 I am delighted to welcome you to the third panel of the McLean Center Conference this year. This panel is entitled COVID-19 Ethics. It is a special honor to introduce this panel's moderator, Dr. Emily Landon. Emily Landon MD specializes in infectious diseases and leads the Academic Health Systems Infection Program and Prevention Efforts. As the medical specialist for the High Consequence Pathogen Preparedness Program, Dr. Landon has helped steer the University of Chicago and its affiliates through the COVID-19 pandemic. She also regularly advises businesses, industries, and government officials on how to best respond to this global crisis. In addition to her current pandemic work, Dr. Landon is a medical ethicist at the McLean Center for Clinical Medical Ethics and is an active researcher who focuses on the best ways to protect patients from healthcare-associated infections as well as the appropriate use of antibiotics and other antimicrobials. Dr. Landon is also a national expert on the automated mentoring of hand hygiene. It is a delight to introduce you to the moderator of panel number three, Dr. Emily Landon. Thank you so much, Mark. That is, as usual, just way too glowing of an introduction. So today, everyone, you know, welcome to the panel. I'm so happy to be here and to be sharing this with you. I can't believe we're still talking about COVID as we talked about this last year, but I think it's going to be many, many years that we're going to be able to discuss what happened during this pandemic. So I want to start today by talking about giving really my experience and some reflections on the pandemic so far. Of course, and today I'm not going to show you any meta-analysis of different strategies or the effects of anti-vax or sentiment and things like that. Instead, I really wanted to talk about what I think happened, why I think it happened, and where that leaves us as clinicians and ethicists. You know, I was trained to do the job of working with things like pandemics, and I'd helped in Ebola and in 2009 H1N1, and so it was my job to do this. And that means that when I first heard about a cluster of money cases in Wuhan, China, my first thought 22 months and three weeks ago was, crap, that's going to be my responsibility. Since then, a lot has happened, and a lot hasn't happened. And I think I'm going to start my story at the beginning. In the early days of March, while February really, 2020, maybe January, we did not do enough as a nation, as a hospital, as a city, as a state, as in anything. We were not prepared to contain a respiratory virus, and we squandered the advantages that we did have on being in denial. We should have built our supply chains. We should have set up data tracking. We should have harnessed the entire biomedical research community to develop testing. And once we had a case in the United States, we should have done a national shutdown until we could provide PPE and testing for everyone. We knew what we needed to do. But we were waiting for our national leaders like the CDC, the DHHS, to make the call to give us the permission to do these really crazy things that needed to happen. Nancy Messinae made a Cassandra-like prophecy on February 25th CDC press call. I'll never forget that moment. And like Cassandra, she was soon silenced. But more about Cassandra later, because I think she's a bit of a COVID icon. The national guidance that we wanted to have never came. It was not going to come. In fact, it left us in a situation where states needed to act on their own. And that's what we did. It became clear to myself and other leaders and other people with similar training and job descriptions that the CDC, DHHS, and FEMA were not going to bail us out of this. They weren't going to give us the guidance we needed. It might help us with a little bit here and a little bit there, but we needed to make our own decisions. We needed to make those decisions locally with the local data and the local resources. Instead of sharing guidance and knowledge from national organizations, we were on our own and we did it. But there are some real limitations to that. We don't have a national perspective. We can't look at the big picture and make trade-offs that are fair for everyone. We had also a very clear understanding that the poorest state borders were going to make the sacrifices that we were recommending for the people here less effective, but we really didn't have other options. We had questions about transmission dynamics. We had questions about testing availability, about optimal PPE, about equity. These were not answered with the wealth of data and resources available to the NIH and the CDC. Instead, small studies from around the world were scrutinized by doctors like me and researchers. We shared them on social media and on listservs. We had less formal descriptions of outbreaks and experiences in other hospitals that spread by word of mouth or professional society dialogues or hastily convened cohorts of really busy experts who were at the same time as they analyzed this data and figuring out what to do for a region, for a city, for a bunch of different people. We were rifling through that while also making decisions every single day about the safety of our healthcare workers, our patients, their families and the public. We didn't have time for real consensus. This was a serious disadvantage because like a contentious journal club, there was plenty to nitpick. Here's where the politics sneaked in. The plan to let states and municipalities make their own decisions led to, predictably, variability in different politics and different policies. This is not actually that bad because the lack of a reliable national supply chain and the differences in local epidemiology meant that nationwide plans were probably not the right thing to do and they wouldn't be implementable or even appropriate for every area. However, instead of having CDC, NIH, FDA, whatever, work with state and local decision makers, national scientists were basically muzzled, leaving a vacuum that contrarians just filled with all sorts of nitpicking of every single policy and plan and introducing questions in people's minds about why Florida and North Carolina do different things. Why things in Chicago are different than they are in Springfield. And this meant that politicians and political actors could use that time to theorize political or possible alternate motivations as to why one state did one thing, one municipality did another. In other words, there was no tiebreaker. Like when there are disagreements in the hospital or problems, there's no authority to step in and help people figure out what to do. In this case, I think it was actually a lot like not having an ethics console available. There was nobody to come in and help see which of the values were at stake. What are we going to maximize here? What sacrifices are we going to ask people to make? And why are they justified? And what value will be prioritized when? Instead, everybody just kind of stomped all over each other's descriptions of the four boxes and the research, and they just yelled about, you know, using different words, of course, but they yelled about justice or they yelled about autonomy or they yelled about paternalism or contextual factors. And like an ethics conference gone mad, everyone just shouted about their favorite value and never bothered to listen to anyone else. And I think that happened to us, too. So for a minute, let's circle back to my friend Cassandra. Cassandra is a tragic figure in Greek mythology. If you are not familiar with her, she was very much admired by the god Apollo and he bestowed upon her the gift of foresight, accurate foresight, in fact. But as things tended to go down in Greek mythology, the relationship between Cassandra and Apollo did not work out. And instead of, you know, separating amicably, Apollo was pretty pissed at Cassandra for whatever happened and decided the best thing to do was to curse her because it couldn't take away her gift. And that curse was that all of her prophecies, though true, would never be believed. This led Cassandra to live out a very short and miserable life in Greek plays and stories foreshadowing as a basically foreshadowing device that went largely unnoticed or occasionally was ridiculed by decision makers. Then when tragedy struck, as she explained that it would, many characters and choruses alike mourned and wept for what was lost and lamented if only I had known. In medicine, we are a lot like the ancient Greeks. We really want to have that foresight and we really only have hindsight. We have devised, however, some very creative ways to make hindsight substitute for foresight. In fact, by systematically observing illness, recording its outcomes, communicating with one another, testing responses to treatments, following people for progression, basically clinical research, we almost transform hindsight for some people into foresight for other people. Every day we engage in this game of calculating risk on behalf of our patients as we decide what to recommend in terms of treatments to offer, when we're going to tackle those treatments, what tests to order, who we should do this for and who we shouldn't. We know sometimes in a moment that something bad will happen if we don't act swiftly and we also understand that acting swiftly has drawbacks. But if someone has already taken the pains to calculate that risk and benefit for us in advance, we diligently memorize them. We know the appropriate remedy. We know it's pros and cons. It's indications and it's contraindications. Sometimes it's really obvious like an ST elevation MI or meningococcal meningitis. But sometimes that risk benefit act is a lot more insidious, like not recognizing that your hands might be contaminated with invisible microbes when you seemingly insignificantly decide to forego hand sanitizer before you examine the next patient, but it triggers a long and complex Rube Goldberg-like process that results in a serious infection down the line. Could you have foreseen that infection? Should you have foreseen that infection? My entire career has been dedicated to getting health care workers to do things that don't seem to be very urgent or critical in the moment, yet when they're missed, they can result in a great deal of harm, but only a minority of the time. I've been prophesying to you for years about the dangers of missed hand hygiene opportunities, and I was very much familiar with Cassandra's frustration long before COVID came. Yet I never ever felt as much empathy for her as I did during COVID. At least health care workers feeling to scrub hubs or wear gowns and gloves was not an open opposition to the premise of safety. It was more of a miscalculation of the risk and benefit in the midst of clearly worrying about other more pressing issues. This wretched pandemic, though, and our mismanagement in the beginning, has created anti-Maxers, anti-Vaxers, COVID hoaxers, and people who seem to be largely avoiding the risk calculation at all for themselves and for the people around them. It was a triumph of denial. Or maybe a triumph of short-term comfort over a long-term benefit. The truth is that most of the time, my attempts to eke out a smidgen of foresight from the experience and data available were heated with fervor. People were appreciative and wanted the help and wanted to follow the rules and do as much as they could to prevent people. They were a little confused sometimes about whether they needed to be at zero risk or some risk or how much risk can I tolerate on behalf of other people? These are decisions that are hard for people to make and make them a lot in my job as a hospital epidemiologist, but it's not very common for someone running a kindergarten or even an opera to make those decisions on behalf of other people. No matter how confident I was in my predictions, though, I never felt quite comfortable accepting thanks for imposing more caution and more restrictions with so little to go on. Bottom line, weighing health outcomes against social and economic ones was not a task that I was very well prepared for in any aspect of my training. But approaching two different ways of looking at the same situation is something with which I am pretty familiar and so are you. Many ethics consults come about when the treatment team weighs the risks and benefits of an action or an inaction differently than the patient or the patient's family. We come into the picture, work