 Hi everybody. Welcome back to our third panel on ethical issues and COVID-19, but just before we begin I have to say how deeply moved I was by the depth and quality of our first two panels this morning. The first panel on healthcare disparities featured Marshall Chin, Monica Peek, Jason Carlawish, and Stacy Lindow. Our second panel on clinical ethics featured Susan Toll, Andrew Hantel, Laura Roberts, Gretchen Schwarzie, and David Schiedemeier. Also, I can't say enough about how Marshall Chin was terrific as the moderator of both panels because Peter Ubel had an acute dental emergency. Marshall stepped in graciously and had less than 15 minutes to prepare to moderate that second panel. The speakers were each incredibly articulate, incisive, and effective in their talks. While I love their compliments about my role as their teacher and guide when they were McLean fellows, the reality is that each of them was brilliant and was my teacher. I learned more from them when they were fellows than they learned from me, and witnessed by this morning's talks, my learning continues. I'm now delighted to introduce the six speakers on this third panel. Emily Landon, Peter Singer, Kelly Mickelson, Savi Fedsen, Karen DeMartino, Aaron DeMartino, forgive me, and Laurie Zoloth. I encourage members of the audience to write questions in the Q&A section just as you did for this morning's panels. Let me now begin by introducing our first speaker, Emily Landon. Emily is the medical director of antimicrobial stewardship and infection control here at the University of Chicago. Dr. Landon is an associate professor of medicine and an assistant director of the McLean Center for Clinical Medical Ethics. Emily's research focuses on healthcare provider behavior as it relates to preventing healthcare-associated infections. She has become a leading spokesperson both in the state of Illinois and nationally on the COVID-19 pandemic. Emily has appeared on ABC, CBS, NBC, television, and has been quoted widely by newspapers like the Washington Post, the Chicago Tribune, and the New York Times. Today Emily will speak on the topic COVID-19 clinical and ethical challenges. Please join me in giving a warm welcome to Dr. Emily Landon. Emily. Hi, everyone, and thank you for having me, Mark. I know everyone is taking an opportunity to say how wonderful you are, but I would not be here today talking at this conference if it wasn't for all of the times that I came to your office to ask, how am I supposed to make these decisions as the hospital epidemiologist? Who helps you figure out these ethics? And you said, well, you're going to have to do it if you want someone to figure it out. And so I learned in the fellowship, and now I'm able to imagine your influence in that is huge, and I hope it will help us do a better job, not just with this pandemic, but with everything we do in this aspect of improving things in healthcare to make things safer. So moving forward, though, I do want to talk about COVID today. This is kind of a mishmash of everything. I think this is a really different time in our lives. And I think many of us, myself included, were even though I knew it was coming and I knew we would need to shut down our lives and change the way we did everything in order to address this pandemic. It still came as a shock to me how much my life has changed since then. And I bring to you today the importance that we probably need to be temporarily closed again. So the most important ethical point, you know, there are so many different ethical things that we can talk about within COVID-19. And it's just every single issue, every single tiny decision brings ethics into the mix. And the one overriding piece for me is that justice, something that we strive to keep out of our medical decision-making with individual patients, where we are often trying to remove justice and the concerns of justice from our individual decision-making becomes quite literally the most important piece. Fairness, justice, the good of the community becomes very important. That's how public health ethics looks at the world all the time. But as this becomes juxtaposed with medical ethics and how we care for individual patients, it can be very difficult to navigate these things. As I said before, there are so many ethical issues and they're very different from the ones, well, of course, end-of-life issues and privacy issues are things that we address every single day. There are new ones that are new to all of us that we're finding our way through and trying to make that balance between public health ethics, which seeks to improve the good of the many, and the medical ethics, which seeks to improve the good of the patient. Today, I mostly want to make a talk about a public service announcement. The current national situation is abhorrent. It is, as some have said, a humanitarian disaster, a COVID hell. Experts have been sounding the alarm about this COVID outbreak resurgence of the fall across the United States. And remarkably, we haven't heard a word from our commander in chief. You can see that right here in the Chicago area is the epicenter, although I would argue that Wisconsin might actually be the epicenter of a very, very difficult time for everyone in the United States. And the wave of cases just seems to radiate out from us and affect more and more places across the United States. In Chicago, our positivity rate has gone up from a 2 to 3 percent positivity rate to 15 percent in the last seven days. There are more than 2,000 cases in Chicago every day. That's the seven-day rolling average. It's unbelievable to me that we have so many people getting sick. I hear many, many arguments from many people about why we shouldn't pay attention to COVID, because most of those people won't die, because it's just a cold, it's just a flu. All of those are false disinformation and a denial that we hear across the board in the United States. Sorry. I want to talk today a little bit about how we can actually use math and science to help us make sense of the situation. In epidemiology, we use what's called an SIR model, or susceptible, infected, or is infectious, and then removed or recovered. And the idea of this model is that every single person in the world can be in one of these three buckets. Now, of course, you can add additional buckets, and then once you know how many people are in them, then you can apply different interventions to try and reduce that bucket or sort of slow the throughput through this whole transmission chain. This is the most important piece of everything that we do. We want to get as many people over to that immune or removed bucket as possible. Most importantly, we want to remove them from the infectious bucket. That's why we do things like contact trace and quarantine close contacts. That way, if we put them into isolation or quarantine before they become ill, we can remove them from being infectious in public, which then reduces the number of interactions between infectious individuals and susceptible individuals. This is also why we wear masks. They provide a physical barrier that helps prevent the sort of ad mixing of the air or the aerosol droplets from infectious people to susceptible individuals. One thing that many people talk about is using herd immunity to get to the end of this very difficult trek across the SIR model. The reality is that using a vaccine would skip over that infectious group and take us to immune without having so many interactions with infectious individuals. It's really important to understand that having people take that transit through is what drives deaths, cost, danger to the economy, and a horrific toll on our healthcare system. Increasing the size of that infectious group is the thing that we do not want to do at all costs. That infectious group costs money, it costs time, it overburdens hospitals, it endangers high risk individuals, and it becomes harder and harder to keep the susceptible individuals safe and having less contact with the infectious individuals if we grow that infectious group. This is why a herd immunity strategy is a terrible, horrible idea when it doesn't involve skipping over the infectious group. So I think I wanted to provide you with a little bit of sort of ability to talk about these things and from an epidemiological way, and this is why there is a real ethical and moral calling to reduce the number of infectious individuals because we need to protect the susceptibles. Of course, we will see vaccines coming soon, but in the meantime, what do we do to try and prevent the movement through that infectious period? Well, the most important thing we could do are layer up all of our things. As you know, there's no one perfect mask that will protect anyone. There's no one perfect distance that we can keep all the time. There's no way to completely avoid having to touch any surfaces. And so we have to acknowledge that every single one of the things that we do will have holes in it and will not in and of itself prevent people from getting sick. So instead, we layer them up so that they overlap one another creating the safety net that we need. The new vaccines that are coming and that we will begin to see in healthcare probably by the end of December will be about 50%, maybe more than that. The new data from Pfizer sounds like they think that they are going to be 90% effective in their interim analysis. I think that that would be amazing, but it's probably a little overly optimistic for the number of observations that they have for us to actually expect that level of efficacy. But if we add that to this, it is just another layer in our layered approach to harm reduction for the COVID epidemic. And so as we head into the winter and we have this huge outbreak that is rippling across the country, it's so important that you all understand, especially as leaders and healthcare providers, that these additional vaccines have to be an added layer. Over time, that layer will get thicker, it will get better, it will become less permeable and we can maybe pull back on some of the other things. But in the meantime, we add vaccines to our masks, to our distance and all of the other things that we're doing in order to prevent COVID. It's not a replacement for any of those interventions. Today, I want to show you a new way of looking at risk that we are adding at the University of Chicago. This is a preview of what you, those of you who work at UCM will see next week. So the issue here is that there have been a lot of discussions and you see in the city of Chicago has put out new travel restrictions saying if you travel to one of these higher risk states and you come to, you know, come back to Chicago, there are certain things you have to do. We've decided that it's much more important as we see 10 to 20 healthcare workers getting sick with COVID every single day at the University of Chicago, not from patients, but from high-risk activities in the home or outside of work, we've decided that it's much more appropriate to do a risk-based strategy. So we're going to ask employees who undertake these high-risk activities to use vacation time or paid time off to quarantine for seven days afterwards, including for the Thanksgiving holiday. And some of you will look at the high-risk list and think, oh my God, I cannot do that. These are things that I'm doing right now. I strongly recommend that anyone who is working in an area or living in an area where COVID is on the rise, that you need to avoid everything in the high-risk category. We provided a lower risk category in order to help everyone understand how to do these things without being high-risk. So just a quick run through here. Eating and drinking indoors with people you don't live with is highly risky. Ventilation systems inside of buildings and homes in America has been made so efficient that it's wonderful at keeping in warm air in order to avoid having losing energy to the outdoors and using too much energy. Unfortunately, that also traps COVID, and that means that if you have your mask off, the droplets from your mouth in the dry air of winter, even heated dry air, can spread much further than six feet. And so it's not just the people that you come that are with you and sitting at your table, but also the people across the room. And as time goes on without masks on, that risk gets higher and higher. When you have unmasked contact with other individuals, that becomes part of your bubble. So anytime you're in a room with other people that don't have their mask on, that is a risk that you should consider that person part of your bubble. And your bubble probably should, this number we have here of five is probably too high for right now. So unmasked contact with more than five people, that's over an entire week. Not at one time, but total of five people unmasked that you don't live with is way too many. I think right now we should probably be sticking with just our housemates and maybe one or two other people total. Working out indoors when you can't both keep distance and wear a mask is not safe. Singing or chanting when you can't both wear a mask and keep distance is not safe. Attending crowded outdoor gatherings where people are unmasked, not safe. And traveling without wearing both a mask and eye protection in case someone else removes their mask, also not safe. It may feel to you like these are very onerous restrictions and how can we ask care workers to do things like this? Well, we kind of have to. And I understand how you feel. There is a lot of denial going around. These are obviously the Elizabeth Kubler Ross's stages of grief and have also been applied to change. But this pandemic represents a big loss for all of us. Each and every one of us have lost something, whether it's just the opportunity to do something that we wanted to do. Maybe it is a science fair like my son was very disappointed to not have. Maybe it's the opportunity to be in school with friends. Maybe it's the opportunity to participate in activities one loves. Maybe it's the opportunity to see your parents or your grandparents or your children. But the reality is that this is a loss just like the loss of any other human life. And we need to mourn it. But we also need to move forward. We can allow ourselves to have some denial, some anger, some