Come for the politics, stay for the snark.

Innocent people don’t delay justice.

Roe isn’t about choice, it’s about freedom.

If a good thing happens for a bad reason, it’s still a good thing.

Yeah, with this crowd one never knows.

A snarling mass of vitriolic jackals

Is it irresponsible to speculate? It is irresponsible not to.

We still have time to mess this up!

I did not have this on my fuck 2024 bingo card.

Never entrust democracy to any process that requires republicans to act in good faith.

There are a lot more evil idiots than evil geniuses.

Damn right I heard that as a threat.

I’d hate to be the candidate who lost to this guy.

The willow is too close to the house.

The low info voters probably won’t even notice or remember by their next lap around the goldfish bowl.

Relentless negativity is not a sign that you are more realistic.

Books are my comfort food!

When you’re in more danger from the IDF than from Russian shelling, that’s really bad.

In my day, never was longer.

A lot of Dems talk about what the media tells them to talk about. Not helpful.

Dear media: perhaps we ought to let Donald Trump speak for himself!

When I decide to be condescending, you won’t have to dream up a fantasy about it.

Putting aside our relentless self-interest because the moral imperative is crystal clear.

Speaker Mike Johnson is a vile traitor to the House and the Constitution.

I see no possible difficulties whatsoever with this fool-proof plan.

You are here: Home / Anderson On Health Insurance / Ethics in preparing for the worse

Ethics in preparing for the worse

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The New England Journal of Medicine ** released an article yesterday on how scarce medical resources could ethicically be allocated when our hospital systems get overwhelmed with COVID19 cases at the end of the week:

These ethical values — maximizing benefits, treating equally, promoting and rewarding instrumental value, and giving priority to the worst off — yield six specific recommendations for allocating medical resources in the Covid-19 pandemic: maximize benefits; prioritize health workers; do not allocate on a first-come, first-served basis; be responsive to evidence; recognize research participation; and apply the same principles to all Covid-19 and non–Covid-19 patients…..

However, encouraging all patients, especially those facing the prospect of intensive care, to document in an advance care directive what future quality of life they would regard as acceptable and when they would refuse ventilators or other life-sustaining interventions can be appropriate.

Operationalizing the value of maximizing benefits means that people who are sick but could recover if treated are given priority over those who are unlikely to recover even if treated and those who are likely to recover without treatment. Because young, severely ill patients will often comprise many of those who are sick but could recover with treatment, this operationalization also has the effect of giving priority to those who are worst off in the sense of being at risk of dying young and not having a full life

This article is merely recommendations. It is not operational guidance nor a legal document. But as hospitals are gearing up to face a wave of high need patients who were infected before we started to physically distance from each other, it is guidance that many hospitals and their clinicians will be consulting in the coming weeks.

One of the most important things that we can do as individuals is to update our end of life wishes. Update our wills. Make sure that our medical proxies are able, willing and have at least one back-up. We should also make sure that our kids will have someone to take them in with appropriate back-ups. The medical system is preparing for the worst, and we should do so as well in our personal life.

** DOI: 10.1056/NEJMsb2005114

Reader Interactions

71Comments

  1. 1.

    joel hanes

    Will updated.
    Have the signatures on my durable power of attorney; need to plot out how to get it notarized.
    My advanced directive is inadequate, and I’ll revisit that this week.

    I’m 67, and an ex-smoker. I probably should decline a ventilator.

  2. 2.

    Sab

    A bit late for rewriting wills and such, since responsible attorneys have gone home to shelter in place.

    I wish Kay still came around here.

  3. 3.

    New Deal democrat

    I am beyond myself with rage and despair. Because (1j lockdowns work, see, e.g., San Francisco and China; and (2) we only need lockdowns for a few weeks to bring the number of infections down, while we ramp up production of testing kits and necessary medical supplies, after which we can implement a system of very aggressive testing and quarantine like South Korea.

    But nobody cares. Nobody is listening.