with both sides, help them to understand kind of like a mediator, what values are at stake, name them, try to get both groups on the same page, and to weigh them similarly. Often denial intrudes on that conversation as well, like a giant gorilla that blocks understanding. And we explain a little more, give more time, devise creative ways to mitigate it or work around it. We sometimes end up having to unilaterally decide that we just can't accommodate it anymore. And sometimes there are even bad actors involved, those that would impose their own will above that of the patient. We call them out, we attempt them to help them see the error of their ways and do our best to uphold all four of the boxes as we resolve the situation. And unless you think I am favoring one group of individuals over another, I'm aware that denial and bad actors are not always on the treatment team. So it was with COVID. And we really should have foreseen it. Are the healthy and optimistic people who oppose masking in schools because they calculate the risk as relatively low, any different from the doc who foregoes hand sanitizer because she isn't going to touch anything, or the nurse who skips scrubbing the hub just this once because she's really busy? Are pleas in favor of following the science are sometimes as hollow and oversimplified as our track record of sending acute MI patients home on beta blockers. But that patient is different, you say. And masks aren't that great for protecting me, they say. Both are right. In both cases, the only benefit is seen when everyone follows the science, even though the individual benefit isn't very obvious, and there are clear inconveniences incurred. The problem is that following the science of prevention is different than following the science of rescuing, treating or dealing with a major problem. It means giving up our own well-honed discretion and accepting that what is best for most is probably what's best for my patient and even for me. It means accepting that our individual judgment isn't best, even as we rely on that same judgment to rescue someone and make life or death decisions on behalf of a vulnerable patient in another scenario. This is a very precarious place to practice prevention, but it's the only place you can come from. We're balancing between that idea of individual experience and population research to inform our foresight, and we can never know in the end if the choice we made made a difference or not. This is why prevention is very unpopular. Humans are terrible at it. We can't really prevent heart disease, we can't prevent diabetes, we can't prevent cancer, just like Cassandra. We know what to do, and we recommend it to our patients, we recommend it to our families, we recommend it to ourselves, and yet we do not follow through. On a societal level, we know that clean air, clean water, food supplies are essential to maintaining both human health and economies, yet we put our short-term gain or comfort ahead of long-term benefit. As we heard this morning, we know that perpetuating inequities is wrong and bad for society. We don't even want to be racist, yet mild discomfort is sometimes seen as too high a price to pay for equity. Consider the COP26, the climate summit that's underway in Glasgow right now. Every one there, every country, has pledged to make significant actions to prevent climate change in the future, but in each iteration, each draft that's presented each day, countries are committing to less and less. Everyone knows and agrees that climate change will be devastating, yet we can't quite bring ourselves to make sacrifices now in order to forestall it later, because even though we may know with Cassandra's certainty how bad it will be, we're not sure how bad it's going to be for us. This is where our experience of COVID lies, not enough and also way too much. In hindsight, we look back and we say, not enough, there weren't enough testing supplies, there weren't enough early prevention measures, there wasn't enough data tracking, there wasn't enough guidelines, there wasn't enough good communication about the vaccine, there weren't consistent enough policies, there just wasn't enough. But every time a new policy came out, every time even we did start to see the CDC, the NIH start making recommendations telling people what was best for them to do, people felt it was overkill, it was too much. Why would I do that? Admit it. Some of you heard my early predictions of the pandemic, and while you were scared and worried and willing to do your part, the reality of keeping your kids at home from school for a year and a half was a bit much. The canceled vacations, the isolation, the constant masking, the effects on the economy, and yet we still had millions and millions of cases, hundreds of thousands of deaths, and we ask ourselves, was it really worth it? Did we do the right thing to have economic shutdowns or should we have just bit the bullet? Should we stop masking now or should we keep masking now? I think the answer is somewhere in both sides. I think we didn't do the right thing every time. I think we tried to do the right thing every time. I think people did, but I think we did both too much and not enough. I think we failed to understand how challenging it is for human beings to do things to prevent stuff. I think Cassandra knew about that. All right. That's all I wanted to say, and I thought I wasn't going to go over, but I guess I did. Look at that. I apologize. Anyway, I want to thank everybody. Thanks to Dr. Siegler and to everyone at the McLean Center for letting me talk today. This was wonderful, and I just love the opportunity to be able to give these kinds of talks here because I don't have to go through all the details of who needs a booster shot, but I will if you need to know. Moving on, I think we should get on to our next person, and I'm so excited to be introducing the rest of this panel because it's going to be really exciting. Next up, Dr. Lydia Duckdale is the Dorothy L. and Daniel H. Silverberg Associate Professor of Medicine at Columbia University, Vagalos College of Physicians and Surgeons, and Director of the Center for Clinical Medical Ethics. She also serves as an Associate Director of Clinical Ethics at New York Presbyterian Hospital and Columbia University Irving Medical Center in New York City. As a practicing internist, Duckdale's scholarship focuses on end-of-life issues, medical ethics, and the doctor-patient relationship. She's edited Dying in the 21st Century and is the author of The Lost Art of Dying Well, a popular press book on the preparation for death. The native midwesterner, Duckdale attended medical school at the University of Chicago, and she singularly credits Dr. Mark Siegler for inspiring her career in medical ethics. Thank you, Dr. Duckdale. Great. So wonderful to be with you all, and thank you, Mark, for everything. Thank you so much, Lydia. You have asked the age-old question. If the NBA could have a bubble, why can't a nursing home? And I think it's a great, great question. Okay. Moving on, I want to introduce our next speaker. These are such great talks today. More importantly, as you all are going about listening to these talks, if you've got us full screen, you're missing out. There's a whole question section, and you can put in questions. Otherwise, I'm just going to have to make stuff up to ask people. So be sure to ask your questions and then vote on the questions. If you don't feel like asking a question, you can thumbs up or thumbs down questions. We really could use more questions, and I know you have questions. Otherwise, maybe I'll just go through what, who needs a booster and who doesn't. Anyway, in the meantime, next up, Dr. Harold Pollock is the Helen Ross Professor at the Crown Family School of Social Work Policy and Practice. He's also an affiliate professor in the Biological Sciences Collegiate Division in the Department of Public Health Sciences, co-founder of the University of Chicago Crime Lab and co-director of the University of Chicago Health Lab. Professor Pollock is also a committee member of the Center for Health Administration Studies at the University of Chicago. His current NIH-funded research concerns improved services for individuals with the boundaries of behavioral health and the criminal justice systems, disabilities, and the two major new efforts to address the opioid epidemic in Illinois and across the nation. He served as past president of the Health Politics and Policy Act section of the American Political Science Association and was appointed to three committees on the National Academy of Sciences. Professor Pollock received his undergraduate degree in Magna Cum Laude in electrical engineering and computer science from Princeton University. He holds master's and doctorate degrees in public policy from the Kennedy School of Government, Harvard University. Before joining Crown Family School, Professor Pollock was a Robert Wood Johnson Foundation scholar in health policy research at Yale and taught health management and policy at the University of Michigan School of Public Health. Welcome, Dr. Pollock. Thanks so much for that introduction. I appreciate that you let my mom rate it and include so many wonderful details in my background. I want to talk today about some personal reflections about the case for affirmative action for conservative students in public health and social work that reflect some of my experiences. I should say it's a real honor to be on this panel today and I was so moved by the presentations that we just watched. I think that what I have to say links today with our COVID response because some of the gaps in our COVID response, both in our credibility and in our cultural competence, may reflect some of the issues and the lack of representation in our own communities. I should say that I have no disclosures today. But I do feel that in the absence of an effective national response, particularly when national political leaders who were happened to be conservative, when that response wasn't there, the gap between our community and the conservative political communities and some of the communities that we need to serve proved quite damaging. I should say I'm not someone that you would expect to make this argument. You sometimes hear people who are conservative talk about cancel culture or talk about complaints about academia. I'm a liberal democratic activist. Here's just some random things that I've done. There are some links to YouTube videos that I made in political campaigns in 2012 and 2018 and 2020. There's a tweet that I made just yesterday criticizing President Reagan noting his opposition to civil rights legislation and his poor response to the HIV epidemic, some of the op-eds that I've written on health reform that certainly are from a very liberal perspective. On the other hand, maybe that makes me actually a good person to make this argument because it's not coming from the place of personal pleading. One of the real challenges in COVID, and I'll show you some statistics in a minute, although I'm sure those will be familiar to many of us, politically, culturally, religiously, conservative communities are ones that have been especially hit hard by COVID. Those are communities that we are really trying hard to reach in an effective way. Just to give you a sense of the statistics, if we look at the state level, the statistics don't look great, but if we get below the state level, we see really huge disparities across political communities. What you see in the upper left there are just big differences in vaccination status by party ID where you see real huge differences between self-identified Democrats and self-identified Republicans. When we look at the county level, when we compare counties that are heavily voting for Biden with those that are heavily voting for Trump, we see tremendous differences in COVID case rates and also COVID death rates. The stakes are really high and it's just really important to have connection, credibility, and cultural competence to serve these communities in the same way that we need those qualities to serve every other community that we seek to serve in public health. That is not something that we are preparing our students well for in our classrooms. It is really, there's a palpable and I would argue growing imbalance in our rooms, and I'll just mention a couple of anecdotes, but I think for all of us, if we are self-aware, we could provide our own anecdotes