bargaining, some depression. But at some point, we need to make our way towards acceptance. Of course, there will be bad days where we don't feel like we can really do it where it feels like too much. But you have to be, you have to acknowledge in my experience at least has been as a human being that I have to acknowledge when I'm feeling denial, anger, bargaining, depression, when I have COVID fatigue, and make a conscious decision not to let that become a replacement for my own personal risk assessment. And the same is true of all of our patients. Right now in healthcare, we are the only people standing up for what's right. Obviously, there are many others that are helping us, but we are the voice of reason in a complete vacuum of silence. And it is, in my opinion, our moral and ethical responsibility to speak out, tell the truth, and to help as many people as we can to find their way from denial and anger to a place of acceptance where we can work together to get through the next months. These will be very dark days indeed. The newest models suggest that we won't reach our peak until late January, that numbers could just continue to skyrocket upwards unless we do something different already doing quite a bit. In other words, we have a long way to go. And it's incumbent upon all of us to work together to make that road as smooth as it can be and to remember that even though in March everyone clapped and shouted and flashed their lights and called healthcare workers heroes, that even if they do not say these things today, you are all heroes. Everyone listening to this talk and everyone here and all the people in hospitals and in clinics across America, across the world who are caring for patients right now, who are trying to help their friends understand that a mask is essential, they and we are all heroes. And we need to use that status to help others come along with us. Thanks everyone and good, I'm sorry I won't be able to be at the panel at the end today. I do have other commitments today, but I also wish all of you the best of luck and all the best that can come and hopefully we'll see each other again next fall in person. Emily, can you hear me? Thank you so much for the lovely talk. What is your thought on when we will stop seeing a rise in cases per day and somehow reach the stabilizing point? Even a stay-at-home order at this point would probably, I think there probably will be a stay-at-home order coming soon in Chicago and there probably should be in many other states whether or not there will be, I don't know, but I'm not sure that that's going to be enough. It really comes down to individuals having groups of people in their homes and thinking that six feet is enough, thinking that they can take that barbecue that they did last summer outside indoors and just recreate it but with six feet of distance indoors and that's not working. We also are seeing additional sort of increasing deaths again as well. Obviously, there's new evidence now that masking actually reduces, having worn a mask reduces the likelihood that you'll have severe illness if you do get infected. So it's important to wear masks but oftentimes people are having unmasked contact indoors and the Thanksgiving and Christmas and other holidays that are coming up really are pulling on the heartstrings of every American and encouraging them to do things that are not in our best interest as a society or in our best interest for our health. The largest economic burden that we carry is the health loss that we've had and that is going to continue. In other words, I don't see a stop to this until we get vaccines widely available which is many months away. The weather changes where people begin to understand. There will probably be a turning point where people begin to follow these rules but I'm not sure how many people it will take. Thank you so much. Thank you and we deeply appreciate your being here. I encourage the audience again to please send their questions as the talks go on through the Q&A section. Let me introduce our next speaker. Our next speaker is one of our early fellows, Dr. Peter Singer. Dr. Singer is now special advisor to the Director General of the World Health Organization. Dr. Tidros Adanom Gibreis. Dr. Singer serves as the Assistant Director General of the World Health Organization. In this role Peter Singer supports the Director General to transform the WHO into an organization sharply focused on impact at the multi-country level. Before joining WHO, Peter Singer co-founded two innovative results-driven social impact organizations. From 1996 to 2006 Peter was the Sun Life Financial Chair and Director of University of Toronto Joint Center for Bioethics who some of us believe may be the largest center in North America and from 2008 to 2018 Peter was Chief Executive Officer of Grand Challenges Canada. Peter was also Professor of Medicine at the University of Toronto and Social Scientist at the University Health Network. Peter had trained with me and with Al Feinstein at Yale for three years before returning to Toronto. In 2011 Peter was appointed Officer of the Order of Canada, the highest award in Canada for his contributions to health research and bioethics and for his dedication to improving the health of people in developing countries. Today Peter's talk will be on COVID-19 and the World Health Organization. Please join me in giving a warm welcome to Peter Singer and don't forget to submit your questions. Thank you so much Peter. Thank you so much Mark. It's terrific to be with all of you. It's like coming home and let me start Mark with a note of appreciation for you. I'm really looking forward to tomorrow's session but it's just amazing to see that you've trained 488 fellows maybe more by now and that's an incredible legacy. So in these times when we're all feeling a little bit isolated that's something that connects us all and I think many of the people on this webinar and really just wanted to start with expressing appreciation for you. We'll have a chance to do that I think in more depth tomorrow but just wanted to start on that note. I have a very simple message actually because it builds very nicely on that wonderful talk that Emily just gave. I fully agree with her. I mean my message is that ethics and ethical values suffuse most of the all of the elements of the COVID response the COVID-19 response and foremost amongst all those values is justice and at the same time the practical approach that's been taken at the McLean Center for Clinical Medical Ethics is very useful and applicable. So I want to just really offer a way of thinking about the COVID response and I'll highlight some of the ethical values along the way but most of them actually the one that really rises to the top is justice and one other one that I'll come to in just a moment that I think actually may trump everything supersede everything shall we say. Before I go further let me just say that my Twitter handle is at Peter A. Singer and it would be great to stay in touch with many of you at Peter A. Singer. If you follow me now I'll follow you back and we'll have a chance to have some greater connectedness even after this a couple of days. At the beginning though let me start by saying a bit where we are we're in a bit of a churchillian moment as people were mentioning cases are rising sadly there have been 51 million 52 million cases reported globally to the World Health Organization and almost 1.3 million deaths worldwide. I think it's appropriate that we maybe just start with a moment of silence reflecting on those people who've died because this is the biggest humanitarian tragedy really the biggest global health tragedy in 100 years and probably one of the biggest global tragedies since the second war. So let's just pause if you will join me in a moment of silence and on behalf of the World Health Organization I'd like to extend my condolences to the families of those who have lost loved ones. Thank you I think the other thing I'd like to do is on behalf of the World Health Organization just extend appreciation and respect to the health workers in the United States and around the world who've put themselves in harm's way to serve their communities and in fact all essential health all essential workers as Emily was saying you know health workers constitute about two to three percent of the global population and about 14 percent of the COVID-19 cases which shows you the undo or extra risk that's taken on by health workers often to serve their their communities and they really merit our respect and appreciation. So let me then just cover the one way of thinking about the COVID response. You know at the very foundation of the COVID response is actually a type of soft infrastructure of values and the principal value is the value of solidarity in more than 115 news conferences since January of this year Dr. Tedros my colleague and friend has been emphasizing the importance of global solidarity that's how the world defeated smallpox which killed more than 300 million people in the last century more than all the wars combined at the height of the Cold War with the United States working closely with the Soviet Union and with other countries and with the World Health Organization that's how we will defeat COVID with solidarity and even though the cases are rising now and there's an incredible devastation of lives and livelihoods and we might be at our darkest moment there is hope and I'll come to that it's the it's the vaccine news and and the the exit from this pandemic is really in our hands and I hope that we never lose hope because that's so important so the soft infrastructure here is the value of solidarity and that's one that's the bedrock of the whole response and it's quite interesting that the bedrock of the response is solidarity it's justice it's leadership it's trust between communities and governments those are all soft ethical values and yet without them nothing else matters in this response sitting on that very important foundation of values really are the public health fundamentals and at the heart of those public health fundamentals are testing isolating cases tracing and quarantining contacts the only way any country has really been able to keep the epidemic or the pandemic under control is just that through a very robust system of testing isolating cases contact tracing and quarantining contacts and of course caring for cases and contacts who are in isolation or quarantine that should be accompanied by masking physical distancing washing your hands staying at home when you're sick and avoiding poorly ventilated indoor spaces and as a type of last resort restrictive measures or so-called lockdowns but that is really the last resort and unfortunately we are resorting to that and we probably do need to to tamp down the virus as Emily was saying but the heart of the response is to use a Canadian metaphor putting the virus in the penalty box through the testing the isolation of cases and the quarantining of contacts now underlying the aspect of the response is also equity and justice and to take a concrete example in Toronto the public health agency public health authorities in Toronto have started to look at inequities in the response and have been able to show that racialized communities have higher test positivity rates which of course means that the diseases is running more rampant and just one little example on the public health side of how justice and equity has come to play so we have the bedrock of values solidarity we have the public health fundamentals and there's a lot of inequities being disclosed and shone a light on in the public health arena and then sitting on top of that is the new scientific tools that's drugs that's vaccines that's diagnostics we did have some good news this week on drugs vaccines and diagnostics and in particular with the announcement of the first interim early in a news release positive results of one of the vaccines this was an RNA-based vaccine against the spike protein as its target and it was the Pfizer BioNTech news and it's probably good news for Pfizer and the Biotech and the specific vaccine but it's also good news for vaccines in general in a sense as Tony Fauci was saying in the immediate validates the target of the spike protein it validates the RNA-based platform and there there is no RNA-based vaccine on the market now so that validation is important. What I want to say about vaccines is they're not a silver bullet we'll need to continue the public health measures through the vaccine period into the vaccine period and after the vaccine period. The WHO has led the development of something called the access to COVID tools accelerator which aims to accelerate the development of these new scientific tools but also ensure their equitable distribution so safety and efficacy are very important and WHO will only stand behind a vaccine that it believes is safe and efficacious and that's important for building vaccine confidence and equitable distribution is important there's some modeling work I think is done from a university in the Chicago area that shows that you can essentially drastically cut death rates through equitable allocation of a vaccine globally leading us to say that it's better to distribute the vaccine to some people in all countries rather than all people in some countries in fact it cuts the death rate the death subverted in the modeling studies at least almost in half which is a remarkable outcome from simply an equitable allocation scheme and of course WHO has been developing with its member states an equitable allocation scheme focusing initially on health workers and those most vulnerable those at highest risk those at highest risk of death so there's a lot that WHO is doing in this area of the new scientific tools and equity is front and center in many of these many of these considerations so on top of the bedrock of values like solidarity sits the public health fundamentals and on top of the public health fundamentals sits the new scientific tools solidarity and equity being key values throughout and sitting on top of that and something that is a little bit early to start thinking about in great depth is the issues of the recovery so-called building back better now this can be a slogan unless it