 I want to wish everybody a healthy, happy and safe new year. I'm delighted to welcome you back to this year's McLean Center annual lecture series, which as you know is entitled, Ethics and the COVID-19 pandemic, medical, social and political issues. I'm very excited about the 11 lectures during this winter quarter, the first of which will be today by Dan Sulmasey with this special emphasis this quarter on healthcare disparities and on the allocation of the COVID-19 vaccine. For example, next week, Dr. Monica Peake will be speaking on the topic of health disparities and the COVID-19 pandemic. Today, we're delighted to welcome Dr. Dan Sulmasey as our speaker. As many of you recall, Dan worked for seven years here at the University of Chicago, where he was the Kilbride Clinton Professor of Medicine and Ethics in the Department of Medicine and in the Divinity School, and was also the Associate Director of the McLean Center for Clinical Medical Ethics and the Director of the university's program on medicine and religion. Currently, Dan Sulmasey is the Andre Helliger's Professor of Biomedical Ethics in the Department of Medicine and Philosophy at Georgetown University, where he is also the Acting Director of the Kennedy Institute of Ethics and a faculty member of the Pellegrino Center for Clinical Bioethics. Dan received his AB and MD degrees from Cornell, trained in internal medicine at Johns Hopkins, and holds a PhD in philosophy from Georgetown. He served on numerous governmental advisory committees, including the Presidential Commission for the Study of Bioethical Issues between 2010 and 2017. His research interests encompass both theoretical and empirical investigations of the ethics of end-of-life decision-making, informed consent for research, and spirituality in medicine. He's the author or editor of seven books, which include his original book in 1997, entitled The Healer's Calling, and his 2001 first edition and 2010 second edition of a book entitled Methods in Medical Ethics. Dan's most recent book is entitled Physician-Assisted Suicide and Euthanasia Before, During, and After the Holocaust. Dan also has served for many years as editor-in-chief of the journal Theoretical Medicine and Bioethics. Today, Dan will speak to us on the following topic. Age, life years, and fair innings, the ethics of chronometric rationing in the COVID-19 pandemic. So, please join me in giving a warm welcome to our great colleague and friend, Dr. Dan Solmezzi. Dan, welcome. Hi, everyone. Thank you, Mark, for that very gracious introduction. I wish I could be there with all of you in reality. We have to accept Zoom for now, and I guess we're all grateful we've been able to continue our academic lives through the courtesy of this kind of technology. And what it would have been like to have gone through COVID without this kind of distance learning. I mean, I taught my whole seminar this past fall semester online, and that's something I'm grateful I was able to do, although I still missed the interaction with my students and missed the interaction with all of you. Let me try to share screen here. Let's see if I can get that. Is that sharing? Can somebody tell me? No. No. I've put this up. There we go. Good. Chair. Good. And we've got two. I'm going to slide show. Good. Yes. Okay, so we've got it all now. So what I thought I would talk to you about is something that has been of interest and concern to me in the setting of the COVID pandemic, which is the use of age and life years and related topics in talk of rationing particularly intensive care resources during the COVID-19 pandemic. So the question is, how should we allocate scarce medical resources? And there have been some answers you've probably seen recently in the last few months in the literature, one by Zeke Emmanuel and his colleagues in the New England Journal of Medicine, in which they say that saving more lives and more years of life is a consensus value in how we ought to approach the use of scarce resources like ventilators and intensive care units in the setting of potentially an overwhelming surge of patients with COVID-19. Likewise, in a JAMA, Doug White and Bernie Lowe said that younger individuals should receive priority, not because of any claims of social worth or utility, but because they are the worst off in the sense that they have not had the opportunities to live through life's stages. And so the idea has been put out there in prominent venues that we should ration ventilators, intensive care units, by a principle of maximizing not the number of lives saved necessarily, but the lives, total years of life that we would save. So most of this talk are to identify where those came from, to demonstrate impact state policies, to introduce four challenges that would counter the claim that saving more years of life as a consensus value, and then present to you an alternative proposal that I think is a better way to think about justly allocating resources, the event of an overwhelming surge of patients with COVID-19. So where did this concept of life years come from in the first place? I did a lot of digging on this, and actually it goes back to the 40s in epidemiologic literature. And the concept then was the number of years of potential life that were lost due to the burden of disease in society. In 47 and 48, talking particularly about tuberculosis, but also other causes of death. So it was initially a way of measuring the sort of burden that disease placed upon society and the sort of cost of total potential years of life that might be lost due to those diseases. Then came thinking about dialysis, and then there was a twist. People began to talk in terms of dialysis of the years of life that would be saved by the introduction. So it goes from a negative concept of what disease does to society, to a positive concept of what medicine can do for society, and dialysis justification, one of the justifications for it would be how many years of life would be saved, even though it was an expensive technology. It gets into the medical literature, slightly medical ethics literature, slightly after that. Jonathan Glover is book causing death and saving lives and talks about it talks around it a little bit. John Harris in a book called the value of life. And I'll come back to this quote later in the talk, wrote in chapter five of that book, it's always a misfortune to die. But it is both a misfortune and a tragedy for life to premature reflecting the kind of view that it is better in fact to save young lives and have young people live longer lives and if we're going to have scarce resources for healthcare. And the idea that's being depicted here is that the best way to ration them would be in a way that minimizes the tragedy by giving resources preferentially to persons who are younger so that more life years could be saved. And I'll come back to that because that quote is used a lot, and I'm not sure is being always interpreted clear. The concept of life years sort of was in the background of a lot of medical ethics decision making, talking a little bit about the use of scarce resources but largely dormant for a couple of decades, until the questions arose about pandemic flu and SARS, and the need to have emergency response plans for society. And then it came back with a vengeance, if you will into the literature, Zeke Emanuel and Merthimer, who should get influenza vaccine when at all can and