that would be similar. A colleague was praising a student recently and noted that the student was so convincing in espousing a conservative perspective in classroom discussion when the student himself obviously didn't home that view. A second colleague noted in lecture with a properly distanced intonation, what would you say to a conservative who might respond? Of course, the implicit presumption of both of those conversations was clear and it was probably correct, which was that no one in the room actually was holding those conservative views and we really weren't in a position in that room to really know whether conservative views were actually being accurately captured by what the speaker said a conservative might say. This puts us in a position where we might be committing avoidable errors in cultural competence in our public health and social service messaging, and I think that was most pronounced if you looked at the contrast in the public health community's response to the anti lockdown protests and to the Black Lives Matter protests last summer, where it was clear that many conservatives were extremely offended at that contrast. Now, we can of course litigate whether their perceptions were accurate or fair, but we know from our work in community-based public health work that when you're litigating community perceptions, that that's the wrong place to be. When you're an outsider litigating and explaining to people why their perceptions are wrong about you, you've got a real problem. If we look at some of the statistics, I think that we can see the problem. The overall academic world has always leaned liberal and we can obviously give many sociological reasons for that, but even in this context, the political imbalance in the helping professions is really striking. There was a 2018 survey of public health scholars in the Society for Epidemiological Research and 72% reported their politics as liberal or left-leaning and less than 5% conservative or right-leaning. I'm someone in that 72.4%, but that less than 5% is concerning in the context of what I'm talking about. There was a 2014 analysis of a social work program. I couldn't find too much data on that, but 9.4% of students identified as Republicans and 56% identified as Democrats. I think if you looked at the top social work programs in the country, we would find even greater imbalance. I'll tell you one aspect of that which people often joke about, which is the social policy want gap. It's sort of a joke, but it's actually a real thing and it's not funny. I was actually at a 2017 policy dinner with Democratic and Republican representatives who were talking about the Republican effort to repeal Obamacare. One of the really striking things was that the Democratic members were all really connected to the academic community and health policy in a way that the Republican members were not. People were quite aware of that on both sides of the aisle. One consequence of that was that the Republican repeal effort basically self-immolated due to poor craftsmanship. Part of their bill would have raised the health insurance premium for a 64-year-old woman earning $26,000 a year from $1,700 a year to about $14,000 a year. The inability of the policy community to provide better guidance to Republican politicians and for Republican politicians to be organically connected was a real policy problem there. I think the estrangement between the academy and American conservatism really widens the gap and it hurts both sides because I think this also enables a probable sense of absolutism and groupthink among progressives. I would say many of our students don't have and maybe have never had the experience of being openly challenged by a conservative peer in their own classroom in the sense that there's people in this room who hold views that are very different from mine and these domains. Ironically, legal academia seems to be more balanced in part because of the reality that conservatives play such a key role within the judicial branch. If being a Supreme Court clerk is something that is a very important credential to getting a job teaching in the leading law school in the United States, we're going to have a lot of conservative law professors just because of the way the American judiciary is shaped. What are some consequences for our students? I think our students have a lot of trouble distinguishing some basic arguments. Here's some arguments that you'll often hear. If you're on Twitter, you see this all the time. I won't regurgitate these arguments, but what many of us including myself would say, hey, these are very unworthy arguments that are coming from the conservative side of the political aisle and our students are rightly reject those. I think a lot of our students have trouble distinguishing what's on the left there from what's on the right, which are very serious arguments that we need to take seriously. For example, the political influence of public employee unions can sometimes produce poor policy. If you think about some of the reactions to COVID in public employee unions, it's hard to do evidence-based policies sometimes. Critiques of rent control as creating a problem in hindering the supply of affordable housing or randomized trials that show that no excuse charter schools often do quite well when compared to traditional public schools. We can go on an argument that the Americans with Disabilities Act may have unintended consequences or may worsen in certain situations, hiring discrimination. The point is not that any of these arguments are right or that they're decisive, but they're serious arguments that our students have to contend with. We have to contend with. I would also say that some of the arguments that I've heard in the popular press where conservatives worry about job discrimination, I think are actually understandable as well. It's not that Milton Friedman or Richard Ebsen are not going to be able to get a job. The superstars will, but at the margin when you are an outsider to a community, you have less margin for error. Let me give you a couple examples that I think in a social work context could well be telling. Imagine that you have Martin and Michael. Martin gives a talk where he finds that cultural norms among recent immigrants promote upward mobility and that the role of structural barriers that might block that mobility is overstated in his data. This challenges the sociological consensus in his field. Michael does an analysis of absolutely equal quality, finds the opposite result. The structural factors are actually more important. Lynn and Laurie are studying mandatory minimum sentences for illegal gun possession, and Lynn finds that the mandatory minimum is reduced crime and that they're valuable. Laurie finds that mandatory minimums really don't reduce crime and that those policies actually exemplify the ways that we pursue mass incarceration strategies that fail to address the social community and economic determinants of crime. I fear that Michael and Laurie would at the margin have an easier job talk at many places because they come bearing more politically congenial findings and that Martin and Lynn would have a narrower margin for error. If there's the methodological judgment call or a presentation stumble or some sort of an error in their analysis that moves it from into the A minus B plus territory that they have less margin for error and that if they were discussing a truly sensitive issue they would have even less margin for error and that as a community we should be self-aware about that possibility and certainly the idea that conservative scholars would worry about that. Every human group is vulnerable to its own blind spots group things and pressure for conformity and I think this has gotten worse and this is my personal reflection during the Trump era because what we've seen as a kind of palpable moral and intellectual decline of American conservatism is a political movement and that really has reinforced the absolute absolutism that we sometimes see on campuses including our own and because we are a collection of imperfect human beings with our own blind spots and biases we need organic voices in the room to call us on our errors and to maintain our credibility and cultural competence throughout the society which is at the moment quite divided. And so this leads me to this very pack of paradoxical idea that we should be pursuing affirmative action for conservative students and faculty at least that we should be thinking about that. I realize this is a highly ironic argument to make because conservatives are the greatest foes of affirmative action in many ways but that targeted outreach and specific attention and hiring improvement is something we should think about. Interesting enough I've published an article in Politico that argued for this and I got a lot of emails from law school faculties who said you know we actually do this at our law school and these were both from liberal and conservative faculty and I thought you know what if they do that's good. John Stuart Mill reminds us that's not myself by the way that's John Stuart Mill a caricature from Punch Magazine. John Stuart Mill reminds us those who know only their own side of the argument know little of that and I think that as we think about our own failures in COVID not only are not only our failures but failures that that include us you know this is something that we need to think about and take seriously. So with that I will say thank you and and I look forward to the questions and conversation. Thank you Dr. Pollock. I think your conversation about how important it is for us to be able to have conversations across the aisle so to speak or at least begin to under that we need to have those conversations or to be able to begin to understand other individuals and other points of view is part of this whole thing that I think everybody's talking about here about this tension between what is best and what is good and what is bad and how to live with that ambivalence of things being both good and bad at the same time. Next up I talk about scarcity Professor Laurie Zola holds the Margaret E. Burton Chair of Religion and Ethics and serves as the senior advisor to the Provost in Social Ethics at the University of Chicago where she also served as Dean of the Divinity School. She has a distinguished career as a bioethicist and a scholar of Jewish ethics writing or editing eight books and over 300 articles. She was elected both president of the American Academy of Religion and president of the American Society for Bioethics and Humanities receiving its Distinguished Service Award in 2007. She was the founder and vice president of the Society for Jewish Ethics. She was the founding chair of the HHMI Bioethics Board and has served on the national boards of the International Society for Stem Cell Research, the Society for Neuroethics, Sinberk, the Society for Scriptural Reasoning and the Engineering Biology Research Consortium and Bioethics Boards for the American Heart Association and the American Society of Reproductive Medicine. For most recent books, second texts and second opinions, essays toward a Jewish bioethics is forthcoming in 2021 from Oxford University Press. Thank you Dr. Zola, you're up next. Thank you very much. I love this panel. Thank you Emily and thank you Harold for reminding me once more how much I love teaching at the University of Chicago where you can hear the most interesting sets of views. I have nothing to declare. I am a moral philosopher and so I am no one pays me money to give my opinions, I do that for free. All right, so I'm going to talk about, make yourself scarce, I'm going to talk very much along the same lines that we just heard Harold speak and I'm going to give a Marxist analysis about why, why it's the case, why it's not just in the realm of ideas, but why it's actually our relationship to production. So indulge me here. COVID of course uncovered a cascade of ethical issues, but many of these issues were really justice issues and they were really, they were issues about how we, how we deal with scarcity, how we deal with, with, with allocation, how we live our lives as in a just society. And you saw over and over again, major contention between libertarian principles of justice, there's a justice, egalitarian principles of justice that we yearn for. And every now and then, a, a, a slight gesture towards a preferential option for the poor or liberation theology, theory of