really means something what can it really mean I'd encourage us to focus in the context of the recovery on primary health care which is access to essential services but it's also empowered communities and multi-sectoral action and it has a very very strong focus on equity I'd like to encourage us to think about how the global challenges we face in health but not only in health also in climate in inequity and the range of global challenges we face in financing the SDGs where we're slipping behind these challenges converge and we should deal with them in a convergent way and here I'd also like to say that COVID-19 is obviously a crisis of not only lives but also livelihoods there was one estimate published by Larry Summers that the price tag of COVID-19 for the United States was 16 trillion dollars and compared to that type of money or the more than 10 trillion dollars in stimulus spending the gap the financial the immediate financial gap of 3.8 billion dollars in the ACT accelerator that I described the access to COVID tools accelerator is actually very good value for money so I'd like to encourage us all to to push on the on closing that gap because that's what will yield the equitable distribution of vaccines around the world and also in addition to that lifeline a type of insurance policy for high-income countries where they have access to a portfolio of vaccines so in the recovery the last point I want to make is there's really only one way to solve the economic crisis and that's by solving the public health crisis so primary health care with a focus on equity the convergence of global challenges and solving the public health crisis through the solving solving the economic crisis through solving the public health crisis and again COVID-19 is a very cruel virus it's shown a very harsh light on the inequities the pre-existing social and structural inequities in our societies and we see that coming out in all kinds of ways if you have a look at the Twitter thread I mentioned at Peter A. Singer I just retweeted a very nice thread from a colleague at Harvard Medical School who was focusing in on this issue of inequities and give several great and important and sad examples of inequities so in closing I would like to just back to where I began I'd like to appreciate the work that all of you do in ethics in respect to COVID-19 and more generally ethics is at the very heart of the COVID-19 response it's the foundation of the COVID-19 response and I've tried to illustrate that in the talk solidarity equity are actually the values on which the whole response is built they are inherent in the public health fundamentals they're inherent in the issue of allocation of vaccines drugs and diagnostics they're inherent in the recovery agenda with primary health care and how we build back in a different way with greater with greater equity and they're inherent in the whole thing so the work you do is so important I'd like to thank you for that and I'd like to thank you Mark for enabling the work that we all do and look forward to appreciating that in greater detail tomorrow I would just like to end with one word and that's hope it may seem like a very dark time in the coming weeks and months and in fact it is a dark time in the coming weeks and months but there is hope we're getting the early signals from the vaccine portfolio we see countries who've been able to control COVID-19 with only the public health fundamentals and please maintain that hope because the world defeated smallpox the world will defeat COVID-19 how will we do that we will do that together thank you very much and I look forward very much to the discussion period and to hearing the comments of all the other speakers thank you so much Peter thank you so much for the beautiful talk it was extremely moving and thank you again we look to the panel discussion I'm sure there'll be questions from panelists and from the attendees in the audience let me now introduce our next speaker Dr. Kelly Mickelson Dr. Mickelson is the Julia and David Uline Professor of Bioethics and Medical Humanities at Northwestern University's Fine School of Medicine and is also the Director of the Center for Bioethics and Medical Humanities there at Northwestern Dr. Mickelson is Professor of Pediatrics at Northwestern and an attending physician in the Division of Pediatric Critical Care at the Leury Children's Hospital as well as the Director of the Institute for Health and Medicine for the past eight months since March Kelly has been the chair of the Chicago Bioethics Coalition which is an organization of more than 50 or 60 ethics experts in the Chicago area who focus on the COVID-19 pandemic Dr. Mickelson completed her ethics fellowship here at the McLean Center in 2010 and today she'll speak to us on collaboration from crisis we are all in this together please join me in giving a warm welcome to Dr. Kelly Mickelson Kelly thanks so much Mark and I I'd like to start by joining others in congratulating you on your award I am incredibly grateful to you and to the McLean Center I would not be where I am today if it wasn't for you and so thank you very much and congratulations such a well-deserved achievement okay we're going from the World Health Organization to here in Chicago and I love the theme of solidarity because I hope that this story will be a story to show the value of solidarity I think that we have seen and heard and felt some of the major challenges that COVID-19 has presented but I think many would agree that despite all the challenges there are some silver linings I once started a class by asking people what are the good things that have come into your life as a result of COVID-19 and I hear things like new pets an opportunity to spend more time with my family because I'm staying at home with them for me one of the benefits one of the silver linings I would say of COVID-19 has been this group so I'm going to give you a story about how we came together and some of the accomplishments of this group and values in solidarity here in Chicago so I'll just tell you a little bit about how our group formed talk about some of the value that I see in the interest in this inter institutional collaboration I'm going to touch a little bit on some of the challenges that we've faced as a group in terms of what to do with some of the issues that have come up for us and then think for a bit about the future of our group so I'm going to start by refreshing the timeline in our minds and I do this because I just feel like the context of where this group started is important so if we remember it was the end of December when we heard reports from China about a new disease emerging and then just a few weeks later we would hear about the first case of COVID-19 here in the United States by the end of the month the World Health Organization had declared a global health emergency and everyone was well aware of the COVID-19 situation and the concerns about the pandemic I put up here the date March 11th the day the NBA shut down not because I'm a basketball fan but because I feel that that really marked the time for me when I could when I could sense the huge change and shift every time I would turn on my computer and open my email there would be another conference that got canceled or another issue that was changing and I think that there that there was right at this time that sense of impending concern and it became clear also at this time that there were going to be a number of challenges that we would all face and that many of them would be ethical challenges so I had been at this same time working on a meeting with some of my colleagues at Northwestern and said to them gosh do you think it would be helpful to talk with some other folks around Chicago about some of the issues that it seems like we're all going to be faced with and of course there was interest in this so I sent a few emails out to about three or four colleagues around the city of Chicago to ask if there was interest and not only was there interest but the interest in my mind was overwhelming I think I sent the email out on a Monday and by that Friday we would be having a meeting with over 40 people from across the Chicago land area the stay at home order just to give you a sense again for the for what was happening in the world at the time or the our location at the time the first day at home order in the U.S. came in California on March 19th the first meeting of our group was the day after that and then the following day here in Chicago or in Illinois what this day at home order also in our state and then relative to what this group would do is the context of what would happen over the next few months just a few weeks we would see the peak the first peak unfortunately we have to say the first but the first peak of cases in Washington state by about by the beginning of April we'd see the first peak of cases in New York state and then it wouldn't be until almost a month after this group started to get together that we would get Illinois guidelines for hospital preparedness and all this while we were seeing what was happening in Washington we were seeing what was happening in New York and the challenges that the hospital faced and all of us working together to think as a group about how we would face those challenges here in Chicago and it would be then about two months after this group started to work together that we would see the peak number of the first peak number of cases here in Illinois so what is this group as Mark mentioned we're about 40 50 it's hard to know individuals representing at least 13 healthcare systems largely in Chicago though we have folks across Illinois and even in some of our meetings have had people from other states across the country we have virtual meetings we have a very active email listserv where people can post new questions share new information and even an online presence we've worked some with the bioethics.net site which is managed by Craig Klugman here in Chicago as well as the Northwestern Center for Bioethics and Medical Humanities has a site on our page for the group. I think that the major value in our group has been efforts to share and collaborate and the sharing has been in a variety of ways and situations whether it's educational materials about public health ethics about COVID ethics about the COVID virus the SARS-CoV-2 virus itself a lot of knowledge sharing we are so fortunate here in Chicago to have a deep fund of knowledge in bioethics in all areas at different institutions to share that and their experience a real way to form connections and I hope that some of the things I'll show you that have come out of this group will reinforce that and again this sort of website presence. Not surprisingly the topics of conversation have at least initially really focused on allocation of critical care resources and policy development around those resource allocation issues as well as DNAR policies CPR policies which were required in some cases as in part related to those policies we talked a lot about hospital visitors and visitation restrictions as the pandemic has unfolded we've been discussing distribution of medications vaccine development and distribution is becoming a new important topic of our group research during the pandemic and even managing outpatient clinics but as I noted at the beginning the issue of allocation was very front and center because of what we were seeing in Washington and New York and concerns that there would be a need to ration and I use this as an example of some of the issues that we've talked about but also some of the product that has come from this group and some of the challenges that we've faced so at some point during our conversations Dr. Gina Piscotella and Dr. Will Parker put together this table about the protocols that different hospitals had put together around this issue and I'm not going to go into the details that would be another talk in and of itself but what I want to point out is that when we looked at the different schemes and compared two different patients what became very clear was that it depended on which hospital you went to what kind of resources you might get so in this case if you were a 65 year old then you went to hospital one and two you would get a particular resource but if you were the 45 year old and you wouldn't get that resource unless you went to hospital three and four and this issue really came to the fore of the discussion among the group that there was an enormous amount of inconsistency about these policies and I think in part this is what spurred Dr. Piscotella and Dr. Parker and others to write about it and so what I want to highlight here is some of the scholarly output that's already come from this group and that is on the way as we look forward so this work by Gina has been I think really incredibly important in highlighting some of these inconsistencies across our country. Other work has recently been accepted by a journal by members of this group as well as future collaborations and then not just has this group been focused on academic scholarly productivity but I think really noteworthy is the focus on connecting with the community outside the academic world and to highlight that I am going to show you some examples of writings of this group in the lay press. This came out by as you can see a group that came from different institutions across the city of Chicago that was really spurned by this notion that we want the public to know and hear what's going on that may help them feel more comfortable. Dr. Polly Gandhi and Dr. Angira Patel wrote about this issue of ventilator and resource allocation. Dr. Dahlia Feldman published something about the issues of COVID in pediatrics. Dr. Aaron Paquette was really forward thinking in the impact of social distancing on health disparities. Others about resource allocation and just to end by highlighting this piece by four of the people in this group commenting on some of the worries that we've identified as a group that come as a result of inconsistencies and challenges with distribution and coordination of resources in Chicago. We've seen a lot of the challenges in Chicago related to disparities of certain populations and one of the topics that was really front and center in this group was how do we engage