science in 2006 and then Doug White and his colleagues in the annals of internal medicine in 2009, who should receive life support during public health emergency. In that article, White et al quote from from John Harris and say that we should really be doing in the setting of an emergency like this is responding in a way that maximizes the total number of life years rather than foolishly if you will, or naively simply trying to save the most lives possible. A little bit after this, there was a push for further planning for this to be done at state levels, some of which actually, as you may well know has come to be prominent in the coven 19 pandemic. But there was a push to develop what are called crisis standards of care from the national academies. One of their reports talked about this idea of providing a framework for catastrophic disaster responses, how a society how a medical system should respond. And crisis standards of care. Promote the idea that in a medical crisis, let's say, an earthquake or let's say pandemic flu. How we should respond will change the standard of care because of the scarcity of resources and the overwhelming needs. And they give in these kinds of reports guidance on mobilizing resources how to do this how to differentiate how to conduct triage these kinds of standards, give legal protection to practitioners who follow the worry from lots of physicians that well if we're rationing and we're not doing would do when all the care resources are there, how are we going to be protected from malpractice suits if we don't give somebody something that they ordinarily get. So that was one of the ideas behind crisis standards of care to give the sort of legal protection to practitioners. They typically will require an official state level adoptions is not just something that's done by a medical society, but a formal crisis standards of care plan is an official legally recognized plan for response by the medical system. In the event of catastrophe. And typically they require some formal activation order, either by the governor or by the state health department director. I should note that there have been some objections to these particularly from from George Annis who's a legal scholar suggested that the standard of care actually never changes we're always trying to do the best we can for patients and then that's the concept behind a standard of care and saying that it changes is actually from his point of view legally problematic. Of course, we would do the best we would do within the setting of a catastrophe that doesn't necessarily mean that the standard of care has in a legal sense changed to be less than what the best physicians would do. And then secondly, he's argued that the sort of blanket immunity that these things give leaves the public too little way of legal protection. I'm not going to talk more about that but you should know that they are of themselves, somewhat controversial. But as you know, there were policies that were hastily updated or frantically written in the face of the surgeon patients in the spring in COVID 19 cases. And one of the things that I know some of you have done. And, and my team has done a little bit too has been to study the way these pandemic response plans have been updated in the face of COVID 19. And we did it specifically looking at the use of age based rationing, either in formal state based prices standards of care, or in other state endorsed pandemic preparedness plans. What we've concentrated on are the legally approved state level documents, and we studied specifically age based ration, not everything about these various plans, but just the use of age based ration. And some of what what we found in looking at these, at these plans that many of them do use age or longer term on prognosis by longer term. We mean something other than short term, short term we define as anybody who said survival to hospital discharge or survival up to one year was going to be their rationing procedure. And that was basing it on age so much as the patient's ability to benefit from from the treatment. But medium term was anybody who said well we'll screen out people who are expected to only live one to five years. Life years are those plans that specifically said, we're going to try to calculate the number of life years the person is expected to live and that's the way we're going to do ration, or something that's called fair innings I'll get into that in a moment, or under Eve for other, and you'll see your own state is is in that of places that did not have an official age based rationing plan but gave sort of more general guidance about how to, how to do. And so that was a great of places that had no official sick planning whatsoever. So, here's as best you can later correct me if, if our reading of Illinois was incorrect, but there was a pandemic flu plan in 2006 that only covers operational plans for meeting a surge without explicit planning for rationing. So the ration's plan in 2018 urging priority to those who can most benefit into healthcare workers without any mention of age within that. And then the work covert guidelines fairly late in the process and may suggesting who should do triage and planning. They were just using ethical principles that were based on a working group that was working on official crisis standards of care plans for Illinois, and the principles they mentioned in their white paper, but didn't mention any specific criteria for how to do that rationing other basic principles such as respect for dignity and justice. Questions like that. I can tell you another very significant finding we had, if you read all of these things and the way in which they are operationalizing their concept of life years, many of them will use life years in the text. This is just the way they will cash it out. For some of them life years means one to five year survival. For some it meant greater than 10 year survival. For some it was a more formal incorporation of age. And for some it was just they would prioritize children over adults, all of which they claimed was somehow incorporating the concept of life years. It's very confusing, not just in these plans and but also actually in the literature about this life years if you think about it formally means that you should ration according to a principle of maximizing the net expected life years to be saved in that procedure. How do you operationalize that. Well, maybe you can do it by just age. Are you going to adjust for comorbidities how are you going to do that. Nobody actually says. Another variation on this made especially prominent by Doug White at the University of Pittsburgh, which was then incorporated into the Pennsylvania guidelines, and then copied by several others was a term they called life cycles, which was to assign weighted priority points to brains of age groups. Now again they just took arbitrarily certain kinds of age groups but there was no real principle behind how one does that and says that that's a way of cashing out life years. And then by stages of life and a sort of developmental sense of infant versus toddler tween, teen, etc. should it be by deciles of age should be quartiles of age. Again, no rationale given for this and some variations in different states. So the concept of fair innings. For those of you who are not cricket players certainly not me I guess the closest it comes to our American by game of baseball