justice. And these three or four theories contended throughout, throughout the epidemic. And COVID though revealed even deeper structural problems. Healthcare disparities, of course, in class and race, a legacy of research and healthcare delivery discrimination that we are, we've also, we've mentioned Henrietta Lacks once already or twice already, Tuskegee of course comes up over and over again, a faltering hospital system, faltering local hospitals here in the south side, case in point, Michael Reese closed, and then Mercy Hospital staggering on the Chicago south side, underfunding across the board for all public health systems, a lack of pandemic readiness at the CDC despite, by the way, dozens of reports, including one that I was on a committee that became to them in December 2019 that warned exactly of this happening. And the segment of the population already in despair. I'm going to talk about that here. So it's a crisis in America's ICU capacity that drew the attention of bioethics. And Paul World Parker is going to reorganize the deck chairs on the Titanic. I'm going to make the claim. And while I love to scheme and trust him implicitly, I'm going to try to explain why that's a mistake. In the ICUs, it was a quote, never-ending nightmare. The hospitals where the ICU filled up rapidly, not a single ICU bed free in some places, a COVID surge continuing over and over again, every time in state after state after state. COVID overload US hospitals are running out of beds for patients, people in hallways, people in utility rooms. And these are all states as it happened in every state. There was no one state that managed to escape this. And in fact, the first time in recent history, justice was at the forefront. Justice was at stake because most Americans are just not used to scarcity and health care delivery. And in fact, the specter of death panels was a critical issue in the rejection of a single payer system in the attack on the Affordable Care Act of 2009. And just to refresh your memory, here we have a few quotes from Sarah Palin 2009. The Democrats promised that a government health care system will reduce the cost of health care. But the economist Thomas Sowell has pointed out government health care will not reduce the cost. It will simply refuse to pay the cost. And who will suffer the most when they ration care the sick, the elderly and the disabled, of course, the American America I know and love is not one in which my parents or my baby with Down syndrome will have to stand in front of Obama's death panels so that his bureaucrats can decide based on the subjective judgment of their quote level of productivity in society, whether they're worthy of health care. And of course, this became the system is downright evil. This was a moral choice and we thought we could never do such a thing. And of course, this idea that the elderly and the sick and the disabled would be discriminated against was something that we reassured everyone was not the case. So for most Americans, and I understand here there's not the case for if you were uninsured and for many minority populations, but for most Americans, the health care insurance covered most most most situations, most interventions with medical care. Drugs were in plentiful supply, never ran out of drugs really. ICU beds were always available if you needed one. And new emergency surgeries were really never post phone surgeries won't respond, you could schedule non-emergency surgery at basically at your will. And this all changed. And of course, bioethicists immediately responded, we were ready. We had our schemes, we had worked it out. We had complex triage systems. They were already drawn up within a month of the COVID outbreaks. By April, we already had our schemes. There was news coverage of worried bioethicists making these triage plans, charts and rankings, systems based on qualities became on the front page of the New York Times, quality was explained and tried not to call them death panels, but then there you were. And in fact, by May 2021, 2020, in fact, May, which is really early on in the course of the pandemic in America, there was a major article in the New England Journal, fair allocation of scarce medical resources in the time of COVID-19 by Zeke Emanuel and his colleagues who put together the sort of master rationing plan. And we were aware that we only had at that point 62,000 ventilators, which was the immediate problem. And even a conservative estimate shows that the health care needs created by the coronavirus pandemic go well beyond the capacity of U.S. hospitals. Of course, as I said before, we already knew that. According to the American Hospital Association, there were 5,000 community hospitals and 209 federal hospitals in the United States. The community hospitals, there were this scarcity and all of it was laid out for you, how very scarce we were and what a dreadful problem we were actually facing. And in fact, the utilitarian surged to the front and made a series of recommendations. In the context of a pandemic, the value of maximizing benefits is the most important. This value reflects the importance of responsible stewardship of resources. It is difficult to justify asking health care workers and the public to take risks and make sacrifices if the promise that their efforts will save and lengthen lives is a losery. So this set up, in fact, a pure utilitarian scheme that if you're going to work that hard and risk your life, it better be as it were worth it. The value had to be maximized in units of years, units of health years. And in fact, it set forward priority, which was younger over older in general, healthier over sicker, younger over older, absolutely. And in fact, other priorities were health care workers, doctors and nurses over other people or new people who had other jobs and research subjects, which is an interesting aspect of this, like the people with those whose bodies you actually needed as a health care worker to do work. Each hospital, however, set up its own triage plan. And in research that was done in the Chicago Biowethics Coalition, a large coalition of people like yourselves who work across the Chicago Latin area, it was clear that these triage plans varied widely. In hospitals less than a mile apart, different patients would have been given different priorities entirely, different access to scarce resources based on this constantly shifting and reevaluating set of conditions that were not standardized. And it was unclear in the case of scarce drug supplies, if the allocation scheme should include just the people in your catchment area or should include people across the Chicago Latin area. And drug supplies actually set up a more interesting way of thinking about this than the absolute supplies that I see used. A year later, shortages are not getting better, they're worsening. As new waves as the Delta wave came, the exact same headlines filled the front pages of the New York Times and the Washington Post. In 2019, the resilient drug supply project, which set up a panel of experts from governments and academics across the board set a list of 156 drugs that were considered critical. This is the current list, and this I just did the first, the A's in the current list, and look at how many of them are currently in shortage, currently in shortage over and over again. And these were of the essential drugs, the 166 essential drugs. And the critical acute drugs list, 39% of the acute drugs are in shortage, 21% are shortage by the FDA, and zero of these shortages have been resolved in September of 2021, this was updated in October. So by October, all of these shortages still in place for really dozens and dozens of critically acute drugs. And FDA called it the urgent public health crisis, not as well known as ICU crisis. The academic pharmacist list 194 drugs in shortage now. They were leading drugs for cardiovascular care, cancer treatments, antibiotics, also short on very common items like potassium chloride, certain types of saline units, et cetera, for both pediatric and adult doses. But the ethical question is not only these immediate ones, as the scarcity continues and the supply change problem deepened the crisis over drugs, and then test kits and then instruments, as healthcare workers despair or quit, we have to look at this indemnicity of allocation, and whether it's acceptable to keep on going on with this level of unacceptable, unacceptable loss, leaving aside, said, Sir Arthur Merker G in an article in New Yorker in May of 2020, leaving 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 driven, efficiently obsessed culture of hospital administration contribute to the crisis. And that's the question I'm going to say it did, right? Because the scarcest resource of all is people. According to data published today by the WMC, the United States could see an estimated shortage of between 37,800,000 and 124,000 physicians by 2034, including shortfalls in both primary and specialty care. And in fact, physician gap has long been the case. We've known there's been uneven distribution, regions that do not have doctors at all, incomplete coverage, the uninsured now rising to 13 to 14 percent of the population, a significant people simply can't afford access to primary care and do not have doctors. Despite the fact that the surgeon general says, if you have vaccine questions, go ask your doctor. People don't have doctors in large areas of the country. In inconvenient hours, in many markets, primary care still isn't available on evenings or nights or weekends when people were able to access it. There was inflexible care models. Markets rely on PCPs to deliver primary care in an office. That all fell apart as well. There's a payer version for some practices or insufficient use of physician labor. And in fact, all of these things existed long before COVID. And it's just not enough that there's not physicians, but not enough nurses as well, right? There is a reports project that 1.2 million new registered nurses will be needed by 2030 to address the current shortage. And nurses have been in crisis for a very long time. When hospitals are under staff, people die are one expert warned as the U.S. health systems have reached a breaking point in phase of the Delta variant. It's not just nurses and it's not just doctors, but it's the system of public health. The hollowed-out public health system faces more cuts amid the virus. Even during the virus, state budgets were cut. U.S. public health system has been starved for decades. It lacks the resources necessary to confront the worst health crisis in a century. And yet, Republican legislators still cut their state budgets even more. The CDC itself had a 30% cut. Even before the pandemic struck, the local public health agencies had lost almost a quarter of their overall workforce since 2080, 2028, a reduction of almost 60,000 workers according to national associations and health officials. The main source of federal funding, the CDC, merged preparedness budget, had been cut by 30% since 2003. And the Trump administration has proposed slicing even deeper. In fact, they canceled our committee that had done a report about pandemic readiness. In fact, instead of the 6% of the GDP, David Hummerstein says, we need only 3%, half of what is needed for an adequate public health budget. So why is such a scarcity of skilled workers? Well, first of all, there's been terrible cutbacks in nursing schools. There was a complete end, really, to hospital-based training programs, which offered a direct path to the middle class for many Black and Latino women, by the way. Hospital programs, the three-year programs were cut. There's a fierce competition for medical school places that leaves thousands of people out every year. Every year, I write dozens and dozens of recommendations from wildly qualified University of Chicago students. A fraction of them get in, and the rest of them just don't get to become doctors, right? And what a waste, what a waste of time and talent. This specialization and the MBA tracks drive people even further away from being primary care doctors. Every single funding incentive works to limit the number of trained physicians. And that means there's an artificial scarcity at the root of the problem of this scarcity. You have made yourself scarce. There's, of course, a deep structural injustice. In addition to all of this, in the U.S. medical school, particularly with U.S. census data, found that more than three