the community. We saw in Gina's work that of those guidelines that exist in the United States for resource allocation only half of the ones that she was able to identify reported community involvement and just a small fraction recommended community involvement but didn't state whether they had and this was something that the group talked about and thought about a lot how can we really engage with the community. One thing we did try to do was engage with an organization called MAPCORS that has a connection with University of Chicago and Dr. Lindo who we've already heard from earlier today. The idea here was to have conversation with youth about some of the ethical challenges in COVID-19 and get their views and we hope that this will be something that we can continue going forward. So I mentioned thinking about some of the challenges and the fact that we had recognized a lot of inconsistency across the hospitals in Chicago related to policy and I think this issue has created some challenges among this group. You can imagine a group of bioethicists getting together and identifying sort of an injustice and really feeling the need and obligation to mitigate that injustice in some way shape or form and I think that this group has and continues to struggle with how can we leverage the group to advance policy and issue that we think can promote justice and where's our space to do that? Where's our authority and how's the best way to do that? We are a group of many different people from many different institutions. We each have individual identities as citizens, as professional identities, as clinicians or bioethicists or other roles that we carry as well as connections to our institutions and all those things have to be balanced as we try to think about approaches to move all of this forward particularly when we identify something that maybe we don't agree with or we think there's another solution for. I see that as a challenge almost reminds me a little bit of what is the role of the ethics consultation in the clinical setting to impact change. I think maybe there's some parallels there to what is the role of our group in impacting change or helping the society, the culture, the world deal with some of these challenging issues. Where are we now? We moved kind of to monthly meetings but I feel like as our world is changing again and we're seeing an uptick in cases here in Chicago and across the country there seems to be some thirst for a little bit more connection and that may change. We certainly are continuing to discuss issues related to COVID and vaccine for example vaccine distribution but I think there's been interest in expanding the focus of the group not to focus not just on COVID-19 issues but other issues and things like electronic pulse in Illinois have come up and some other things to use possibly this group as a work in progress and opportunity for people to share their research for further multi-institutional discussion and really I think the sky's the limit and we'll see where this collaboration can go and I just want to stop or end here with some acknowledgements and I can't even list all the people that have been involved in this work but what I would like to say is how honored and humbled I've been to be able to be involved and to work to learn and sort of to try to create change with such an extraordinary group of people. I really do think that this collaboration does demonstrate the value of solidarity that we heard can help the world and I think can also possibly help us here in Chicago so thanks to everyone who's been involved in this group and thank you to Mark for inviting me to share all of this with you and with everyone during this seminar. Thank you so much Kelly. It's a great honor that McLean graduate from the fellowship is the director of the COVID-19 Chicago Biorethics Coalition and that perhaps a dozen or 15 other members of that program. Thank you for a lovely talk and you'll be with the panel. I now want to introduce our next speaker, Dr. Spurgeon. Dr. Fedsen is an associate professor at Baylor University at Baylor College of Medicine and is also an attending and associate professor in cardiology at the Michael DeBakey Medical Center. Dr. Fedsen is an advanced heart failure transplant cardiologist and before her move to Texas worked here at the University of Chicago with then the busiest heart transplant in Illinois. Savi also is a McLean fellow. She's been a speaker at national and international heart failure transplant in bioethics meetings on topics such as end-of-life ethical dilemmas in heart transplant candidacy and candidacy circulatory support. Today Dr. Fedsen will speak to us on experimentation in a time of crisis control trials or case reports. Please join me in giving a warm welcome to Savi, Dr. Spurgeon Fedsen on her return to Chicago by Paisu Savi. Thank you. Thank you Mark. Thanks to the McLean family for the continued support of the Center and to my colleagues. This is always my homecoming time to Chicago. I would also just I did the math this morning and I've known Mark for 96% of my life now. So we go back a ways and it's really thrilling for me to be here. And I really appreciate the opportunity to talk about some thoughts I've had about the role of sort of scientific inquiry in the setting of a pandemic and there are many light sort of issues that come that come up in this setting that we have to think about in the setting of a pandemic. So I am now at the Texas Medical Center which is the largest medical complex in the world and it's interesting following that wonderful talk. We at the Texas Medical Center have also set up an ethics consortium in part to address the hospital shopping so that we actually manage to create consensus among all the hospitals here so that if you went to one hospital as a patient you would be certain of getting the equivalent care or the equivalent level of care as at other hospitals. So I think it's interesting that groups of bioethicists have gotten together in different settings and have done that. So we've also at the at Baylor come up with a scientific review committee for studies and to really offer guidance to the IRB to think about prioritization of studies not only for the quality of the study and priority to get through the IRB but also to think about if you have a limited number of patients what studies perhaps these studies the patient should be directed towards. So looking at again some of the very different aspects I think of ethics that the pandemic has brought to light. So in Madison we are really governed by the rule of rescue. The desire to do something to try new therapies to find new purposes of old therapies to save the dying patient in front of us with little regard to cost. And I think when we would think about cost there the obvious financial costs they're the resource costs that all of us have become familiar with with COVID and the pandemic and just ventilators and ECMO and staffing and beds and all of the the sort of physical costs that take into it. But I think these are just some of the costs that we think about in the setting of the care of patients under COVID and I think also in the ethics of research in the setting of the pandemic. And I think that we have to think differently about how we might need to approach this. So by spring time as you've heard that the timeline that was just we were all reminded of you know we had a global health emergency. COVID had spread well beyond China was spreading through Europe and we were in search of a cure or at least in search of things to attenuate the disease. So we had a disease for which we needed to find things to do. So we were faced with a challenge of wanting to do something, do something to take care of the patients in front of us to sort of stamp out this disease. But we were also counterbalanced with the desire for the pursuit of scientific knowledge to understand this new yet similar respiratory virus that we were facing. But this graph is not the graph of COVID cases. Although it looks like it. No, this is a graph of the PubMed citations. If you just look at searching up COVID-19 and treatment from January 2020 until last week. So just taking COVID alone have been over 70,000 published works within the past year. Related to COVID and treatment there have been 1900 cases or publications showing just the determination and the urgency of the need and the desire to get answers about what to do so we could do something. So the case reports are nearly 4,000. 4,000 unfortunately not all peer reviewed or adjudicated but published. And I think this is important because with this exponential explosion of information and publication they've come retractions some of them fairly prominent journals. And I think this is an entire talk to itself about the responsibility of the scientific community to maintain peer standards and peer adjudication. But if you just look at the numbers of retracted studies related to COVID this year it's been 35. If you look and that's just 2020. If you look at all of the published literature on HIV, there have only been 100 retracted studies. Hepatitis C, 34. Influenza, 45 retracted studies, SARS-1. And for Ebola which absolutely had a higher case fatality rate. There are no retracted studies because you didn't have this churning out of information. One could argue that was very local, wasn't a global pandemic. Absolutely. But it's interesting to think about how we have to address some of the sort of responsibility and the ethics of getting all of this information out. So we have a rush of excitement and perhaps some misdirection. So how can how can we try and balance our wants and our desire to do something or you know the rule of rescue related to the pursuit of scientific inquiry? Part of this dates back to the Belmont report. And since the sort of scathing release of the Belmont report we have classically separated scientific research and clinical medicine. And the reasons for this you know the myriad reasons and the benefits I think have been fairly obvious. You know protect human subjects, make sure that the research is of good quality and for beneficence justice although that's arguably been the case in the selection of study subjects. I think those are clearly the benefits but they've been burdens associated at least with the gold standard of scientific inquiry which is randomized controlled trials. You have the burdens of randomization. You have the practical aspects of you know how do you order a drug versus a placebo and getting a research pharmacist involved. You have the fact that many of these are only done in limited academic or very sort of advanced or larger community settings and therefore you are necessarily excluding access to studies from the very subjects from whom we could gain a great deal of information and certainly in the setting of this pandemic we know that these are people who at higher risk for having higher health care burden of this disease. So I think that part of the problem about the way scientific research has has tried to push towards the randomized controlled trial has led to some of the problems that we have right now in the pandemic because we have a hierarchy of research design. You know we have at the very top the randomized controlled trial and if you have one or two randomized controlled trials you have a level of evidence that A for any guideline recommendation you make this is really what we're looking for and so going down sort of the the cascade we have prospective non-randomized somewhat less worthy cohort case controlled and then perhaps even falling off the slide almost we have the case reports which may be the weakest or the lowest level of evidence but this is often the first sighting of disease and I think this is important as was mentioned this morning the recognition of Alzheimer's was first mentioned as a letter to the editor. So we have to realize that there are many things that really can inform science that come out of case report the lowly case report or the case series and case reports are the results of doing things this is how we we achieve sort of our fundamental need to take care of patients there are the results of the practice of the the practice in the art of medicine with a keen eye for observation this is following classically in the footsteps of people like Oslo or Sydenham or Bohov this is how we discover syndromes and conditions you know the recognition of Kaposi sarcoma and immunodeficient state was first published as a case report in the MMWR the association of Fen Fen with pulmonary hypertension was a few letters to the editor and Lancet the discovery of factor five Leiden came as a result of a hypercragable state recognized in a few hospitals in Leiden itself which is how it derived its name and of course years ago you had or centuries ago I should say you had the recognition of smallpox and Jenner and it's interesting of course that Dr. Singer mentioned the eradication of smallpox because I I actually want to talk a little bit about smallpox and Jenner because I think he plays a role in in what we're talking about now in some respect Jenner recognized the clinical events and put them together with the known practice of variolation which had been practiced for years I mean for hundreds of years before the common era but Jenner put this together with a keen eye of observation that milkmaids didn't get smallpox so what he published was actually a case series of 23 cases the first 16 of which were observational studies based on these on these first 16 milkmaids and then the last six he actually used a method of inoculation with cowpox virus so cowpox vaca is cow and latin vaccinia is cowpox and from there we actually get the term vaccination because we took an inoculation from a cowpox and then we vaccinated people against smallpox so it's interesting that you mentioned smallpox because with the with the development of vaccines and the discussion of vaccine development it comes down to actually smallpox and Jenner and how this came about so I think case reports certainly have advanced medical awareness and knowledge and I think they're they have an important role they could suggest pathophysiology or biochemical mechanism of a disease they're incredibly useful in orphan illnesses such as pulmonary