would be that after you've played seven innings and you can call the game on account of right. So the fair innings is the idea. I'm coming out of cricket that as an analogy that there should be a specific age cut off after some somebody has enjoyed their fair share of life. And this view became fairly popular. Jonathan Glover one of the ones who talked about it as a way of rationing. But again, what are your fair innings. Nobody gives really good justification for that is 65 years old, 75 or 90. What about those people who prioritize infants as a tiebreaker in their protocols. Is that in some ways of variation unfair innings just cutting it off really short. I'm not not quite sure. But again it's a complicated process of saying, when somebody has had their fair innings and we should give somebody else a chance. With that, I want to turn to one of the arguments that have been given for rationing ventilators and intensive care by any of these age related criteria in the setting of a pandemic like COVID-19. The first argument that's been given is that there is public support for this one reads that in literature one reads that in some of these protocols. But, you know, you've got to be a careful reader of the literature. And I'm one of those people who actually looks at people's references and tries to see what they actually will be saying. And not surprisingly, a lot of people cite things that don't actually support the premises that they're saying is supported by the citation. And just since Doug White was saying, well, you know, base that there's public support for rationing ventilators by age. And the citation they gave is a 1998 study on allocating liver donor graphs in a survey that has nothing to do with pandemics, and is actually fairly limited in the Democrat demographic representation of people who were in that survey to begin with, obviously, younger, healthier, intelligent, well educated people. Very, no mention of whether anybody was actually disabled, for instance. Likewise, Maryland said they went through a very thorough process published this in several places, put it into their guidelines. But again, they had a limited demographic representation, mostly younger, they had middle class to upper middle class people that did it by focus groups with potentially leading questions like they gave them the six principles they were supposed to use and guiding their decision making. And in some instances actually even said that the, for instance, in reallocating ventilators, one of the things they said they in their report that they supported. They actually said that the people in the focus groups were very uneasy about this nonetheless. They said that their report was represented by the empirical process of going through these focus groups. So, I'm not sure that we have a huge amount of well founded information that suggests there's high public support for this kind of age based rationing of ventilators. Another argument is given is we have the precedent of organ transplantation protocols, which are done by age. Well, again, we've got to be careful about this. The one of the reasons given is lung allocation scores, and Doug White has has given this. But that's not rationing by age necessarily. What they did was to, I'm sorry about the mix up in order there. What they did in lung allocation scores was to decide that they would ration on the basis of the life expectancy without the transplant, which was the patient's need versus the overall effectiveness of the operation measured by one year survival probability. The fact that they're measuring whether somebody survives for a year or not and measuring that about how long they would live without the transplant is hardly justification for I'm saying that there is a precedent for rationing organs by age. The first one, I'm sorry that came up second is that there is this view that early on people were rationing organs for transplant on the basis of age cutoffs. But that wasn't on the basis of maximizing the life years they expected the person to live as a social value. The basis of at least what was thought to be the ability of the person to survive the procedure, both the surgery and the immunosuppression, not a way of giving priority to younger people per se as a social value. And in fact, for almost all organs age cutoffs are really a thing of the past. It was only very early on that people talk to those terms. The other president that's given in Laney certainly knows knows this very well. The organ procurement and transplant networks, addressing how to allocate kidneys explicitly rejected life years for kidney allocation which was really being forcefully put at the time, and instead they adopted something which makes reasonable sense to me to match the expected life of the organ, the expected life of the patient as a way of maximizing the value of the organ without rationing according to the expected life years So again, that's not rationing by life years. What are the philosophical defenses that have been given for rationing by life years. Now, well, you know if you look at them, you can read for instance in Francis Cam. She says, give to those who have not helped will have had less of the good that is longer life that our resource can provide before giving it to those who had even more of it, even if they're not helped. One of the problems you get into in these sorts of philosophical discussions about rationing by life years is a confusion I think on the part of the philosophers who are not physicians who are thinking this about this. They're acting as if we're rationing his life. We're not rationing life. We're rationing the resources that we give to people who are alive. And that's different. They act as if, for instance, life is a pie that we sort of divide, right. We're going to make sure that everybody gets an equal slice of the pie. That's the just and fair thing to do. But it's actually not unfair that somebody lives longer than than another person. It's not unfair to others. It's fortunate that they do, but it's not unfair. It's not as if this is some limited fungible commodity that we're dividing among people. Life is not like that. There's no obligation in justice, for instance, to be sure that everyone gets an equal share of life. We're not rationing life here. We're rationing resources to people who are alive. And I think there's a confusion that we're actually somehow rationing life when we're thinking about this. Dan Brock gives a similar kind of argument. He says fairness would require allocating resources to persons so they could reach a normal lifespan. But again, are we obligated to give people more or less equal sums of life? I mean, is that what he's really trying to say there? How do we make these kinds of judgments? How sure can we be particularly in giving resources that somebody's not going to be hit by a truck the next day? We're not rationing life. We're rationing ventilators. We're rationing access to the intensive care unit. How do we determine what a normal lifespan is? Do we do that by polling? Do we do that by the intuitions of Dan Brock and Francis Cam? Dan Brock doesn't give us any defense for this beyond his intuition that this is the fair way to do it. You might think of, and Dan Brock specifically then turns to Norman Daniels and talks about a prudential lifespan account. But what Daniels is doing is he's aiming to distribute resources over