quarters of medical students come from families in the top two quintiles of family income. This AIIB replicates the previous research and methodology to provide updated parental income data from 2007 through 2017. And structural injustice is really important. That means half the students come from the richest 20 percent of the population, half the students in medicine. The percentage of students from the lowest quintile has never, ever risen above 5.5 percent. Moreover, the percentage of entering medical students from families in the highest quintile, highest, the 1 percent people, have increased from 50.8 percent to 55.2 percent between 2000 and 2005. So the situation is getting worse. There's been also a general decline in the public spaces that relied on public spending. So everything was more crowded and more contagious. Public hospitals, clinics, mental health, long-term care, congregate settings, all of them cut back, crowded and difficult places to live. But also public transport surely buses and trains, airlines, courts, government offices, all the places that the poor need to be served. And that's the ethical issue. So they're a long duration. They're not easily solved. They're going to require massive public funding and a clarification of three things, agency, expertise and authority, which have become completely modeled. The logic of medicine was completely taken over with the logic of the market with neoliberal schemes about how to run a business. In the late 1900s, a shift in the idea of a public hospital as a source of community well-being, a place for equity and mercy, to a place that was a business that needed, if not to make a profit, at least to be able to provide competitive salaries for physicians and healthcare administrators. There was a shift to these new management ideas that have been promoted in industrial production — and by the way, don't work very well either — this just-in-time supply rationale, which is why PPE was not there because it was only there for just in time, and rewards for people who were able to cut budgets. A corresponding shift in logic from production to consumption happened across the board of the United States. The consumer citizen, says Porter, is firstly a person who devotes much of their time to things besides citizenship. More specifically, the consumer citizen is a person who spends a lot of his life shopping and making consumer decisions. Most people don't spend much time thinking about, say, monetary policy, but they make many choices every day about what to buy or not buy. As a result of this, people develop the habits and techniques as consumers, and these habits and techniques shape the decisions that they make. They're not developing habits of citizenship. And as healthcare becomes a commodity, just another thing to buy, then it becomes a problem, right, a supply chain problem. And a scarcity in the case of a shared social good under conditions of social difficulty could theoretically be an event for a shared morality and could create unity. But a scarcity in the marketplace, unlike for citizens, just creates wild competition, as toilet papers, paper tour rules did. Healthcare then becomes another product, and patients become consumers that need to be pleased or tempted, right? And that is what I call the American Idol effect, right? And in a meta event like this, you actually get to vote for which of the many American Idol type shows you like. The American Idol effect is that everyone's opinion counts, and it's just a matter of choosing your preference. And while voting deteriorated in the last four years, this American Idol effect actually increased, communal choice. The widespread then collapse of the supply chain collapses the idea of consumption. And across the country, Americans' expectations of speedy service and needy access to consumer products has been crushed like a styrofoam container in a trash compactor. There was time for some new, more realistic expectations. We were told to lower expectations and for healthcare too. Justice needs a democratic polity with people used to being citizens. A system of justice needs to be represented in democratic in nature, or the entire tree out systems that people were setting up just become one more place of social exclusion. So let me explain. There was an epistemic crisis in what the facts were. After a decade in which expertise became degraded in favor of American Idol popularity. People said things like, I need to do more research. I have done research. So it wasn't the idea of fact finding that was the problem. It was experts that were the problem. Most people, of course, don't have the skills to do their own research, but they didn't trust anyone else to do it for them. And this was because in large part because they had legitimately been forgotten. This is because of something called the deaths of despair. Morality from the deaths of despair far surpasses anything seen in America since the dawn of the 20th century. The recent increase is primarily driven by an unprecedented epidemic of drug overdoses. But even excluding drug overdoses from opioids, the combined mortality rate from suicides, alcohol-related deaths, is higher than at any point in more than 100 years. This is pre-COVID, right? Pre-COVID. There is a large population who is suffering from what we call these deaths of despair. This is put forward in a wonderful book about deaths of despair and the future of capitalism by Angus Deaton and Anton. And case to Harvard economists whose books are quite important about this. This is the deaths from the drug overdoses. These are the deaths of the deaths of despair that they've identified in adding into single-car vehicle accidents and suicides. And this is, of course, the map of vaccination. And notice this, this, of course, final map is the percent of the county's residents living below the poverty line. So what happened here was there was a conspiracy. It is not crazy to think that these people were ignored, right? And in fact, Congress investigated McKinsey over the role in the opioid crisis. Opioid manufacturers put new farmer pleas guilty to fraud and to kick back conspiracies in the titles. These are the people that were, in fact, lied to by the very people that were asking them to trust at this moment for vaccines and to trust for the triage systems. And in fact, just this week, the Oklahoma Supreme Court threw out 465 million opioid ruling against J&J, right? So the courts, your conservative powers, Harold's conservative courts, actually, throughout this ruling. But people knew that their situation, they had been abandoned. And they had been abandoned by their physicians and by their pharmacists and by the drug companies. So it's not a surprise to me at all that the same people who are visually killing themselves in greater numbers than the last 100 years don't especially respond to the idea that they should practice good health care behaviors from being told or from the drug companies who they don't trust because, in fact, they did lie to them, right? Our situation is quite uncertain. We're in a poetic situation. We're in a time of great uncertainty because we do not know the next turn of events politically. We do not know the next turn of events scientifically. We don't know that the virus were mutated in what direction. And this is a time, in fact, we have a plight, right? Ethicists believe that we're condemned to act, meaning that we have to make a moral choice even when we feel sad or upset or morally distressed or whatever we feel, because moral choices made by moral agents in every choice we make, every action we take, we are plighted to do this. And it is this action that defines our characters as persons and as nations. One cannot not act, right? This is what moral philosophy does call our plight. And the structure of health care, though, has deepened the problem instead of addressing it. And so we can make triage schemes, but if no one trusts you, then it's a really, it's a big problem. There's a through line that runs through the pandemic and the through line is justice. It is the economic disparity of modernity and the use of the market to try to do health care. And that's why it feels like health care, the health care system is the Titanic and the virus is the iceberg. And why the efforts by bio, whether it is to allocate dectures, seem so futile. The deep lack of trust between people and their doctors, the only scientists that most of them will ever know extends this catastrophe, which leads us, of course, to classic ethical debates that we saw happen over and over again. And I won't have time to go through all of those, but it's impossible to make judgments with epistemic chaos that we're facing, whether we don't agree on the facts. So what do you do in an aporetic situation, how to proceed? And I'm going to say first, physicians need to act as experts. Physicians and scientists need to act as experts. And by the way, philosophers do. We do what we do. We're experts. But we have to defend the scientific method. We have to take responsibility for being experts and to own that capacity, but then understand it's not universalizable. It used to be that expertise and authority went together. And for the last 50 years, that was the case no longer. Secondly, we have to act as citizens. We have to enter into what a rent calls the space of appearance and make the claim there, not only in our small areas, but also going out to people who don't trust us now and figure out how to make a claim in the space of appearance. We have to be really willing to stand up to irrational or uninformed arguments or bad arguments and explain why they are bad and really never give up. That's critical to act as a citizen. And finally, if you want to act as an authority, it can't be just because you're an expert. Authority is not derived from expertise. Authority is derived from winning an argument, from representing someone. In locations of responsibility, a duty emerges for leadership as an authority that's different from your doctor expertise. In your realm, for instance, as medical educators, expanding the number of places in medical school, changing how medical education happens so that many, many more people can become doctors, even if it comes to personal sacrifices and doctors don't make very much money anymore, that should be where you focus your energy, in my opinion. And finally, democracy needs truth. This is Joseph Priestly. Joseph Priestly, who, of course, figured out how to get oxygen and what oxygen was as an element, but in fact was run out of town and fled to the United States because he loved democracy. And because his way of being a scientist meant at some level abandoning his science in favor of his capacity to act as a citizen and as a moral authority. So I'm going to end with this and say, Joseph Priestly, think of him when we negotiate this throughline of justice throughout the epidemic. And I want to thank the University of Chicago colleagues and the organizers at this very complicated meeting at the McLean Center, done beautifully and virtually. So thank you. Thank you so much, Dr. Zoloft. I'm going to save my comments for later because we're running a little bit behind. I'm going to introduce our next speaker, who is Dr. Will Parker, a medical ethicist and health services research researcher who studies the allocation of scarce medical resources. He is specifically interested in absolute scarcity problems where demand greatly exceeds supply and healthcare systems cannot avoid triaging life-saving therapies. He applies advanced empirical methods to evaluate and design allocation systems according to the underlying ethical principles. His current projects focus on deceased organ donor allocation, critical care ventilator triage under crisis standards of care and COVID-19 vaccine allocation. A reminder to everyone, this presentation is your last chance to put questions into the chat and to vote up the others. Dr. Parker, I'm looking forward to hearing about your topic. All right. Here are my slides, please. Thanks for that introduction, Emily, and I'm glad that Lori went right before me and sets up this talk well. My disclosure is just the NIH support to work on hard allocation. So I think Lori outlined the broader problem of scarcity and healthcare very well, right? We have tons of market failures because it is a market-based system where people don't get the resources they don't need. There's not enough doctors because there's artificial supply constraints on the number of physicians that are in the United States. We're not making drugs that patients need because there's not enough profit in it, right? These are all ethical issues, but they're kind of health policy failures that are kind of uncontroversial ethically. I'm interested in a narrower set of scarcity problems where we're restricting ourselves to therapies that are unambiguously life-saving or dramatically improving health. There is demand for these therapies that vastly exceeds some hard supply limit, and that usually the resources are centrally controlled and delivered via an algorithm and a market is not appropriate. And what are some examples of absolutely scarce healthcare resources? So deceased donor organs is the classic constantly absolutely scarce healthcare resource. 