    And while most of the blue States of the Eastern megalopolis and the West Coast and Southwest have moved towards lockdowns, they have not followed up by coordinated incoming traveler quarantines.

  4. 4.

    West of the Rockies

    Ford, GM,  Tesla gearing up to produce ventilators.  Don’t abandon hope.

  5. 5.

    Jeffro

    I’ll put this here and in the thread below: Fox News dot com is positively livid at all the things Nancy Smash managed to get into the COVID-19 relief bill that’s about to pass.

    Which means, as usual, that we should all drop to our knees and praise the FSM that she is Speaker.

  7. 7.

    Salty Sam

    Twenty years ago, when my wife was on a ventilator and losing the battle, I had a long discussion with our friend (who happened to be the hospital Chaplain, and had written one of the textbooks on end-of-life issues) about the ethics of life-support withdrawal, aka “pulling the plug”.  It was the most painful, fraught, and challenging conversations I’ve ever had.

    Who’d’ve imagined we’d be having that conversation about entire populations?

  10. 10.

    MomSense

    @joel hanes:

    Some states are passing emergency legislation to provide for online notarization.  Can you email your attorney?  Find out if this is a possibility- otherwise most banks have notaries and they may be able to do this for you through the drive thru window

  11. 11.

    joel hanes

    @Jeffro:

    Nancy SMASH is currently our Lincoln.

    We need a Thaddeus Stevens, but Schumer is not up to the role (closer than Leahy would be, though)

    Just think: we _could_ have had Seth Moulton as Speaker.

  12. 12.

    joel hanes

    @MomSense:

    If it comes to that, I’m pretty sure that the hospital always has a notary  .. but I’ll check.

    The local notary is the UPS office, and that may be a vital business within the meaning of the act.

  13. 13.

    Ohio Mom

    Because Ohio Son has autism, Ohio Dad and I got our affairs in order years ago — it’s really important that anyone relying on SSI and Medicaid not directly inherit anything (special needs trusts, and some other asset sheltering vehicles must be used).

    All the documents, including advanced directives, are in a nice binder the attorney put together. I ocassionally allow myself to feel smug about this.

    But who would take over as Ohio Son’s immediate family, on that I draw a blank. It takes a lot longer to launch a young adult with a disability, we’re working on it but we have years to go.

    And now I am worried that the social service safety net, which would be one of Son’s main supports when we are no longer, will be in shreds.

    Just heard that Governor DeWine is cutting all DD Boards by twenty-percent. Is this some sort of temporary stop-gap, or is this part of a larger, long-term GOP quest to shrink all social services?

    DeWine has already used this crisis as an excuse to shutter Ohio’s abortion clinics, I don’t put anything past him.

  14. 14.

    Chief Oshkosh

    Didn’t read the NEJM article. I’m assuming the guidelines are:

    1. Determine whether individual is over 70 years of age and voted for Trump. If so, decline any care whatsoever.
    2. Determine whether individual is under 70 years of age and voted for Trump. If so, decline any care whatsoever.
    3. Determine whether individual is 70 years of age and voted for Trump. If so, decline any care whatsoever.

    This is based on the sort-of Golden Rule: You are to be treated as you would or do treat others.

    Since this removes about 57 million people from the potential care pool, the rest of us should be OK. Not great, but OK. Solves a lot of other problems, too.

  15. 15.

    Salty Sam

    @Sab: What book was that? We all probably need to read a version of it.

    Sorry, I don’t remember.  But he (the Chaplain) was an adviser to Bill Moyers on Moyers’ excellent “On Our Own Terms: On Dying” series on PBS.   That show is worth watching, especially now.

  20. 20.

    trollhattan

    @WaterGirl:

    Developmentally disabled? California has a system of regional centers supporting that community. Sounds like maybe Ohio once did.