a single lifespan, so it's better than thinking about rationing life. So I think Daniels has that on his side. He's clearer than others that we're thinking about resource, that what we're rationing is not life, but rationing the resources to give to people over the single span of their life. And he tries to give this Rawlsian account of how many, how should we divide resources over the account of an entire lifespan, where we're in the original position, not knowing how long or short of life we were going to have. What he explicitly, so I think that's better, but what he explicitly rejects is exactly what people are trying to do in COVID. The piecemeal use of age criteria in any way to be part, that's not part of an overall prudent allocation of resources over a lifespan. Just sort of deciding what we're going to use age criteria for pandemic surges of need or for earthquakes is not part of the of Norman Daniels account. And if you think it's your intuition that we ought to save people who are younger, rather than people who are older Daniels explicitly rejects arguments that are based on intuitions. There is also, and I told you I would return to this an incredible amount of really sloppy scholarship in this in the medical literature about this. And I see numerous people quoting, and particularly people who are quoting from the Pittsburgh protocol and copy and pasting it into their own protocols. The quote from John Harris that the difference between that being a tragedy to die young and rather than this fortune just to die as their justification for age based rationing and life years. John Harris explicitly opposites age based rationing and has for the entirety of his career. In fact, he's just so good about describing the opposing position that people take it to be his own position. Since he wrote the survival lottery in 1980 up to the present in the setting of the COVID pandemic. He wrote an article against age based rationing called why kill the cabin boy in very colorful language. He does so as a bent the might utilitarian, because everyone is to count for one and no one for more than one, no matter how old you are. That's his view. And so it's puzzling that people have been allowed to quote Harris as the basis for their philosophical justification of a life years approach to rationing. That in fact, opposes it. Puzzle. I think the New York State Task Force on life and the law got it right. Got the intuition that Harris has correct. The components argue that it's more appropriate to maximize life years saved rather than the number of lives saved over the task force believed that to exclude older adults discriminate against the elder. I'm simply saying on the basis of some age cut off, or the number of life years the person is expected to live that they are not eligible for a ventilator that not on the basis of their medical condition on the basis of age alone that is discriminated. There's also discriminates against the disabled who are very forceful and coming out against these sorts of protocols, many of which, because of the office of civil rights, coming after them on on it, had to actually scale back on what they were doing in their protocols, and the disabled on life years criteria are often expected to have shortened lives due to their disabilities and therefore would be discriminated against. Moreover, they're often mistakenly taken to have shorter life expectancies based on prejudice, and we're very worried about these sorts of age based rationing approaches. Now, what's the alternative. The one that I think is just. Is the decisions ought to be made on the basis of need prognosis and effectiveness that our principles don't change how we apply them changes with the circumstances in a crisis we need our principles more than ever. The decisions ought to be guided by the standard duties of beneficence respect for persons and justice. So here's what I would propose that adhering to the standard principles, even in these crisis circumstances would be the way to go. How you each person equally regardless of age and disability and if any of you are involved in the Illinois. planning for for this I think the principles will be will sound very similar to you that we should decide which treatments are potentially beneficial and ordinarily indicated for each patient just as we would do in any other circumstance. The likelihood of effectiveness will vary between patients and some interventions will not be effective at all for some patients. We recognize that morality requires faithful and unbiased efforts and making these clinical judgments, even if our judgments are imperfect. So I think the only limited resources on the basis of the expected effectiveness of treatment for each patient would be the proper way to go, which is the way we would typically think anyway. One of the alternatives short of rationing and I think we have a moral obligation to pursue that first and you know many of you as we did in DC I'm sure in Chicago as well. We do this in the first wave, we're a little in a little better shape right now than you may be involved and it again in the second wave here. We do everything reasonable and possible to benefit patients. We try to increase the supply and I think at least a number of ventilators has increased, you probably as we did we're able to increase the number of intensive care units. Use alternatives that are almost as good to temporize in fact they turn out to have been better patients who just got oxygen, the happy hypoxics did did better to use alternatives to try to transfer, if necessary impossible. You probably don't have the benefit of this but at MedStar Georgetown MedStar as part of the system. We were actually able to exchange patients across the system when one was pressured more than another try to offload the others. Georgetown in Washington Hospital Center a better intensivist so we got more sicker patients working as a system together. Chances to be creative. You know I don't know if these worked or not and there's some controversy about it, but I applaud the ingenuity and the ethics behind trying to find ways to help people which is what we as physicians and nurses and other healthcare practitioners ought to be doing in the setting of the crisis. I'm doing the best we can for our patients. Majorly though, I want to suggest that we do ethics as usual. That we discuss patient goals and preferences upon admission, if not sooner and certainly that's doing is outpatients is probably better. We respect the decisions that patients might make to forego intensive care. We can offer suggestions to patients based on the individual likelihood of benefit. I don't think we should be manipulative real worries about places like Colorado, where they're trying to give patients COVID specific events care planning and saying, well you're old anyway wouldn't you want to sign on the dotted line here and say you want to give this to a to a younger patient. I don't think if the person spontaneously says that it's a noble gesture, but I wouldn't want to sort of push them into that kind of a view. I'm against blanket DNR orders. Again, ethics as usual, there should be no carte blanche exclusion of COVID-19 patients solely on the basis of the diagnosis or solely on the basis of age. There's no doubt about this. And there may be cases where it's futile and we can argue about that as back in my seven years in University of