100,000 people on the wait list. There's either, I think it's one person on waiting for a kidney either dies or is delisted every hour in the United States without receiving a transplant. The initial supply of COVID vaccines were absolutely scarce for several months. Many people died waiting for a COVID shot and never got their chance. And then theoretically life support or critical care ventilators could have been scarce in a situation of absolute scarcity. I think Dr. DeMartino this morning made paint of the picture that it's much murkier and there's this gray zone between severe strain and absolute scarcity and critical care resources. So how does one address this problem when you're faced with a situation where not all of the patients are going to get to receive a life-saving therapy? Someone is going to go wanting. Some patients are going to die because they don't get the treatment they need. And someone has to make this tragic choice about rank ordering these people for treatment. So the classic process is to take a set of ethical principles and develop a coherent multi-principle framework, right? This is the paper that Lord just mentioned from his ecomanual in Govind Prasad it's popular in the Journal in 2020. It's actually a rehash of a 2009 Lancet paper that divides these principles or values into four large buckets. I'm not going to go through this in detail. I'm sure most of the audience is familiar with this but you know, the one point that is important to make is that these principles often conflict in triage situations. So for example, the principle of maximizing benefit perhaps quantified by saving the most lives is in direct conflict with the concept of treating people equally, right? If you are rank ordering patients by their expected survival benefit from a transplant or a vaccine, for example, you are by definition not treating people equally. So but once you've decided on your ethical principles, the next step, we're going to have the next slide to my clicker's not working is to derive a practical allocation protocol from these values, right? But this process is not possible without referring to observed empirical data in most protocols, right? I think we went a little too far but now we're flying past but this picture is fine but you can't develop a practical allocation protocol that tries to maximize some objective outcome like saving the most lives without referring to empirical data. The covariate distributions of the patients on which you are running a triage program over is incredibly important to actually achieve the ethical aims or goals of the protocol. And so what I'm interested in is this process of combining normative ethical principles ideally articulated into a coherent framework with the observed empirical data together into an allocation protocol and what that process what the process of developing these systems and evaluating them looks like. It's critical that these systems are constantly being evaluated once they're put into place like the deceased owner or an allocation systems with respect to their baseline ethical framework. And what I think is interesting and that was said in the previous slide is that occasionally sometimes the results of these protocols when put into place makes one question the ethical framework that they were supposedly resting upon. I'm going to tell a brief story about crisis standards of care because I want to spend most of my time talking about vaccine allocation today. So this is work done with several McLean fellows Monica Beacon, Kelly Mickelson from Northwestern is among others where we actually took ventilator allocation protocols that have been described a couple times during this conference and ran a simulation of a 50% shortage. And you can see that the four articulated there on the screen lottery is just random assignment youngest first is prioritizing patients solely based on age adhering to the principle of fair innings or potential lifespan equity lowest sofa first is an attempt to maximize the number of lives saved based on an objective measure of acute organ dysfunction which is supposed to predict in hospital mortality and then a multi-principle framework one that invokes saving the most lives but also tries to have some consideration for life cycle or life years right how if you deprioritize patients with severe chronic conditions in theory then you're going to be increasing in the number of adjusted life years the system is saving and then finally age is used as a tiebreaker in the Maryland in Maryland system and what was surprising is when you actually simulate these systems and again this is a 50% shortage so there's only half as many ventilators as we need so an overwhelming surge of patients unlike anything that was really seen in the United States where literally half of the patients are not receiving life saving life support the efficiency of these protocols are relatively similar you only gain a couple of percentage of patients survive surviving by using their SOFA score for example to rank order them that in turns out the most effective system was one that relied on the patient's age as the sole predictor that outperformed SOFA score and this is actually is not surprising because SOFA has subsequently been shown to be very inaccurate in predicting hospital mortality in particular if you can only use data from before the point of intubation so what's the cost of these small efficiency systems gains an efficiency number of life saved well every system except for youngest first severely disadvantaged black patients in particular because in our data set which is a combined data set of Northwestern University Chicago patients black patients had higher SOFA scores on presentation but in the lottery system where allocation was equal across all racial and covariates and SOFA there was no difference in survival and what so why what explains the discrepancy well it turns out that as work that we and others have shown this multiple times across multiple data set is that SOFA the SOFA score over predicts mortality in black patients that systematically you know a black patient with the SOFA score of five a white patient with SOFA score of five the black patient will have a better survival and that often is related to them being younger at the point of developing critical illness I think that's the main explanation for that for that finding but this is a way where a system that it's in theory raised blind can create a substantial inequity and the reason I bring this then the other point key point of empirical data that fits into this allocation protocol development process is that the burden of COVID-19 itself was very unequal across different communities in the United States we've seen this map a couple of times today already but it's still always striking to look this is the first 270 deaths in Chicago the white dots here are deaths from people who are self-identified as African-American in the Cook County health examiner data set and you can see how these deaths are concentrated on the south side of the city and what this is reflecting is that where the pandemic hit hardest was in communities where there were structural factors creating systematic disadvantage for the people living there so I wanted to the reason I'm showing that empirical data is to reflect back to this process of developing a protocol so Bernie Lowe and Doug White developed a really reasonable framework for rationing ventilator and critical care beds originally in Anilson internal medicine paper updated for the pandemic in spring 2009 rest on two principles at that time saving lives and saving life years and a SOFIS a SOFIS score-based system to identify those patients who are most likely to survive but in response to the empirical data of the uneven treatment or the burden of COVID being uneven across various racial and ethnic communities this protocol was revised and not only did SOFIS score get kicked out Bernie and Doug also changed the underlying ethical principles that were contributing to the normative ethical framework so not only was the allocation protocol failing to satisfy the original ethical principles that they set out the empirical data made in conversations with other people in reality too but I would argue striking empirical findings motivated in a normative ethical change and that's not actually what's supposed to happen but happens all the time in this area especially in organ allocation where an unintended consequence of an allocation protocol makes you realize that maybe our normative ethical reasoning wasn't so sound in the first place so with that I want to spend the rest of my time talking about some errors in bioethical reasoning that was made in developing the COVID-19 vaccine allocation phases this is work that I've done with Govind Prasadamanika peak throughout the pandemic but now I try to bring it together and put this particular framing around it this mistakes not necessarily in the original set of principles I don't think I need to remind everyone here I'm going to skip past this that vaccines were absolutely scarce in the US right it was incredibly difficult to get a vaccine initially within each phase there was 200 plus million people who were FDA approved for a vaccine but our initial vaccine supplies were very limited and there were tens of thousands of people who wanted the COVID vaccine they weren't hesitant this is you know March January February but just couldn't get it and instead died of COVID-19 that's sort of the definition of absolute scarcity and so the the advisor community on immunization practices the CDC committee that was designed to give guidance for the entire United States is was tasked with developing vaccine allocation phases from underlying ethical principles and so they had to take this this go through the same process that the the bioethicists trying to design crisis standards of care algorithms did that the people in the OPTN developing or get the organ allocation policies have to do every day combine ethical principles with empirical data to come up with a practical way to give these things out and that they're underlying principles are here on the screen I am not going to spend any time debating whether or not these are the right ones I would point out that there was no specific length waiting made on each each principle or rank ordering given so there wasn't you know the explicitly laid out that maximizing benefits it's more important than mitigating health inequities for example and I think to be a complete ethical framework I would argue you actually have to do that you have to put relative weights on these various principles and make sort of philosophical normative argument for why that construction is correct but for this for the purposes of today's talk my remaining time I'm going to assume these principles and I'm going to show you how the resulting phases violated all three in various ways so advancing forward if I can all right so we're assuming these principles are the right ones and we're going to look at the phases and see if the phases satisfy the principles basically by incorporating the empirical data and pointing out where some things went I in my opinion horribly wrong and so I'm sure everyone's familiar with these things with the world's construction of the phases but these were the final recommended phases from the CDC's advisory community and immunization practices so there I think there are four key mistakes two errors of omission and two errors of commission the first was that the CDC failed to recommend place-based vaccine allocation second they implicitly endorse first come first serve the hunger