hypertension the rare side effects of medicine and it gets the pros and the storytelling of the past were simply case reports that help describe all the phenotypes of a disease that we later went on and to list other diseases that were first discovered this way legionnaires disease for example West Nile encephalitis graft versus host disease oh and just COVID COVID was first reported as a case series of two to the WHO so from there you know that was simply the beginning at the crest of a wave that is now crashing all over the world was the fundamental it started fundamentally with the recognition of something new and the case report but we really want to crave randomized control studies you know we want to be scientifically vigorous and we really want to have equipoise so is it ethical to demand a randomized clinical trial if there is no clinical equipoise if we want to design such studies sometimes we actually have to change the question to fit the mold and we end up answering a different question not the one we want so if you think about this description of the elements of a good study the hypothesis hypothesis must be an important and unresolved issue it must be designed to provide evidence to address the said question be feasible can be dealt with scientific rigor and accurately pour the methods and results in a timely fashion now I might argue that researching the use of hydroxychloroquine in critically ill hospitalized patients was fairly timely addressed over 100 years ago but yet we went through it again I could also say in my field of cardiology there have been studies reported on the use of oral ionotrips a full 10 years after the close of the study which I think in any lenient say would still not be considered a timely fashion so certainly there have been flaws in how we've designed some of our clinical studies so we have to weigh the benefits and burdens of our trial design and our trials indeed you know the benefits of these large trials are that they have public health and perhaps individual health benefit but the burdens are that many people who need medications can't get to them we all I'm sure have patients who need hydroxychloroquine who couldn't get to it because of it and there are many small studies that are done so our questions actually can't be answered properly because they aren't powered to address them enough so if we look at just some of the studies that have gone on now for COVID it's really mind boggling what some of the the drugs that have been trying to find a new treatment how are we as physicians supposed to keep track of them or rank them let alone patients we have right now a pandemonium and I think we have to be careful and this is yet another aspect where in ethics we have to be careful about it is that we have to worry about how they're presented the public views case reports as sound randomized controlled trials as strong in evidence as randomized controlled trials you know the the announcement of the vaccine while very promising was not pure reviewed their data have not been reviewed the question is was behind this was this to boost up moral support for the fact that we have perhaps some dim flickering of light at the end of the tunnel or was this sort of driven by politics and perhaps even monetary gain for the company the public the publicity associated with trials and the results new uses for old drugs and marketing I think is one of the things that we have to make sure that we govern or at least have a role in how that information is coming out there I'd like to sort of show an example of of what we also I think have to to think about and this is actually I think this comes up with a whole idea of of justice and equity because a lot of the the drugs and the trials we're talking about are going to be available for a small fraction of the global population so I want to look at some of the smaller studies which are not class one tier randomized control studies but sort of class three class four tiers cohort design studies looking at old drugs so let's take a look at an old friend this is you know a role of ace inhibitor which of course as a heart failure doctor I find incredibly important but with the press coverage about the role of angiotensin angiotensin converting enzyme and COVID and its mechanism of action people stopped taking these medications so this study looked at what happened when people stopped taking ace inhibitors or actually comparing people who maintain their ace arbs in the hospital and those who didn't and there was a 40 percent reduction in 28 day mortality if people continued the use of the ace and arms while hospital hospitalized with COVID for dollars a day what a bargain 40 percent reduction in mortality on the public side of this you know one would think okay but take this further so this was a case control a case control study of 602 patients in three Belgian hospitals the mean age of these patients was 83 years old overall mortality of 16.5 percent for those hospitalized with COVID high mortality high risk people they took 201 of these patients who were on statins when they came in and they did propensity matching for age sex high risk medical conditions given where they were it's likely that most of these patients were white white Caucasians but they looked at those on statins and then the use of ace and arms and you had to 28 adjusted mortality reduction of again 40 percent phenomenal this is a case control study these are drugs that we have great familiarity with we know the side effect profiles of aces we know the side effect profile of statins these are available for dollars a day for generics and these are therapies that can actually attenuate disease it may not be able to prevent it but can attenuate it can decrease mortality and more importantly I think might have a wider spread use in a global population if we're thinking about it and I think part of what we have to think about in the research related to sort of COVID and ethics and other pandemics is how we can develop therapies that might have a global application and not just pertain to those people in the sort of developed world where we have access to things like ECMO and ventilators although depends on where you are that those may not be there so I think that we have come to a place where we have to have the public facing sort of sensible medicine and our role as ethicists is really important in this because even though medical knowledge typically doubles every two years it's going much faster in COVID but what's surprising the typical situations you have a delay of five to ten years in the uptake of medicine and medical therapies now with COVID it's sort of happening simultaneously and we have to figure out how we could sort of not necessarily break it but make sure we don't slide down the ramp into the crocodile's mouth and should we perhaps think about every single patient being enrolled in a trial and that trial may not be a formal drug trial but maybe a registry or database trial think of how much we've learned with the Framingham database and other epidemiologic databases should we use this is this a way we might be able to look at the long haulers with COVID and just get everyone enrolled so we could follow things and learn from things and get signals of mechanisms of action and I think that these are things which are not necessarily going to be driven by Fama not going to necessarily be driven by you know NIH and NIH equivalents but things that I think are equally important that we have to keep our eye on because the opportunity costs of the pandemic are really quite great we have many many studies of therapeutic of therapies with very little sort of collaboration and oversight or collection of data so we may lose opportunities to think of or to recognize small signals that either have great harm or great importance that otherwise otherwise might be missed so I think looking at I sort of took this question to think about you know the the pitfalls of research during COVID or during any academic is really what who gets access to the drugs who gets access to the trials or what trials get access to what patients and how we need to perhaps govern this in a more thoughtful way so this is a picture of the Texas Medical Center and as I said at the Texas Medical Center we have created a bioethics consortium we have also now created a Texas wide consortium where we have a week biweekly meetings with people throughout Texas looking not only at how we have hospital standards for crisis and contingency but also for lobbying and whether or not we could affect policy change and you know we have a unique legislature here and that we only our legislature sits only every two years this year they're actually sitting and we have clinicians and ethicists at all of these institutions who are prepared to go to Austin if we need to try and appeal things to make policy changes to help with some of the inequities and try and address some of the sort of ethical issues that have been brought up beautifully this morning sessions and again earlier by my the speakers before me so I think that we have many important things that we could contribute to but while that is where I am now this this view from Rockefeller is still really where I consider home having lived in Chicago for most of my life thank you very much for the opportunity to be back even virtually and thank you again for inviting me to speak Savi thank you so much I'm just wondering that with you at the one of the largest cardiac hospitals in the world if investigations of of cardiac issues related to covid are being considered there they certainly are I mean they're involved in in many of the trials at st. Luke's texas heart they're involved in many of the trials as they are at bentop certainly a lot of the you know columbia is doing lovely work Pittsburgh is doing lovely work michigan's doing lovely work their number of centers and it's it's interesting the the collaboration and I mean this one of the other silver linings of covid is the fact that people are doing things on zoom so much that it's very easy to have you know cross-country meetings or international meetings because people are so fast about with it now so I think that is really that that is you know a silver lining to this and I can't believe I've only known you for 96 percent of your life your dad followed me as chief resident the year after I was finished it's amazing thanks so much we'll have you on the panel our next speaker is going to be Dr. Aaron the martino who's an assistant professor of medicine in the division of pulmonary and critical care at the Mayo Clinic in Rochester Dr. D martino did her undergraduate degree at Williams college and her md in residency at Dartmouth and then did a fellowship in pulmonary and critical care at Mayo's Aaron was a mclean center fellow in 2015 and 16 her primary research interests are in areas related to clinical medical ethics including advanced care planning surrogate decision-making on a national scale and health policy Aaron headed up a group of scholars from Mayo's and the University of Chicago and Harvard to write a powerful paper a few years ago in the new england journal on healthcare surrogate state laws the enormous differences among the states Dr. D martino will speak today on the topic dispatch from the front lines balancing personal risk and professional obligation it's a pleasure to give a warm welcome to Dr. Aaron D martino Aaron thank you Dr. Siegler first of all I want to begin by echoing the messages of appreciation and gratitude for your mentorship and teaching this army of clinical medical ethicists of which I am proud to be a part that fellowship was pivotal in my own professional and personal growth and I am eternally grateful to you and to the mclean center the mclean family and the University of Chicago for the opportunity so my talk today is a dispatch from the front lines as you've heard in the introduction I am a medical intensivist I have been taking care of patients I actually admitted the first COVID-19 patient to any of the male clinic health system sites back in March and continue to care for them just came off a week attending in our COVID ICU I don't have any financial relationships to disclose but that doesn't mean that I'm without conflict in fact I think that my role as an intensivist and the fact that I am personally taking care of patients and in the fact that I also am able to zoom out and look at things through an ethics lens gives me both a unique vantage but also places me in conflict especially when you think about my other primary role which is as a mother and the responsibilities that I have once I doff my PPE for the day and resume my role at home during today's talk I'm going to be discussing professional obligations both in terms of the loftier virtual-based obligations that we have as healthcare professionals and then some of the more nuts and bolts real world considerations I'll be talking about risk then physical risk psychological risk and even briefly touching on legal risk associated with being a frontline healthcare provider during the COVID-19 pandemic I'll discuss different methods of mitigating and reconciling the risks that are faced by healthcare professionals and to foreshadow without offering firm solutions but fodder at least for conversation and for our panelists discussion later and finally I do want to end with some comments on training during a pandemic which I think is a highly unique topic worthy of its own talk in and of itself but at least some comments and reflections on training during pandemic so to begin professional obligation healthcare professionals are described as having a duty to care most of us have made a voluntary commitment to enter a profession in which we care for other individuals and we alone in society are uniquely positioned to deploy those skills and that high level of education for the benefit of others in society who become ill we alone are the ones who have the knowledge and expertise and skill set to care in the way that is needed during the pandemic many individuals have entered healthcare because they feel called to do so though not all and many individuals including physicians have taken an oath to uphold certain values but it's important to note that not all