Chicago I often did particularly with Bill Meadow, but nonetheless, DNR orders can sometimes be appropriate recommended and consented to by the patient. And I think CPR can be biomedically futile, and it would be business as usual about that as well, not simply excluding patients on the basis of age on the basis of their diagnosis. I think we would have a duty. Now, if we get to the point where all other alternatives have been exhausted, and we need to start rationing intensive care resources to say that we may be having to do rationing, but then it's going to be done fairly based on what we always do need prognosis and effectiveness of treatment. What do I mean by need it's a normal clinical decision. Now this patient has a medical need for a ventilator yes or no. It's the same standard you would use to ask for a mickey consult for for a patient. The difference maybe I have some trepidation but I think in general, having triage teams available in hospitals might be the way to do this if you really need to ration to make sure that it's more than one person. One of them should be an ethicist and one a critical care physician who's not in the intensive care unit at the time, and maybe a third person. More than one would keep everybody honest, it's a group decision, and it separates the team treating the patients from those excluding the patients which I think is valuable, and that could help to reduce the moral distress of the clinicians who are actually doing it. Other patients I think it may increase the moral stress of the people around the triage team, but either that is may at least divides those two. What do I mean by prognosis which is what that triage team should take into account. If you're going to be in a triage situation then patients who do a reasonable degree of medical certainty have a less than six month life expectancy I think could be reasonably excluded. The justification would be that they are unlikely to survive to hospital discharge, and there's little chance of even a short term benefit. So if you've got somebody who's already hospice eligible from cancer, they've got in stage dementia bedbound I'm able to recognize loved ones not early dementia that the people who are not going to live six months in the gardens of what you do for them. If those people were to be excluded, it wouldn't be on the basis of life years but in the basis of really extremely short term potential gain. Most people who've been on the, or in those conditions even if they do survive would spend the rest of their lives, which would probably be very short anyway in rehab and never, never get out. So largely it should be done then on effectiveness if you need then, if you exclude to those people who are going to die within six months anyway, on the basis of effectiveness. People who have a need and are not terminally ill. You could use a scoring system to help. There's some data that would suggest that Apache is actually Apache to is actually better than sofa. People for instance with Apache to score over 35. And the rest would be prioritized and the lowest score gets the highest priority. If you needed tie breakers and again, I think it's complicated enough to try to do any of this if you need to do rationing. I'm puzzled by the people to think oh we need to have tie breakers if people are tied. Again, some people have suggested using age for that I would say no then it's either first come first served or a lottery, but not age or life years if you need to have a tie breaker I think, getting to that point in that heat of battle of the chaos of actually doing this kind of triage be really unbelievable that people are thinking about ties and tie breakers. Now what should we do save the most lives. Yes, save the most life years. No, that's my view at the bottom line. Objections that can be raised you could say our proposal runs against intuitions, but intuitions differ. Right. And in fact, when we began to probe the intuition, it turned out that the intuition was about the way in which we divide up life, which is not something we can actually divide up as a commodity. And in fact there are other cultures, for instance Sub-Saharan Africa, or Asia, in which the elderly would have priority, a very different intuition. So, I'm always skeptical about unexamined intuitions. You might say well ages already baked into effectiveness and prognosis I don't think it's based into the prognosis and the way we're talking about very short terms, six month prognosis hospice eligibility. But it could be to some extent baked into effectiveness, but that's probably, you know, reasonable to think about age for instance as one criterion in the scoring system about how people are going to fare if they're put on a ventilator. It's probably there standing in for things like stem cell reserves, immune capacity, etc. that we can't can't actually measure, rather than valuing the number of years the person will live per se. How do we justify looking at short term but not long term prognosis maybe your objection. Again, I'm talking about very short term prognosis which is really a sort of slight extension of what it means to be effective, and valuing age and years of life per se. And those who say that we're in unprecedented, precedented times that we need unprecedented measures. I say no, we need to stick to our principles and apply them in these particular circumstances. We ought not abandon our ethical principles, even in these circumstances, not to discriminate against the disabled and the elderly. And our decisions ought to continually made on the basis of need prognosis and effectiveness guided as best we can by standard duties of beneficence, respect for persons and justice. And that I'll conclude by thanking my co investigators on both the theoretical and the empirical project bernard cruzack of philosopher Kings College, Mary Kate garky one of my PhD students, Tony john, a fourth year medical student here at Georgetown, and Emily share, who's a MD MB candidate at Penn, who decided that she'd rather work with us than with the Zika manual on this issue. So with that, I think I have some time for for questions thank you. Great. Again, I just want to thank you on behalf of the organizers of the ethics series Dr soul Maisie for for this talk that that continues to sort of contribute to our discussion about resource allocation. And just to note that that two of the names you mentioned, George and us and Doug white will will be part of the lecture series later on in this quarter so we look forward to hearing what they have to say. And sort of response to what you said as well. So there are a number of questions in the chat and in the Q amp a and I just want to remind people to please try to put your questions in the Q amp a rather than the chat. But I'll get started with two sort of comments and questions that are similarly aligned from from Monica peak and will Parker. And Monica notes that we can estimate a normal lifespan based on the average lifespan in an area say the US or Illinois. We can divide research resources in a way that supports those populations whose life expectancy is shorter than the average because of social inequities such as structural racism. So that sort of sort of Monica's comment, and then I think will Parker kind of follows up on that. By asking the question, can you address the racial justification of prioritizing younger, younger patients, and he