  21. 21.

    germy

    Fortunately, because America, contrary to all other nations, has safeguarded the freedom to choose between the Aetna Bronze Shield High-Deductible Plan and the United Silver Bullet PPO, it is well positioned to address this health crisis, once millions of people lose their jobs
    — Gabriel Zucman (@gabriel_zucman) March 24, 2020

  23. 23.

    Nelle

    We moved to a new state so just got our new wills notarized and a copy to our son (the executor).  Quite relieved to get that done.  But my husband has a nearly impenetrable system for our financial system and was resistant to giving the methods of it to my son.  I finally made a document and gave it to him, though it isn’t actually current – he constantly fiddles with it.  But at least my son can see the patterns and has the passkeys (passwords) to the system.  There still seems to be the expectation that we will be around to explain things (as in denial of the real effects of death).

  24. 24.

    L85NJGT

    Ventilators are a last resort, the survival rates for ARDS patients isn’t great, and surviving makes for long term health issues:

    Up to 5 years after discharge from the intensive care unit (ICU), ARDS survivors still present persistent disabilities, including muscle weakness, altered lung function (e.g., decreased lung volumes, or decreased lung diffusion capacity) and an impaired mental health and cognition

  25. 25.

    Ohio Mom

    Water Girl: The County Board of Developmental Disabilities, the agency formerly known as MR/DD (we don’t use the word “Retarded” anymore), is the agency that provides social work services to disabled individuals.

    When Ohio Dad and I have shuffled off this mortal coil, Son’s DD caseworker will be his point person.

  26. 26.

    Sab

    @Ohio Mom: I like a lot of what deWine is doing lately, but he is insane on abortion. My very Catholic nieces used to be also, until they talked to their very Catholic cousin who is a pediatric icu nurse. She faces couples making horrible decisions almost daily.

    I am not Catholic. It has been interesting to watch these girls deal with the real world over the last ten to twenty years.

  28. 28.

    Ohio Mom

    Trollhattan: Every State sets up their DD services somewhat differently, though all must be within general guidelines set by Medicaid, which partially finds them.

    We still have a County Board system in Ohio, it’s just about to be cut a fair amount by our governor.

    I suppose a lot of state programs and services are going to be cut as a result of CV-19’s economic fallout. I mostly wonder with how much glee my Republican Governor is going to do the slashing. He surely enjoyed closing the abortion providers down.

  30. 30.

    Sab

    @Ohio Mom: I am kind of freaking out about my granddaighter’s prospects. She is six and autistic. Her mother smokes. My husband is sending her (mother) out to shop. I think he has lost his mind.

    Interesting times.

    They are in Ohio lockdown ( Yay!!) so they texted for art supplies. I have lots, since used to be artistic until life intervened. Sent them on. It was a wrench, because I have been cherishing some of those items for decades, and now pre-schoolers are chewing on them.

    Life in a time of pandemic. Makes you focus and rethink.

  31. 31.

    dmsilev

    God damn that fucking sociopath. WaPo:

    Breaking: Trump says he wants ‘country opened’ by Easter, despite warnings from public health experts about coronavirus outbreak

    President Trump said during a Fox News interview that he is worried that federal guidelines for social distancing, including the closure of some businesses, and other steps to mitigate the outbreak could go too far, despite warnings from public health experts that the restrictions may need to stay in place for weeks.

  34. 34.

    Ohio Mom

    Sab: I agree, DeWine deserves props for making us all stay at home. That was quite a bold and daring action for a run of the mill Republican such as he. I do feel safer this way.

    But I remain royally passed off about not knowing when I am going to be able to vote in the primary. I get that he was In a tight spot but illegally cancelling Election Day is huge to me. A big red flag.

  35. 35.