of the individuals who are present at the bedside who are exposed to risk will have taken an oath and will have approached their profession in this way I think particularly of the phlebotomists the radiology techs the nursing aides who are at the bedside with me when we're resuscitating a patient who may have a very different conception and set of reasons that they are present in the workplace that day and I would add that whether or not we've taken an oath the extent of that commitment isn't infinite in fact it's quite individual and I would argue even it's an existential question that a lot of individuals have grappled with over the past few months particularly people who are serving on the front lines there are also some much more pragmatic real-world considerations to be mentioned when you think about professional obligation and particularly I think about my team so healthcare particularly intensive care medicine is a team sport where every person fulfills a unique role and if you turn to your right and you turn to your left and the skilled individuals you expect to be there are not there the team doesn't function highly and it compromises the safety of the patient but also of the entire healthcare team in this moment and even now in Minnesota we are calling upon professionals to slot into different roles than they had previously filled so outpatient nurses filling in in inpatient settings and ICU settings and there are individuals who have particular skill sets that make them of instrumental value kind of almost irreplaceable in a pandemic response or mass critical care response but we are also relying on individuals who have different levels of other skill sets and different roles who are stepping in to help out I would mention too that there are some financial realities and other types of realities that confront individuals and will cause them to be at work potentially even if they feel conflicted about being there and concerned about their own safety where they don't have the financial security or otherwise where they can sit out sit on the sidelines so having talked about some professional obligations let's then talk about personal risk to our bodies to our minds and also to our families this photograph was taken during August after a high-risk exposure that I had at work it was after my first of three negative COVID PCR nasal swabs but I was advised to physically distance from my family including a son who I was breastfeeding for two weeks for 14 days and that takes a tremendous toll and also called upon our family to make some very difficult decisions about the type of distancing that we were going to enforce in our house and how to handle those recommendations I'll mention that staffing shortages are increasingly becoming a huge concern here in my part of the upper Midwest and throughout the country and I've mentioned already this issue of redeployment it's important to talk also about personal protective equipment much has been written about the importance of protecting our healthcare workers with personal protective equipment and also different ways of mitigating scarcity including reuse or flexing the ways in which we are used to using our personal protective equipment we each carry with us visible and invisible risks in terms of our personal health status for instance I have colleagues who are in the early phases of pregnancy and whose pregnancies aren't widely known or people who have a vulnerable member of their household as I have had with an infant son at home and it cannot be overstated that the risks here are very dire they're serious risk of serious illness and death many of the initial individuals in the US who were stricken and around the world were in fact clinicians who were exposed through their work I want to spend some time on the psychological risk so I can tell you that from the front lines these shifting recommendations that we were say hearing about in the news feel very different when you are in the intensive care unit and so when you report to work in the spring one day and are told you have to wear a papper or an N95 very high level protective equipment before entering the room of the patient and the very next day 24 hours later when you are rounding on the same patient you're told that you can wear a simple surgical mask because the CDC recommendations have changed it feels very uncomfortable and yet as the attending physician who is supposed to be an example of leadership and also stewardship I have abided by recommendations around PPE but I can tell you that personally it makes you feel uncomfortable to have shifting recommendations within the same week caring for the same individual patients and this is also borne out when you talk to people anecdotally about the decontamination processes that they go through as they leave the workplace in terms of showering at work or changing in the garage or things like that adherence to different policies it's useful to have protective policies and yet at the same time adhering to them can feel very uncomfortable as we've talked about in other talks so far today bending the ways in which we practice medicine away from autonomy based care to justice based care feels uncomfortable and unnatural to a lot of us in western medicine and is contributing to moral distress we are isolated from our patients and in many cases where we are discouraged from going in and out of the room often so we're communicating with them maybe more often than we would normally by calling them on the phone or face timing with patients who are not intubated from our families from co-workers who might otherwise be sounding boards and persons with whom we could decompress and we are witnessing suffering on such a mass scale and we're seeing it firsthand we're seeing those gurneys go down to the morgue at a clip that I have never seen before and moreover we are seeing the inequities play out just in the number of ICU patients on a given day who require an interpreter changing demographics in our medical intensive care unit at a rate that is really alarming and disquieting I know that we'll be talking about this more tomorrow one of the McLean Center law professors will be talking about patchwork her work on patchwork liability protection and so I won't dwell on this but it's also worth noting that in addition to the other risks that I've touched upon there are legal risks to being a frontline healthcare worker both in terms of civil and even potentially criminal charges that could stem from the care provided during a pandemic and particularly if it deviates from standard care how do we reconcile these risks there are systems-based approaches which can include protecting the workforce by providing adequate PPE and then very importantly when scarcity arises having institutional or state level guidance about what to do and so if there is a shortage say of PPE then our healthcare providers still encouraged to respond to a resuscitation without adequate PPE I would argue that they are not obligated and that endangers the population if they continue to rush into rooms in the way that we used to do in 2019 we need to provide adequate mental health resources for all frontline providers and then there are different states and institutions that have proposed and some with varying levels of granularity different methods of prioritization for scarce resources which can include mechanical ventilators or ICU admission but also vaccine allocation or novel therapeutics novel antivirals etc and then as we've heard about more in the essential worker health workforce hazard pay and so incremental increases in pay but it's really vitally important to recognize that none of these is a complete compensation for the level of risk incurred and being on the front line we each have to take our own pulse about our personal health family health and obligations and our beliefs and as needed seek accommodation from superiors finally just some closing remarks on training during a pandemic it's important for us to remember that learners should be considered a vulnerable class in particular during this pandemic they have less experience they're more prone to exposure they may have a fear of retribution for declining to participate and have a limited amount of time to accrue knowledge and skills and so it's important for us to work with graduate medical education and medical schools to think about ways in which to include learners but do it in a sensitive and empathic way to check in with our learners about their comfort and experience and caring for COVID-19 patients and offer reassurance and solidarity and finally I just wanted to close on a slide that in memory of the many many health care workers who have lost their lives through their front line experiences taking care of COVID-19 patients. Thank you so much Erin for that lovely talk. Professor Zolot's interest focuses on the intersection of bioethics and religion particularly Jewish studies. Professor Zolot is past president of the American Academy of Religion and the American Society for Bioethics and Humanities the ASBH. Her work on bioethics in health care led her to serve on the NASA Advisory Council the Space Agency's highest civilian advisory board and on the International Planetary Protection Committee and the National Recombinant DNA Advisory Board and the Executive Committee of the International Society for Stem Cell Research. Today Laurie Zolot will speak to us on the topic Journal of the Plague Year Ethics and COVID-19. Please join me in giving a warm welcome to Professor Laurie Zolot. Laurie. Thank you Mark and I want to join my voice to the chorus of people praising you and thank you for your extraordinary work in the program and setting up the McLean Center and really transforming this very special corner of bioethics by your work and your vision and it's long been something I've admired and respected even before it long before I came to Chicago so I also wanted to say thank you to Mark who earlier this year because after these conferences are finished as you know Mark right away starts to plan the next one and I think it was in December or maybe early January when I said you know there's some I want to give a talk about these cases that are occurring in China about this strange disease I think that I'm worried about those cases and I want to give a talk about the ethics of this of this new disease before it was named COVID and and you tolerated that um quite well actually that you sort of like oh yeah that might be curious and interesting and then who knew so here I am now talking about something quite different um the Journal of the Plague Year so so I wanted my disclosures or um I have no one pays me any money but I'm on all these boards and and I am influenced by my colleagues on these boards so that's my disclosure um this is going to be a very brief talk it's a hermeneutics um and it's going to consider one question about bioethics how did we do in a time of plague as bioethics so instead of turning the lens on the external questions I want to turn the lens on ourselves to reflect on how we do as a field when confronted with a challenge of magnitude and I'm going to ask you to begin by considering Daniel Defoe now Daniel Defoe wrote about the plague of his great plague of his of his time when he was a child 1666 and he wrote about it as an adult reflecting on journals and records the the plague of 1666 it's a extraordinary bubonic plague the the book Journal of the Plague Year was written in 1722 and it's his reflections as if he is there at the time but there of course he wasn't there at the time he was a child at the time but it tells us some interesting things about plague it's a book I think you should make the time to read and here's the um orders he transcribes the orders that were conceived and published by the lord mayor and alderman of the city of london considering the plague of 1665 notice that the first thing they did was to appoint examiners in every parish it was thought requisite and so ordered that in every parish there'll be one two or more persons of the good sort and credit chosen and appointed to continue with that office for the space of two months at least and if any fit person so appointed to refuse to undertake the same the said parties so refusing to be committed to prison until they should conform themselves accordingly so everyone had to volunteer um to be uh an examiner if you were a person of wealth like as as the the protagonist of of Defoe's novel and the protagonist of Defoe's novel says that he actually just served for a month it was the month of august when the plague was at its height and then he paid someone to take on his responsibility but he didn't shirk the responsibility an important notice examiners were not the only people these are the senior people of the city examining what was going on there was a watchman appointed for every house where plague was found there were searchers who were women who would go into these houses and check on people's status the searchers were forbidden to do anything but work on the plague no other work no no elective surgeries um there's a sequestering of the sick there was airing of all the stuff after the plague had passed there um not to the so there couldn't be looting um no one could leave the infected house if someone was infected it was sealed and the watchman were put in front of it and the watchmen were responsible for providing food the city provided food now as you can see this is a lot better than 2020 and it's 1666 so that's just my first example my first case study and this didn't go well all the time it was tragical as Defoe said it was authorized by law to be sure it had the public good in view as the end chiefly aimed at and in all the private injuries that were done by putting the rules and execution must be put to the account of the public benefit so even though it ended tragically for many people who were trapped in these houses with sick people everyone understood that it was the law and even though Defoe says it's doubtful to this day whether on the whole it contributed to anything to stop the infection because it raged with what he says greater fury and rage than the infection did he still supported it in his in his novel he supports the use of these of