goes on to state that white people have longer age expectancy in the US because of racism. The equality amongst young black people is dramatically higher than white people younger people of color are much more likely to get coven than young white people because of structural racism. The working paper estimates that the US Latinx population has lost 48,204 years and black populations have lost 45,770 years compared to only 33,446 for white people. So, thus ignoring age would likely lead to triage protocols that would exacerbate existing racial disparities in health and life expectancy. Not to for you to sort of unpack there. Yeah, no, I, I think that you run into problems trying to use age as a proxy for for racial disparities right. And that's sort of what you're, you know, what you're trying to do here. There's a lot of comments that you that you're that you're making what we ought to be able to do is to. And secondly, it seems to me that addressing racial inequalities, you know, retrospectively by rationing at the bedside is a wrong headed way to do it. Clearly, racial disparities that lead people to be at higher risk for this and we should not, in fact, exclude people, obviously on the basis of race. We may have a moral obligation to reach out to make sure that people who are in minority groups that are disproportionately affected by this, get the resources that they need. But once they come to the emergency room and once they're in the hospital. The life expectancy of the survivability of a black person versus a white person and this has been studied is exactly equal. And I'm talking about what happens when they're actually in the in the hospital. I can't make up for in the hospital. I can't make up for those background on racial inequalities and sometimes sometimes people get some of this they get so convoluted about this and we went through this in the District of Columbia that they're trying to sort of correct for racial injustices in the society that pre exists and shamefully make people more predisposed to high mortality by saying that we should, for instance, ration vaccines so that we give them to people who are in first line jobs where there are more minorities in things like bus drivers and emergency kinds or other kinds of frontline workers other than health care workers, rather than giving them to people who were over 65. That winds up in the end actually exacerbating some of the racial inequalities, because older black lives matter too. And Kaiser was very good about pointing this out in a, in a paper that was done back in March, the mortality rate for from COVID in the age 65 to 74 range for African Americans for black people is five times that of white people. So we shouldn't be saying as the ACIP said, well, we give vaccine in order to engineer retrospectively make up for racial injustices to people who are in jobs that are frontline like postal workers or bus drivers, because there are more minorities there we should give it to them, and not give it to people who were over 65 you wind up actually exacerbating mortality and precisely the group that you're trying to, to help. So I appreciate that there are deep injustices in our society. But I think that trying to use age as a proxy to try to retrospectively make up for that now is the wrong. It's just the wrong way to go. We need in fact to address those, those disparities but not doing it through this convoluted way which might want to be wrong. And is that your intuition that it exacerbates, you know, like older black lives matter, or is that is there, is that proven by data that did the mortality for African Americans between the ages of 65 and 74 is five times that similar situated white people. Those are people we need to come need to help those people need to have those are data from the CDC. That's not just an intuition that state. And, and hopefully that answer suffices to answer those questions along a sort of similar line. So the question comes up that pointing to the duty of justice and how coven has exposed entrenched medical and health disparities. How would you respond to a question of access to resources, especially vis-a-vis your formulation of need prognosis and effectiveness. Yeah, I think that that's a better way to go at this right. So the justice is, you know, that we can make up for as a health care system there in the realm of access, right. And making sure that we have, you know, sufficient amounts of vaccine that go to hospital for instance what we did in the District of Columbia and in distributing vaccine was we did it by case load among the hospitals. When the University Hospital had more cases of COVID, they got more vaccine, right. That's putting access to where the need is, and the need is differentiated by the, by the conditions of the local local community. So anything we can do to improve access, if that means, you know, giving more ambulance services to differentially impacted communities so that those persons get equal access to the resources that we can give them. Those are things we can do in the way of justice. But once people are in the hospital, the sort of decide that we're going to, you know, ration on the basis of age, race, anything else. I think it just goes against our instances as clinicians. Great. And I just want to sort of point out to all the participants and sort of let you remind you that sort of this quarter we're really going to be focusing on health disparities in subsequent lectures. So we'll tackle this subject through that mechanism as well. Moving on to sort of just sort of thinking about the sort of the value of life there are a few questions that sort of raise this point. So all these arguments appear to value life only in an egocentric way. I either value of one's life only to oneself. How do you take account of the value of a life to others. No, that's a terrific question. And certainly, the one, you know, hope we may have for for what COVID vaccine might teach our society is a better sense of responsibility for others. You know, we, we all know, despite the messaging that we get, which might be tailored to try to get more people to wear masks that the main reason for wearing a mask in public is to prevent other people from getting sick, not to protect you. Right. It is other centered. The main reason that I often have success in in our resident clinic and convincing patients to get vaccinated against the flu. When they've initially told the resident no, I go back into the room and say, Well, you know, do you have grandkids? Are you in a church choir? Right. This isn't about you. This is about all of us. Right. And the sort of sense in which we can, in fact, work collectively to help the community is the instinct that we, the moral instinct that we ought to cultivate as best we can. In terms of somebody who comes into the hospital and says, says to me, you know, I'm 80 years old, I've lived a good life, let somebody else who's younger get the ventilator. I'm not going to object to that. Right. What I object to is forcing that person to not get it, rather than allowing them to be communitarian and other other centered in their own thinking. So the more we can, in fact, cultivate that in the setting of the pandemic. So, so to think about, to scale up that that scenario where there's an 80 year old who comes in and said, you know, declines it to say give it to somebody younger. So to scale that up to think