    JAFD

    To Mr. Hanes, re comment #12

    The essential parts of the New Jersey economy:

    “The following businesses are considered essential and will remain open, but customers and employees must practice social distancing:

    • Grocery stores, farmer’s markets and farms that sell directly to customers, and other food stores, including retailers that offer a varied assortment of foods comparable to what exists at a grocery store;
    • Pharmacies and medical marijuana dispensaries;
    • Medical supply stores;
    • Gas stations;
    • Convenience stores;
    • Ancillary stores within healthcare facilities;
    • Hardware and home improvement stores;
    • Banks and other financial institutions;
    • Laundromats and dry-cleaning services;
    • Stores that principally sell supplies for children under five years;
    • Pet stores;
    • Liquor stores;
    • Car dealerships, but only for auto maintenance and repair, and auto mechanics;
    • Printing and office supply shops;
    • Mail and delivery stores.”

    The UPS store is probably included under the last.

    Meself, have usually gone to my bank, asked for their notary to seal whatever needed.

  36. 36.

    LuciaMia

    Trump says he wants ‘country opened’ by Easter, 

    He can ‘want’ it all he wants. He has no authority to make states open up.

  37. 37.

    dmsilev

    @Elizabelle: He’s actually retreating a bit. Yesterday, it was “we’ll think about reopening on March 30”, and today it’s Easter which is April 12. Given how things are going, and assuming we follow similar trends as Italy and Spain, that’s going to be close to the peak so I kind of doubt he’d have much headway with any governor at that point.

  39. 39.

    Ohio Mom

    Chief Oshkosh: I think you need to add to your to rubric to include never-Trumpers.

    i live among them, my pretty solidly Republican suburban subdivision went for Hillary. It was historic.

    But they also continue to vote for Senator Rob Portman. It’s Congressmen like him who could have booted Trump out but declined to do so. I  afraid that the Never-Trumpers are not willing or able to connect those dots.

  41. 41.

    Sab

    @Ohio Mom: I disagree with you on the primary. My sister was in CA intending to fly back that Monday, then couldn’t or wouldn’t because corona virus. My niece expected to vote but couldn’t because in hospital because corona virus.

    Lots of voters wanted to vote but couldn’t because corona virus. Everyone else shouldn’t because it was already here and we shouldn’t be congregating.

    I early voted. Kind of wish I had waited. Who knows who will still be aound.

    I am afraid for the metroparks levy, when everyone has lost their job.

  42. 42.

    West of the Rockies

    @LuciaMia:

    If as predicted a week from now the figures illness and death rates have risen, there will be minimal appetite to churn forward in a Mission Accomplished mode.

  43. 43.

    Elizabelle

    Raring to go.  The NY Times.  Note Trump’s “expert.”

    Participating in a town hall hosted by Fox News, Mr. Trump said he wanted to have the country “raring to go by Easter,” less than three weeks away, a goal that top health professionals have called far too quick. “I think it’s possible, why not?” he said with a shrug.

    ….

    President Trump uses a town hall for politics.

    Given a microphone for nearly two hours, President Trump used a town hall on Fox News for politics.

    Mr. Trump lashed out at New York Gov. Andrew Cuomo, who has been holding daily briefings of his own every day that have gained national attention as fact-based and emotional counters to Mr. Trump’s own daily briefings. Mr. Cuomo, who is seeking federal aid, has at times complimented Mr. Trump for his leadership during the crisis.
    But Mr. Trump said he did not appreciate criticism he saw on television from someone he views as a rival. “I watch him on this show complaining,” Mr. Trump said. “He had 16,000 ventilators he could have had a great price and he didn’t buy them.”

    Within moments of going live, he also went after his likely foe in November, former Vice President Joseph R. Biden Jr.

    He referred to him as “Sleepy Joe” and claimed that Mr. Biden did not know what the word “xenophobic” meant when he criticized Mr. Trump’s approach to the spreading coronavirus.

  44. 44.

    Ohio Mom

    JAFD: that list from New Jersey is similar to Ohio’s. I can see the logic behind each item but it’s a pretty long list. Those are a lot of businesses still in operation. I wonder if we are doing enough.