these um the city paid for the the the the entire sort of structure of response was supportable and important even though he's not a hundred percent sure that it even helped the next person we're going to turn to is of course mary shelly beloved of bioethicist for her work on frankenstein but frankenstein the book that shelly wrote on on plague was a much more important book one i hope that you read sometime in the next few months before this our period of plague is over the last man is shelly's masterpiece really much more complicated much much more much darker than frankenstein actually and it's takes up the same things what's the meaning of civilization what's the meaning of social organization in the face of a disaster again a disastrous plague that emerges from Istanbul and sweeps across europe and eventually sweeps into england and eventually kills every single person that won who is the last man and here again shelly describes a society in which the nobles gave over their estates to be used as agricultural sites the labor necessary to bring to the land this sort of culture employed and fed the outcast of the diminished manufacturers so here in this in this example in this excerpt she describes how people when they're the economy collapsed and the factories closed everyone had to go to the land and they showed up at the land of the states and they turned them over to agricultural production and it was hard and yet to the honor of the english be it recorded that although natural disinclination made them delay a while yet enthusiastic generosity inspired the decrees again an extraordinary response social organization primary now of course shelly also comments about the enormous importance of the religion of the plague and shelly's bad guy in the story is a terrible leader a man who had in his early life lost through the indulgence of of the father all sense of rectitude of self-esteem and who when ambition was awakened and he gave himself up to his influence unbridled by any scruple sort of a familiar story for us as well an instructive book for us to take a look at after the everyone is killed everyone is dead killed by the plague or other other injuries other mistakes easy to make in a plague in a plague time the last man just gets on a boat and just is going to travel around looking for other survivors and read books in the libraries in every city that he comes to he is verny he is the last man a very bleak story but a story that's inspired by her commitment to the social organization that precedes the collapse of her civilization and this is of course a story of her life as well this is a picture by Robert Fournier it depicts Mary Shelley who shattered in the way in the back there and in front in the foreground is is Lord Byron lay hunted for Wani three poets and writers who were in the foreground they're looking at shelly's body which is burned on the beach he shelly drowned after he drowned in the Mediterranean after a visit that he had taken to Lord Byron and they just his body washed up this is replicated in the novel itself and she's going to return Shelley will Mary Shelley will return after this with her one remaining son after the death of five other children and several miscarriages and all the men pictured in the story will be dead of malaria or other actually infectious diseases and Shelley goes back and writes this tragic story of the last man based on her own sense of incredible isolation so a moment of humanity sir how do we consider these and what are these four what do we teach these narratives to give us I think some humility about our own situation because I think it's important for us to reflect on how our actions not as physicians which were noble to be sure as we just heard our actions as moral leaders how can you evaluate them against these accounts of other plagues in which moral leadership was offered and was nobly given and these are questions I think of agency and authority and polity my research of course just like everyone else's and had focused on basic biological science and emerging technologies especially genetic technology and like everybody else I turned my research code COVID-19 I was interested in how this disease particularly would affect the poor and the many ethical issues that have emerged during this pandemic and because I think some of them are the most the oldest and the most enduring questions of societies how to have justice under conditions of scarcity how to balance the power of the collective and the liberty of just the individual what are fair limits of research what are the product the product of research or part of the marketplace how does that work how should a society respond when the burden of disease falls disproportionately on vulnerable communities who should get access to valuable social goods when the choice is the choice between life and death and the nature of the duties of health care providers when their own lives are at risk we've seen all of this people have noticed the same the same ethical questions that I did these of course the cascade of questions about state and moral activity scarcity individual choices about mass you risk your life all of these many things we've already spoken about so I'm not going to spend time because we agree we agree that these are critical we've all taken them up and but there's one more thing I want to point out and this is I'm Siddhartha Mukherjee pointed out very early May 4th in New Yorker leave aside the windblown avenues of an empty joyless city the generation defining joblessness that has shifted so many from precarity to outright peril to what extent did the market drive efficiency obsessed culture of hospital administration contribute to the crisis and here Mukherjee points us to the very question that I'm thinking about what have we done to make this crisis work how have we collaborated to make this crisis work and what's interesting is that it was something I think frankly disturbing about as early as March though it's a March 11th as we all agree the key day just really a week and a half later we march right up to offer our ethical guidance and it's not on moral activity or why we should we why we we have to comply with public health it's to allocate scarce resources we were right there at the front saying here's how we should allocate scarce resources and we were also but four days later I won't say who wrote this but another bioethicist about how we can safely restart the economy in June this is in March and here's how and had a cheery set of ideas about how to do it that involved workers and customers who have developed immunity going right back because they would have this this immunity and they could go right back to restart the economy and in this in this um this opinion piece bioethicist argues that the economy is terribly important we have to have the economy it goes hand in hand with ethics as if the givenness of capitalism was the thing we had to protect as opposed to the health of the poor for instance and I did the same thing I made the same mistakes I taught bioethics at the time and I was teaching a class I said to turn my class to the real-time ethical challenges and I created a little ethics lab I wanted to do original research in the field by my with my students and since most of our research is done in in humanities very individually I threw the question open to my graduate students and my undergraduate students who are teaching really thinking introduction to biology bioethics course about how you could consider the ethical issues of the pandemic as it unfolded in real time and we focused on vaccines because we felt that the successful development of the vaccine historically is the most reliable way to protect populations although of course not the only way and as it was an unfinished project they could do some individual research and and we went ahead and we did that and I used a methodology of dividing the class up into into libertarians utilitarians catholic jews muslims and protestants um and I had them off scurry off and research their own textual traditions of each tradition the original texts and they interviewed university scholars and then I wanted them to create policy based on these what their particular moral location and make these appeals legible to a policy driven audience of non experts and they did that their university of chicago students and they did it and so we thought we had it nailed down we knew how did the jews think about things how did catholics think about things and once again we were wrong um we got it wrong in quite the same way that the emphasis had got it wrong about allocation here october herrated jewish man burning mass in brooklyn which really shocked me because if you know my work you'll know that I was astonished because I've been teaching for years about how jewish ethics works in other debates for quokneffes for instance have the overriding need to to save a life guides every one of our of our arguments about why we should go forward on a particular kind of research in a bit debates around abortions or stem cells or organ transplants or gene drives or cloning or ai we always say intervention will save lives the sources say it's not only permissible but it is obligatory religiously obligatory they also we've i've taught the dina de marruta dina the principle of dina de marruta dina means that for jews obedience to the civil law of the country in which they live is viewed as a religiously mandated obligation and disobedience is a transgression not only of the civil law but of the religious law i've also taught that we don't like appeals to naturalness we know natural law right we know unpaganism and i've taught that there's the jews do not think there's such a thing as unlimited liberty that jews are not autonomous that there's very weak appeal for autonomy in traditions and not even an unfit no one is an unfitted individual and they're surely not free of community constraints and i've taught that the world is broken and a need of repair and the jews have a mandate to heal and a supportive of health care interventions and yet there they were reminding me once again of the big difference between theory and practice so because you oppose the wearing of the ass or the closing of schools or economies would normally be straightforward and lock a case it just would be impermissible and it's really interesting even though very quickly jewish authorities in the lay and rabbinic communities began to to denounce these these outbursts and to rein people back in it still is an important phenomena that shows how we had gotten far from from some of the some of our communities and by the way wasn't only jews that that acted um with less nobility than one would want given our textual understandings missions began saying things like this all the time one of my favorite images because what is this actually it's Passover right so all right i wanted to ask this question so i've gone sideways into it by showing you how other communities in in previous historical eras acted in plagues how we didn't um why our research might have been off but here's my question to consider and i want to leave this open um for your discussion did the way that bioethics is the way that the bioethics is constructed as a discipline limit our ability to offer serious moral leadership and even in fact to get to the moral structures of 1665 where were we in in that debate did our focus on autonomy our autonomy create this this idea about what autonomy really was um i became the person in hide park yelling at people to wear their masks yelling at my colleagues physicians and um and faculty members to wear their mask and i was often told mind your own business as if the business of public health would be their own and i had my own right so this comes out of what did this come out of our our obsessive concern with autonomy did come out of our focus on right space allocation systems in which people's qualities would be added up in a calculus did our definition of strong feelings of loss as moral distress by by a brand new concept um did that keep us away from thinking politically you know that chart about the Kubler Ross acceptance i want to go back to anger and say what was done to the american polity was wrong and we should fight it not accept it where were we on that but did our ideas about being sad get transformed into into thinking about moral distress instead of thinking about an Aristotelian political response did our commitments to market-based libertarian systems of justice blind us to how these would play out it's when i teach i teach systems of justice and theories of justice it's really rare to see a system of justice fail so utterly as libertarianism failed in the face of covid but it failed in the face of covid market-based solutions failed in the face of covid people did not take personal responsibility and act well and act decently so frider karek turns out to be wrong in this case did our embrace of utilitarianism blind us to what needed to happen to the sensitivity of the or the of of what was happening in in marginalized communities what happened to in in our rush to a utilitarian um allocation which we did very happily and quickly and certainly though as was pointed out differently in different hospitals did that blind us to the need for a preferential option for the poor for example or to an attention to disability what about our idea of freedom did we allow this really tiny chintzy idea of freedom i am free not to wear a mask um um blind us to the the abundant freedom that a manual can't really puts forward when that we should teach that we should know and promote the idea of full human flourishing to see it reduced to the cheapness of i can't wear a mask i can carry a gun is tragic to me and does our trouble with naming practices as evil or even sinful which we have such trouble with like guns or vaccine refusal or Purdue pharma we have a hard time saying that's evil that's sinful we can't allow that that is impermissible in a way that for instance Mary Shelley or Daniel Defoe had no problem naming behaviors as sinful so that's my question and here's my further research is needed slide which one always asks should we turn instead to a rent how do we live in a tragic world she asked with decency and