response to the virus shutdown.

It didn’t have to be this way. Mr. Trump could have pressured Congress to join European leaders — including the Tory-led British government — and proposed to “freeze” the American economy in place. Denmark, the Netherlands and the United Kingdom have all committed to paying at least part of workers’ salaries if their companies don’t lay them off.

The American bailout bill does far less for workers or the small businesses that employ them, while larger corporations reap expansive benefits.

And President Trump appears poised to urge workers in some areas back into the pandemic, possibly as soon as mid-April, to restart the economy — a maneuver health experts agree would cause cases to skyrocket, effectively losing the short-term fight against the virus.

Knowingly putting workers into harm’s way to move the market is both unthinkably cruel and wildly misguided, even from an economic perspective.

With this shortsighted call, Mr. Trump is essentially making a massive bet that political polarization is a more powerful force than the virus’s body count. By picking the usual fights with the press, the president is hoping to change the narrative around the virus.

Take the president’s continued efforts to brand the pandemic as a Chinese virus. For Mr. Trump, such language operates as a grotesque division tactic. It creates an enemy for his base at the expense of inflaming racial resentment toward Asians everywhere. The controversy also creates a diversion. News cycles about the administration’s trollish language compete for airtime with reporting around the administration’s slow and costly response to the coronavirus — one that’s left millions of citizens and health care workers vulnerable. In pro-Trump circles, the conversation focuses on a deranged media that’s more obsessed with political correctness than a pandemic.

Mr. Trump’s desire to end social distancing follows a similar pattern. The president’s short attention span, thin skin and obsession with the Dow Jones industrial average all lead him to push for a reopened economy. Only the president doesn’t have that power — states do. And most states are likely to continue urging their residents to stay home. So he’ll blame the media and Democratic governors for the economic fallout. Here’s where the faulty American bailout helps the president in the most sinister way: Workers left without adequate protections could suffer more under a mass quarantine and might be more likely to resent medical experts and a mass media urging for social distancing. Mr. Trump can rail against the states’ decision to extend the quarantine and pretend, insincerely, to side with workers over the elites. After all, many of them can comfortably work from home and keep their jobs, he might argue.

For the president, it might feel like a win-win. If states ignore Mr. Trump’s advice and beat back the virus successfully before Election Day, he can claim victory. In the very unlikely event the virus doesn’t cause destruction in other parts of the country similar to what it is causing in Seattle, New York City and New Orleans, he can claim fear-mongering on behalf of Democrats and the media.

Meanwhile, the conversation around the virus shifts away from those needlessly suffering and the Trump administration’s woeful preparedness. The pandemic moves from Mr. Trump’s nightmare — a complex medical and logistical crisis requiring empathy and leadership — to Mr. Trump’s wheelhouse — an overly simplified, cynical political battle fought with cruelty and finger-pointing. Just as his coronavirus news conferences have become stand-ins for his rallies, the president’s politicization of the virus allows him to operate in a modified campaign mode. Without an official Democratic challenger to call out and a traditional election news cycle to cover the horse race, Mr. Trump is choosing to use the pandemic as a tool for his usual base-rallying division.

Under normal circumstances, this tactic seems to work for the president. But these are not normal times. Though public opinion around the virus is still starkly divided by party, there’s evidence to suggest that gap is narrowing and could shrink substantially as the spread of infection peaks across the country. Faced with an exponentially multiplying threat, the president has chosen to flirt with disaster rather than avoid it. It’s a strategy with a high risk of collateral damage — namely, us.

Opinion | Trump Chooses Disaster as His Re-Election Strategy - The New York Times