games that we all sort of experience firsthand or many of our friends and relatives to raise to get a vaccine those were errors of omission from the framework commission was using ages over 75 is the only criterion to identify individual high risk of COVID-19 during phase 1b and also by including an overly broad healthcare worker priority in phase 1a I'm going to walk through them all individually in my last couple minutes here assuming my clicker advances the slides so the first one that I wanted to talk about is the overly broad healthcare personnel definition so this this violated all three principles in my opinion first from maximizing benefits and minimizing harms practice standard giving vaccine to healthcare workers who are in not high risk situations and at low personal risk for example working telehealth at home having no direct contact with patients who had no underlying health conditions clearly is not an allocation protocol that's going to maximize the number of people's lives saved when we're raging from the third deadly winter delta wave right from a promoting justice perspective with adequate PPE occupational risk of of quarantine COVID-19 is actually lower than the frontline health essential workers I always felt incredibly well protected in the ICU because I knew exactly what COVID I had a great N95 and eye protection I knew how to keep myself safe and I never got COVID despite spending a lot of time being blasted with it in the micu and of course racial and ethnic minorities are are underrepresented in many healthcare professions and so there's sort of this fantasy that without any empirical data to back it up that giving vaccine to healthcare personnel first would somehow be equitable but as we know it's very hard there's huge gaps particularly at the top of the healthcare professional food chain in terms of racial groups being underrepresented the national academy of medicine phase 1a worker party was much narrower they envisioned a small jumpstart phase of just high-risk healthcare workers people who had high-risk underlying condition instead we got a very long protracted phase 1a that put healthcare workers lexically in front of their patients and so even that they had to the city of Chicago's at one point idea was that literally every healthcare worker in the entire Chicagoan area was going to have to get vaccinated before we would do a single patient fortunately the phases were allowed to overlap and things move forward but I think that was sort of the first mistake and I'm already running over time so I'll try to get through my other critiques relatively quickly place-based and geographic risk of COVID burden was another incredibly low hanging fruit in an allocation protocol that could have been derived from the set principles of ASAP right looking at the national academy of medicine realized this and put it as a cross-quitting consideration that was supposed to exist throughout all the phases areas of a high risk of COVID-19 should have received additional vaccine supply and as I've already shown you earlier we knew where the hot spots in Chicago were we knew where people are at high risk of death from COVID-19 we knew where the fire was burning but we intentionally decided to pour it elsewhere into the areas of the city that were relatively spared from the pandemic and so from a perspective of maximizing benefits mitigating inequity or promoting justice ignoring place in COVID-19 vaccine allocation fails all three right and why did we ignore a place we just leaned into the existing health care system and gave doses to indiscriminately to the zip codes with more places that were distributing vaccine and unfortunately this had deadly consequences this is work from Sharon Zhang one of our medical students who is now a second year and Monica Piqua myself and quantifying exactly how many people died because of this maldistribution of vaccine across the city and if the people in the lowest vaccinated zip codes have received the same zip codes as the same vaccination rate as the highest vaccinated zip codes up to 72 percent of deaths during that spring 2021 wave could have been averted you know at one point and so I think the consequences of this failure of protocol led to serious ethical violations and so what I'm arguing is that failing to incorporate the empirical data on the ground led to substantial issues for the underlying principles and so I'm over time so I'll just go really quickly through my last two critiques first is as I think we all experience trying to get appointments for loved ones vaccine allocation was first come first served no recommendation that it should be done via a lottery within a phase and of course this gave tremendous advantage to people who had internet access time to sit on Twitter and refresh their web browsers and snatch up appointments regardless of where they are in the city right so that's first come first serve vaccine allocation goes hand in hand with a lack of geographic prioritization right if you do if you allow first come first serve allocation to anybody regardless of their zip code you're undermining any of your efforts potentially to distribute vaccine to the harder hit areas of the city and my final comment is that age only vaccine vaccine allocation is problematic right for for across all three principles there are other very important risk factors for COVID-19 death that were ignored by this black patients have a median life expectancy of 74 years which is below the cutoff for phase 1b original phase 1b cutoff the CDC recommended so most states including ours threw that out and went to 65 and older and you know what I think in conclusion since a couple minutes over I wanted to bring this home is that the ethical principles that the ACIP laid out were reasonable I don't I think we may disagree with aspects of one of the two but the the phases and the protocols and key aspects of them were internally inconsistent with those principles and they part of this was sloppy empiricism and not looking at the underlying empirical data but I also think there were covert principles that contributed here like a really heavy reciprocity for healthcare workers meritocracy were working hard to get a vaccine and again we're wanting likely voters who tend to be older and you know people have really good access to healthcare again with so with that I will stop talking and I look forward to panel discussion I want to thank Dr. Siegler and McLean Center for the opportunity to speak well that was a really exciting panel I'd like to bring everybody up we have a lot of questions to get through here and I think it's time to do that all right do I get a timer for how much time I actually have here but anyway until I get that I want to I want to start by saying that I think one running theme through all of what we've been talking about here is this concept of politicization of health and how we've as we're struggling to understand how to reconcile politics and health and I think you know there's some questions about this as well and I think it's important to remember that what we call politics isn't always politics especially when it comes to health I think a lot of people identify with a politic or end up arguing on behalf of a politic because of a conflict in values and there isn't a reliable or good answer for them I think sometimes people hear I think for example you might hear Lydia's speech about the importance of loneliness and think that that means she's against infection control which she is most definitely not this is matter this is a matter of figuring out a way to balance two opposing values and I think that that is not something as someone asked if this ever happened in the past absolutely there are problems people didn't want to mask up during influenza 1918 pandemic there were issues with the vaccine in 2009 H1N1 there every time we have that there were all sorts of problems with equity issues with respect to and look at the quarantine problems with Ebola there have been political issues with infectious disease and any sort of big health crisis or any crisis of all times and so going from there I want to ask a few questions I'm going to start with Lydia since you went first and I think this is a great question did any place in the US or in the world find a better balance between infection control and preventing loneliness and how can we advocate for I'm going to ask you how can we advocate for better policies in our current systems because there are still hospitals who are having this these policies yeah thanks for that thanks for that Emily and thanks for the question so I don't really have a sense I don't have a handle on the global situation what was interesting about the combination of hospitals and nursing homes over the last well 20 months is that hospitals are beholden to many different regulators and they tend to be a little bit more local than what nursing homes are beholden to so then you see much more variety among hospitals I'll just say for us here at Columbia there was a very quick pivot to liberalization of visitor policies actually starting with women in labor and then very quickly expanding even though it was still quite restricted one visitor no more than two hours a day at the beginning when we started to open up we started opening up very quickly whereas nursing homes in the you know the same nursing homes to where we send our patients would not allow visitors I mean this continued through summer so we had trouble discharging patients from the hospital because they had no nursing home to go to that would allow their loved ones to come I'll just say very very briefly while I was giving my talk the CMS released new guidelines for nursing homes just this afternoon and there are no longer any restrictions in nursing homes in the United States as of this afternoon so I'm grateful to report that I think it is I'm going to say again what I said after your talk if we could make a bubble for the NBA that I think it's really just our inability to to do what needed to be done in order to make a bubble for these nursing homes and be able to have family come into them and you know family visited with NBA players too there's a lot that goes into this but if you're creative and you care about maximizing more than just the one value that the decision maker has in their mind at the time you can really do some pretty great things I think that's 100% true and I'm thrilled about that CMS and moving forward talking Dr. Pollock I think that there is a great question in the chat here and I'd like to ask how would your affirmative action plan for conservative students affect the clients served by social workers when they come in asking for abortion care or gender affirming care don't you think it would be hard to attract conservative individuals to a job where they would have to provide those things or how would you deal with that well there's just the values of the client are what are what you're trying to advance when you're a social worker and it is you know if I'm a vegan and a client says I want to take a job in a slaughterhouse you don't say well that's contrary to my values that's not what that's not what social workers do you know I think if we looked anybody who has spent any time with you know with people from the Church of Latter-day Saints or other communities where politically, culturally, religiously conservative people dominate know there's an incredible amount of beautiful human help that is provided within those communities that is a foundation for that and I think it's fair to ask someone when they become a social worker you know if you are if someone came to me and said I was the treasurer for a University of Texas students for life and I want to be a social worker I would say great I want you in my classroom but I would also say you do realize that if you take a direct practice role that there will be you will have clients who wish to have abortions and it will be your ethical responsibility to help them secure that because their life not yours and I think that I mean there are I think all of us in our political and moral views sometimes are faced with clients who want to do something that we personally don't believe you know isn't in accordance with our values I mean physicians face that nurses face that so I think that is a quite quite a reasonable thing for people to do I just want to add one thing to that which is yeah please well because the default isn't like left-wing people