justice understanding the tragedy that's not moral distress but tragedy at the heart of our world a broken and unredeemed world actually that shouldn't we read much more of Kant and ask the question for what can i help and ask and learn more about human flourishing and teach more about human flourishing should we go with hong jones and ask what sort of world do we create with our research or how about Aristotle my monities ravacina the three what virtue should the work foster fidelity veracity and courage or of course my friend and eleven us who always shows up in these in these talks how does my duty to the other constitute my freedom and how is my duty prior to my freedom and finally at this moment this dark winter that we face we should go into it really with with i'm reynolds mebear who thinks always about tragic consistency and is useful in a situation such as this now i want to say that the theories were not fairly fully adequate if these theories were not fully adequate and if i think actually bioethics have some work to do about how we embrace these theories i must say the practice of the physicians was an in grand moral act in country after country and system after system in oppressive countries in democratic countries in countries like ours which is like lord knows practitioners offered an example of the heroic nature of the work that is health care itself and we should all learn from that daniel defoe reminds us i think it ought to be recorded to the honor of such men as well clergy as physicians apothecaries magistrates and officers of every kind and also all useful people who ventured their lives in discharge of their duty as most certainly all such as stayed did to the last degree and several of all kinds did not only venture but lose their lives on that sad occasion to the 922 people who died in the service they're thanked not only by daniel defoe but certainly by me as well so my bioethics has a work to do i think we should take some time and honor um honor those such men and women um who stayed and did not flee so thank you um peter two questions that have come up to ask you in how many countries is the who involved in this and secondly secondly can you describe some positive examples of national responses to covet 19 that that is can you name a couple of countries that have excelled in their particular responses to this pandemic sure thank you so much and i'll be brief i want to say i feel short change though because i've only known you for 50 percent of my life so that doesn't seem fair it just seems like yesterday but it was 33 years ago that we were in the anyway um so thank you very much for those two questions wjo uh is relevant to every country it has 194 member states and its modalities may be different but it's relevant to every country including the united states so for example in terms of its policy guidance um it's relevant in every country it has 150 country offices so it has direct support of governments uh physically in 150 countries but in the context of covet 19 it's had surge missions into countries that have had hot spots even in the absence of country offices so the takeaway message is wjo is relevant to every country um as by the way are the sustainable development goals and their uh their universal and to go back to our inequity theme covet 19s displayed the inequities not just among countries but also within countries and wjo it's relevant to every country on the second uh on the second question which has to do with some national uh good examples you know one of the parts of value of wjo is it's the actually the only place that the governments of the world can all come together and describe to each other their good practices so every thursday we have a member state session on online and often health ministers describe to each other their challenges their successes and so on and that peer-to-peer learning is extraordinarily important in terms of the uh uh epidemic of course it happens sub-nationally as well but wjo provides a platform for the kind of government to government country to country learning in terms of specific examples we published a series of videos actually and you can find it on my twitter thread i'll retweet it immediately after this thing as well so it's more easily accessible at peter a singer but just a couple of examples are rwanda and vietnam were parts of that parts of that twitter thread you know what's interesting about some of the examples is that it turns on its head the notion that poor countries are poor and rich countries are rich some uh so-called advanced economies or developed countries did not do so well for example if you look at it in terms of uh mortality rate per million of population cumulatively since the beginning of the epidemic some so-called developing countries did extremely well some of the factors may be related to the muscle memory of having dealt with SARS-1 helped i think in for example many of the east asian countries um but also you know for example a country with Ebola that has excellent contact tracing uh or that faces recurrent epidemics um and has well-developed contact tracing tends to do well because contact tracing is actually you know isolating the virus isolating cases tracing and quarantine in contacts that's at the heart of the public health foundations of the response so it's quite interesting how it's turned on its head the notion of which countries did well which countries did poorly and maybe mark i'll just end with this um but you know there's about a hundred fold difference in mortality rate per um million population among even the g20 countries it's really a hundred a hundred fold hundred fold difference in mortality rate per million of populate mortality rate so death's per million of population cumulative since the epidemic since the pandemic began and um that's a very large variation you remember we used to talk about jack wenberg and and area variations and it's the same kind of thing and then you look and see and some of the factors i talked about may contribute to that but if there's one factor and thomas boyke at the um council on foreign relations has done some very good work on this if there's one factor that seems determinative you know what doesn't predict it is ihr capacity because it's not what you have it's what you it's how you use it so for example there's a number of um measures under the international health regulations laboratory capacity etc that doesn't seem to be predictive health systems universal health coverage if that doesn't seem to be predictive what does seem to be predictive is trust that communities have in government which is so interesting in terms of the soft uh underbelly and the values underlying this was a paper i think in foreign affairs might have informed policy by thomas boyke recently and so there's a lot more to understand and unpack there in those case examples and in that variation and um i think at the heart of this is uh is a potentially leadership and which of course leads to trust between communities and and governments and its leadership at all levels from community activism right up to the head of state and head of government so um you know in summary WHO is active in every country not only has 150 country offices but it's useful and supports every country including the united states is a long history of collaboration between WHO and the United States that we could go into it's very proud and long may it continue and uh and in terms of the national examples i'll retweet that case series but it really offers some very counterintuitive findings that are really really interesting and again you see an ethical value trust at the center of uh at probably at the center of explaining what's going on here and it's so interesting that values ethics those kind of soft infrastructure um is the most explanatory variable in the variation among uh mortality rates and and the numbers speak for themselves thank you mark thank you peter that that was wonderful um and much appreciated uh 192 involved countries with offices in 150 uh that's amazing 194 member states yeah 194 and including involvement of the u.s which i was not aware of um yeah the u.s is one of 194 yes um i'm gonna i'm gonna turn now to a question that that i'm going to direct to erin and to savie and uh the kelly and it was only it was the last words that that rory zolot said which picked up on among the final sentences that erin de marquino said and tell me if i have this right that 922 u.s health care workers have died in the course of did i get that sort of right erin and lory i i can't hear erin that was from kaiser health news and it was that was as of august 10 so uh one might imagine that number has grown has grown i couldn't find no recent data now there are three questions that were raised lydia duck l is the first one but these are three of the same questions north dakota is asking nurses to work while they are positive so long as they don't have symptoms is this ever ethically justifiable um that that is but both the risk that it may cause to other health providers and the risk that it may cause uh to patients themselves so um who would like to start with that uh kelly can i just say something to clarify i think what north dakota said was that they would allow asymptomatic health care providers who tested positive to work they currently aren't doing that and there was a a very good interview yesterday in npr with one of the medical directors of one of the major um hospitals in north dakota who sort of laid out clearly that this would be sort of last case scenario where if you had no you know no one else would they have people who do this and then you'd have to figure out how they would then interact with their co-workers who weren't infected so well i i think i mean the ethical issues of it i think are are you know there's tons to be sort of deconstructed there but they they've given the sort of permission for it to be done they are not at that phase yet we may well see them if we believe you know emily's projection of what emily said about the projection of the surge not really hitting us or peaking till january may come to there but currently they are not having positive asymptomatic people working what's interesting to me is like no that's not ethical that should be easy for us to understand and that's when i talk about you're not acceptance and and it's moral leadership it's not acceptable um today super thousand nurses in fidelphia are out on strike or pennsylvania and on strike saying it's not ethical and we should be leading them by what this should be leading this argument and not trying to fix up the little pot that we're given in the inadequate but keep on fighting for a much bigger reason for what you know i mean that you know that the lack of political ban is tragic so that's i mean that's that's that's part of why i'm worried what is it about it that's holding us back at this moment when we know we know that's not ethical you know we should charge there you know i i even oh i'm sorry please i was just going to say that i think that this sort of reflects one of the challenges that we have in this country and what we were what we were seeing in chicago and this is this is kind of what i was trying to describe how can we start to allocate scarce resources at one hospital if we know that in at another hospital some five miles or fewer down the road there's the resources that we need and this is where i worry about us as a country and how we can utilize our resources as effectively as possible if there are many people health care workers across the country who could help take care of those patients we need a system that can help galvanize that effort and support sharing of resources rather than relegating some institutions to scarce resource allocation uh that's potentially unnecessary i think so that extent i mean one advantage is about the va system is that certainly when the cases were surging in new orleans at the end of the summer they're in the same vision so the same region we are and people and sort of hard durable goods from houston were redeployed to louisiana to new orleans to help with that i mean so the least good model about sharing resources but see we didn't end up happening because people who showed up so if 150 people showed up and showed up at a you know protest a tiny fraction of angry people showed up protest they got all the attention and people felt like oh no you have to you have to attend to their upset and we were quite polite and said okay we'll help you organize this and help you divide it up so i don't know how you enact that but i know it it i know that Aristotle thought that ethics were political and we have to think about politics and power if we're gonna and and take something that takes some leadership in the moral of it in this country and i'm not sure i think part of it was we were very busy with an election so maybe now that that's cited we should um we should take some responsibility for for for the kinds of for naming something as ethical or something not as unethical and being bolder about it okay thank you erin you you're close to north dakota uh minnesota um is there some exchange of patience and and of caregivers absolutely there actually always has been historically we've been a referral site for both north and south dakota um so that that remains and to the extent that good communication networks are available and that we can trade resources i think that's supported on the regional level the problem is that in our very own region we're um popping up ice views and locations that we never cared for critically ill patients before and aren't in it um and then ideal situation to be to be reallocating in the region uh regional resources to neighbors you have to i i i want to thank the five of you um and emily landon who is off to another meeting at the moment um i think what we're gonna do is take a 15 minute break before going into an additional panel four on covet 19 um that will parker who i think um erin no no no i'm sorry hey kelly you you've worked with will uh in the past have you not um yeah so will will be the moderator on that um so let's gather again in in 15 minutes and and my deep thanks to all of you for for beautiful talks and uh beautiful participation thank you