about public support and thinking about, you know, not just thinking about yourself but thinking about others. What if there was public support, partly based on just sort of the intuition that we should be giving these resources to younger, younger people. So they have have more life. What would your response to that be? Well, it's like anything else in it, you know, in democracy, you don't want to tear any of the majority. Because most people are less than 80, you could sort of say, you know, let grandma go. And so, so you want to balance out a sense of, you know, a communitarian spirit of people's part, but you don't want to force it on people without absolute necessity. And in fact, I think that sort of saying that, you know, it's part of the problem with these focus groups. There's nobody over 80 in them. People say, sure, we should give it to people who are less than 80. Right. We want to make sure that we maybe even in a sense have, you know, a, well, we have a sense. It's always a problem, isn't it. It's a part of the larger part of this is the clash between public health ethics and clinical ethics. Right. It's the same when we're being told now, you know, continually to practice population medicine when we're practicing on individual patients. Right. And, you know, we can set rules as a community within which we can then have parameters to work with. We want to make sure those rules are as fair as they can be to everybody while guarding the collective whole and the value, you know, of caring for elderly people is one we shouldn't dismiss. To to readily lots of other we can learn from a lot of other societies about their respect for the elderly compared to our youth glorifying culture. Great. We did look along the sort of similar lines. The question is asked but but don't some of your sort of prognosis considerations have to do with quality of life, which then discriminates against those whose whose lives, many of us wouldn't want. That's a, you know, that's, you know, potentially a good, good objection it's trying to balance out, you know, sort of, you know, being practical about this sort of how far will you, you know, will you go in terms of, you know, making, you know, if people wanted to do the genocin that completely. The prognosis part. I'm, you know, I'm not sure I'd object completely because so much of that would be tied up into the effectiveness category anyway, particularly in Apache scores comorbid conditions become a predictor as they should have wasn't the person will survive to discharge or I just think it's, it could be a lot cleaner to actually come to a decision that if people have a less than six month survival that they might be the one exclusion criteria and I would be able to tolerate that I think was not in that sense, valuing life years as a value. It was just being practical in this very limited sense about what benefit we could expect to give such a person which I think would be extremely, extremely limited, if at all, if at all. If you wanted to jettison it if you're pushing me jettison that and make it all just effectiveness, it could be rolled into effectiveness but I think as a practical matter, it might be a simpler color. Hopefully we don't have to do any of this. Right, that's, hopefully we don't know what the situation on the ground is it in Chicago it's not been as bad here in the hospitals was in April in the hospital in terms of, in terms of numbers and it's based to four and five intense periods. Our numbers here aren't aren't as high as they were during the spring surge as well. Moving on to a few other questions. So, would automatic DNR's be ethically justifiable in the context of scarcity for patients excluded from a needed ventilator. If the patient was triaged and then placed on a DNR based on survivability instead of life years or specific diagnosis. Yeah, that's again my view about DNR orders is that they should be on the basis of futility right and I define futility. This will go back to discussions that many of us had quite a few times and in, you know, case case conference over the years that if to a reasonable degree of medical certainty CPR either will not work, or would be repeatedly necessary or with patient dying in a very short period of time, even if it were provided. That's a point at which I could say that it would be futile and therefore unilaterally instituted. But short of that, I think the one thing I didn't say by the way was a slide I hadn't another talk left out is. And, importantly, and I'm thinking of it now is that if someone is triaged out. Got to be incredibly sure that that doesn't mean we're not caring for them and not providing maximum kind of palliative care that we can for such persons. And certainly people who are in an intensive care unit should be getting maximum palliative care as well. You know, the patient symptoms under these conditions, you know, obviously many of you have seen, particularly Brian if you're, you know, working as a hospital less you will probably revved up to be the be an intensive cancer and I ER doc and know that the sort of horror of the people who do go south and die from this and die in isolation. And the real need to be as as compassionate and human toward them in terms of palliating the symptoms as we possibly can super ethical priority, particularly for persons who in the event that they are triaged out of intensive care, but not neglecting palliative care needs of other persons as well. And, and thinking about sort of making decisions at the bedside. A question came up that stated, I don't think tie breakers are avoidable sofa scores are the practical ones to calculate in real time and are often similar early in coven. If you don't have an objective tie breaker, aren't you just relying on the subjective and potentially biased judgment of bedside physicians. You, you could. Well, it's maybe another reason why actually, there's at least one study I've seen it was my intuition, initially, that Apache scores will be better prognosticators in in coven and there's in fact been at least one study on that show that to be true. And you know electronic medical records, they're fairly easy to calculate pretty, pretty quickly so I don't know that they are as difficult to do. And I wasn't saying that you didn't need, you might not need a tie breaker. I think you'd need less of it if you've got patchy than if you have sofa scores. But if you do need a tie breaker. Then I think, you know, lottery or first come first serve is what I suggested and not age. And, but again, you know, I think there's a lot of sort of no over over planning of this and it's good to try to avoid prejudices and bias decisions at the bedside. But I think a lot of this, we're going to have to rely on the, you know, the reason and goodwill of clinicians to do the best they can. What will inevitably be an incredibly chaotic situation which is I think underappreciated by a lot of the people who are going through the sort of third level tie breaker kinds of kinds of scenarios. If this has to be has to be done. So if there are tie breakers. Yes, just not age. Okay. Another question. What about auctioning off some valuable resources to raise cash for R&D, or to help even more patients. I'm not sure I know that there would be, you know, quite a, you know, quite a market for that. I can say that there have been a lot of people have said over the, you know, over the years