are kinder and nicer and know the right thing because they're nicer and conservatives are somehow these these wrong angry people actually conservative evangelicals are the people who are mostly taking in foster care children at an extraordinary record of churches we're very conservative right-wing churches evangelical church is taking in foster care children bearing the bearing the weight of that system and and in left-wing communities that rate is almost zero so you know it can it's surprising sometimes that said and and and Dr. Pollock's work is making sure there's space for those arguments it might be ones you actually we actually should agree with is it real? I can say by the way can I just add one thing I'm the guardian of an intellectual of a man who lives with an intellectual disability and and I can tell you that in our own everyday life that that we experience that very very often if we I took him on vacation and I was on a bus on the Hollywood celebrity house tour and there was a religious there was a christian group that was with us on the bus and someone tapped me on the shoulder and said you know I see that you're here with your brother-in-law if you need to go to the bathroom or you just need a break or whatever there's 20 of us and there's one of you you just let us know and we'll watch him you guys join us for lunch and and they and they were just organically reaching out to us in a way that I really thought was striking and I wondered you know I think that there's wonderful people that you know that from that from those communities who who could could add so much to our social I do think that it is appropriate to ask the question can you can you honor the values of people I also say one more thing which is if you if you our clients are very often very socially conservative people in some of their religious values and who elderly people on the south side of Chicago are not the most world population in the United States and if you can't be social competent dealing with that you're gonna have a challenge so I went on too long so I'll stop there no no I I want to say also that those of you who did not see the video in the New York Times this week flu states you are the problem should probably watch it it's great it's a video with a little article did you see it Dr. Zell yeah I want to ask you you know healthcare systems are slaves to the bottom line as you point out but I think there's a lot of argument on behalf of leadership and and healthcare advocates that if they don't act that way they will close and make healthcare even more scarce so how do we balance these competing values in the reality of modern America well they won't close they could we could have to work for free I mean they could take a lot less money doctors could decide you know doctors in in in a in a south side hospital could say you know we could make as much money as the nurses we should all make the same amount of money and then there'd be I would make more money if I got as much as our nurses well whatever it is and maybe everybody should make as much as the janitors there's other ways of organizing what healthcare costs right that doesn't collapse it in the same way that you could expand if there was if there was 40 times as many doctors and there actually could be 40 times as many doctors there's 40 times as many students for every many many many people could be good doctors we don't train them and why right in part because it's a market-based it's a market-driven problem you and everyone feels so special and they only you could be at the doctor but in fact a lot more people could be doctors a lot you know in many countries it's not an exalted position the other thing is we don't see poverty we don't see class in America and even in Dr. Parker's beautiful slides I'm afraid we see race we're much better at seeing race now we're really getting good at seeing race I mean I'm proud of our profession of bioethics and foregrounded and it's been really important but in addition we have to see class and I and those deaths of despair thing the point I really the deaths of despair are are white working class men between 15 and 55 who have no jobs and no college education and that is the demographic that often does not get accounted for and does not get attended to and it's a problem with our inability to see class in this country and to see poverty in my argument basically is as long as you keep having a a professoriate and a medical school industry and a public health industry that's that's driven run and organize mostly by people who are wealthy and in case of physicians quite wealthy the first then you're never going to be able to do you never going to be able to address that problem because people are never going to take seriously that you have their interests at heart because sort of kind of we don't we don't so I think those are very good arguments I want to get well I got to get Dr. Park ran for a question you know there's I'm going to merge together a question from the chat and one that I had written before and I think I think they're about the same the the vaccine uptake and some of those highest risk neighborhoods that you really out you really advocated for them having gotten gotten more vaccine supplies earlier which I will also point out that the city of Chicago did eventually do and provide vaccines off of their regular schedule to anybody that wanted them in those neighborhoods but in those highest risk neighborhoods that vaccine uptake in general is much lower than it is in other neighborhoods be owing to what's been referred to as vaccine hesitancy which is a largely it's a it's a very heterogeneous reason for these things so the question that I have for you is how would even earlier vaccine availability have really improved uptake and what do you think we need to do to get vaccine hesitancy to a place how could we have approached this question of vaccine hesitancy better to get people who really need vaccinations earlier so you know it's a little hard in the talk to make people re-enter that mindset of January in February where every site that had vaccine was using every put and vaccine was absolutely scarce and the problem was not that people on the southwest side of the city didn't want the vaccine the promise there was only for example in Englewood one vaccine site St. Bernard's Hospital initially and they ran out of vaccine on Monday every week and the city didn't give them more but there was 20 in Streeterville and every site had vaccine so I think hesitancy is an incredibly important problem that needs to be addressed but our work empirically shows that this misallocation when hesitancy does not kicked in yet right this is this is January February March we're still working through the very willing segments of the population in each of those zip codes had a substantial effect on surviving that spring wave and the people the lower vaccinated zip codes in the early couple months in the city died because they were not given access to the vaccine not because they didn't want it and the paper is actually up as a pre-print people can read and see the empirical methods we use we use an economy I think you're right in general it's clear that there's there certainly are some people who died because of vaccine hesitancy but there are also people who died because of vaccine available I have sense of and that we could have done a better job of making that match up the access to the willing participants instead of continuing to try and get every last health care worker vaccinated well I think I think I think that's inevitable right I mean that's the other thing about absolute scarcity problems that are so hard is that it's inevitable someone is is going to die because they don't get access to the resource and I think the the problem is that a lot of the phase allocation decisions got nowhere near maximizing the number of lives that could have been saved and also violated important equity principles one thing I would just say go ahead there's a sense that I think when when the system when the people haven't earned distrust of the medical care system that is a structural barrier I mean that if it's true that there are black and brown residents of Chicago who were distrustful of the system and did not take what was actually really important health advice that's not happening in a vacuum and you know we have to build those it's a social justice issue to create relationship and to heal the hurt that people have because of prior mistreatment so that people are in a position where they can trust you when you have really important advice to impart to them and you know the data that we've seen after Tuskegee suggests that people really died because they did not trust the medical profession around basic issues around hypertension medication things like that and that was that was an injustice even if it looks like an individual health behavior yeah just a question I go along you have to quote that okay okay we can't all talk each other over here yeah I want to sorry I was just going to tell a quick anecdote no no no hold on Dr. Praner all right go for it Dr. Dugdale it seems I think you haven't had a chance to speak about this topic yet but I want to like get your thoughts on whether these COVID policies everything from vaccine allocation locations to the determinations of how who is going to be in group 1A1B and then also the issues of whether or not there should be visitation in nursing homes all of it we're looking at with hindsight which is a lot better than when we're looking at in the time and there's you know we've I've made the argument that we didn't do a very good risk benefit analysis sometimes we just sort of did we only looked at one set of one person's key stakeholders values instead of looking at all the values and I want to hear what your thoughts are on the same topic yeah yeah no I mean just listening to you all talk I was thinking well actually I don't know that it was a trust of the system issue just let's just focus on vaccines for a second with regard to Harold's point I had plenty of patients I'm practicing in a black and brown neighborhood almost exclusively plenty of patients come in with zero trust issues with Columbia or with the hospital or with the clinic but there were a lot of YouTube circulating about all kinds of misrepresentations about the vaccine right from affecting fertility for men and for women to you know all of the things that you've heard and so it it was it was I would say a lot of misinformation there was also a sense of I'm not taking it like I'm just not going to do that but but I don't know I have to say it is it's hindsight is 2020 and so we can look back and point fingers but I think that the reality is is that what we went through the last 20 months was incredibly iterative but it's iterative at a policy level where there are a lot of people around the table and you're trying in real time to respond to a real crisis and every day it is different and every day the data is different and I don't know that we can necessarily beat ourselves up over what happened we can look back at it and study it and hope that we come up with new strategies moving forward I was incredibly impressed with how we handled our vaccine rollout here we had all kinds of videos and representations from local communities to go in and speak to those communities we had vans going out to people's houses elderly and shut-in had actually people coming to them to deliver the vaccines they were prioritized all of this was rolled out as quickly as possible and I think that's what we have to do we have to look back at the last 20 months identify what can we can change moving forward and put the systems in place the real challenge is going to be deciding to actually prioritize as you pointed out Emily something that's not quite upon us yet you know a new pandemic or what have you and so that's where we're going to have to decide we want to prioritize moving forward I am going to only add that if history is a predictor of future we will probably not change very many things and we will probably make a lot of the same mistakes again in the future but hopefully we won't make all of them and that I think is the last is going to be the last word for today thank you us so much to all these presenters and thanks for the great discussion so happy to be with all of you and thanks to the McLean Center for pulling us all together and I think there's one more session tonight