that, you know, the NIH budget, for instance, is a moral act, right. So we're deciding how much money we're going to give first to the NIH for research, and then what kinds of diseases we will research are really moral decisions. And there is reason to sort of think more clearly about, you know, whether we're doing enough for common diseases, whether we're doing enough for emerging pathogens, you know, whether we've overemphasize certain diseases that are sexy or they're scientifically interesting rather than significant for the populations that are paying the taxes that go into the research as well. You know, on the other hand, you don't want to stifle, you know, scientific research and allow that to be as free as possible because most of the time, Dr. Serendipity is the one who comes up with the most important discovery that will, you know, save the most, save the most lives. So I wouldn't stifle all, you know, creativity, but I think being the thrust the question should we be more considerate about how we spend our resources on research for things that really matter. Yes, and maybe we will have learned that studying emergent diseases, you know, deserves more, more funding than it's had in the past, I suspect we will learn that. But look at how, you know, isn't it amazing that we have a number of vaccines already, right, and what made that possible, you know, but very basic research on messenger RNA. The fact that there were already people working on coronaviruses that this disease could be the cause could be discovered in the genome sequence within months. The vaccines would be available within a year of the emergence of the vaccine. I mean, all of that, the emergence of the pandemic. You know, all of that is based on some pretty basic scientific research that people were poised to put into use so we can't make, you know, we can't make everything so practical that we're not allowing some of this basic research to go on that will allow, you know, responses in real time that will be creative to very significant problems. So, I'm very grateful. Many of you I presume have already gotten your first shot of this vaccine and that's, you know, it's remarkable. Certainly, although there is a comment that says there had there have been cases of sort of charity auctions and vaccines, though the black market towards the auction market in size sadly. And I think that there's some of that that has emerged in the mainstream media. Yeah, there is. Yeah, I mean, there is, you know, for vaccines right. I got some questions from a reporter actually from the Hill publication about this. Do hospitals have a responsibility to safeguard their vaccines because it is a black market commodity and there and there are serious worries about vaccines being diverted by organized crime, for instance, and we had an unfortunate incident of somebody who for reasons that are still not clear on destroyed 500 doses of vaccines. So, so I do think we do have a more responsibility to be careful about safeguarding our vaccine from from the black market. I just before we sort of get close to wrapping up from a philosophical perspective whether you're talking about lives or sort of life years. Is there a basic assumption of what happens during that time in terms of a life lived or the life years from a sort of philanthropist philosophical perspective, like what do we do with that time that we that we save. Yeah, well, you know, I think people miss the gift of human freedom that, you know, you know, that you do with the life what, you know, what, what you choose to we hope that you are well brought up and use your time effectively to really live a virtuous life. But again, we can't guarantee that. And it's our obligation as physicians, not to decide that one person's life is going to be spent more worthily than another and decide, therefore not to give them health care resources, our obligation is to respect them as individuals, who are embodied, who are, you know, who are in many cases but not all free to make choices of that of how they live their lives, and even those who can't right think of the, you know, think of the, the person who is is mentally retarded. And I want to make judgments that because they might not be as free in their choices, or they might not be as creative in their choices that I don't have an obligation out of respect for them as human beings and as nothing else, regardless of their disabilities, regardless of their age, regardless of their race, regardless of their creed to help them because they are human, and they have come to me for help and I'm a doctor who has vowed that I will, I will put my resources and abilities to their benefit. Actually, a late, a late in in question popped into the, into the q amp a, should those a late inning. Yeah, so should those involved in the vaccine black market be ineligible for vaccines. That's a forensic forensic question I'll leave that to district attorneys and legislators. I think that that looks to be all the questions in the chatter the q amp a Laney and Mark I'll turn it over to you for any last questions and Mark for closing. I had written a question. But but somehow it didn't appear. And that that was that that in the 1918 flu epidemic that killed somewhere between 50 million and 150 million people in the world. I heard that that that the people who were at greatest risk were younger and middle age people, rather than the elderly. Whereas in in this pandemic, the COVID-19 one. Everything seems to point to the elderly being at so much higher risk than the younger people or the middle age people. So does that in any way influence your determination as to who should be who who who might be treated more aggressively in the hospital, or for that for that matter, vaccinated earlier. Yeah, I can. Good. Good question I think you're, you're right. My last look at CDC statistics are that approximately 90% of the persons who have died in the United States of COVID-19 have either been over 65 years of age, or if they were younger had at least two comorbid conditions associated with disease so it's. So if you're younger than 65, you only seem to be a high risk of severe morbidity and death. If you, let's say got diabetes and COPD or something. So yes, it's differentially affects the those who are those who are sickest, but basically I think the view I would say is that, you know, we, we treat the sick. The sick who come to us are five years old that's who we treat. And if they're 75 years old that's, that's who we treat. And if they, you know, if, if in this case, five year old can be treated at home, and the 75 year old needs the hospital. And that's the way we go. If it was nine, if it was a 1918 flu and it was inverted, then we could treat the 75 year old at home, and that five year old needed the intensive care unit that's who gets it right I mean it's just, I think a matter of need prognosis and effectiveness. Thank you. Laney, you know, I just want to offer my deepest thanks to Dan so mazy fabulous, fabulous talk. And I'm actually looking forward to reviewing it again on the video, because the talk and the slides were so critically important. And we miss you at the university. And we love having you visit us even if it's by zoom this time. And I hope it'll be in person next time. So much. Thank you. I miss miss all of you. I'm going to be looking forward to the day I can come back physically. That'll be great.