  46. 46.

    dmsilev

    The news isn’t all bad today:

    NRA to cut salaries, brace for layoffs as coronavirus disrupts fundraising, internal memo states

    The National Rifle Association is cutting salaries 20 percent and bracing for layoffs, as the coronavirus pandemic forces the nonprofit to cancel its annual meeting set for April and a wide range of upcoming fundraisers and programs, according to a memo to staffers from the nonprofit’s leadership Monday.

    More than 800 people worked at the NRA in 2018, according to its latest tax filing, although that number includes part-time workers who would not be affected by the reductions. Schedules for hourly workers will be reduced from five to four days a week, the memo said.

    Some top NRA officials, including chief executive Wayne LaPierre, are taking salary reductions greater than 20 percent, according to a person familiar with the cuts who was not authorized to speak publicly about them.

  47. 47.

    trollhattan

    @Ohio Mom:

    I’m sorry to hear this is occurring. California saw our first round of dismantling direct state support and housing of the mentally ill and developmentally disabled all the way back in Governor Ronny Reagan’s day. The same Governor Reagan who began defunding state universities. There remains a support network, however. But a good chunk of the visible homeless population are folks who would once have been in the state system.

    And here we are.

  48. 48.

    Sab

    @Ohio Mom: I do agree with your concern about a governor postponing an election. But these are weird times, and I knew a lot of people disenfranchised because of travel restrictions who will now be able to vote absentee. I am on both sides on this issue.

  50. 50.

    japa21

    @Elizabelle: There may be more truth to that than you think.  Chicago had fewer shootings overall last weekend and only one shooting fatality. Don’t know if there is a correlation but would be interesting to see crime figures across the country.

  51. 51.

    trollhattan

    @japa21:

    Our regional air quality folks are quite chuffed at the excellent air we’ve had lately.

    Good practice for when we have an all-electric vehicle fleet.

    ETA it’s also instructive how far down the electricity demand is now. Lots of idle generation.

  55. 55.

    Orange is the New Red

    @Ohio Mom: if you don’t have someone to serve to be there for your son, I can volunteer. Also an autism mom. Retired special educator, now advocate. I am old and asthmatic, so may not survive the current circumstances.

  56. 56.

    trollhattan

    Pilot friend just sent pics of Delta’s fleet parked in the desert near Victorville. Eerie.

  57. 57.

    Jim, Foolish Literalist

    sounds like he went pretty nutso during his Fox News ‘town hall’

    David Frum@davidfrum 19m
    Ventilators for flattery is the deal.

    Josh Marshall @joshtpm· 28m
    On Governors asking for help, Trump says, “It’s a two way street they have to treat us well too.”

    Susan Simpson@TheViewFromLL2 1h
    Trump: “You can’t compare with to 1918. That was a flu… where if you got it you had a 50/50 chance of dying. I think we’re substantially under 1%… When you add the millions of ppl who get it and get better, we’re substantially under 1%.” This is, obviously, a bunch of lies.

  58. 58.

    Miss Bianca

    @Jim, Foolish Literalist: At what point are even Republicans going to get sick of Trump’s “I Will Be Treated Fairly OR ELSE You All Will GET IT!” psychosis? Ever? How many people will have to be dead before any of them start to question Dear Leader?

  59. 59.

    Goku (aka Amerikan Baka)

    @Ohio Mom:

    Is this some sort of temporary stop-gap, or is this part of a larger, long-term GOP quest to shrink all social services?

    DeWine has already used this crisis as an excuse to shutter Ohio’s abortion clinics, I don’t put anything past him.

    I guess abortion is being considered as “elective surgery” by the Ohio state government.

    As for your question, I’m not sure. I hope not

    DeWine was asked about Trump’s utterings about opening up the economy in the next few weeks and loosening restrictions. He claimed he and Trump were aligned!

    I don’t get it. I mean, I do. I guess DeWine doesn’t want to piss off Trump or something, but that in and of itself is abhorrent

  60. 60.

    Goku (aka Amerikan Baka)

    @Jim, Foolish Literalist:

    I think we’re substantially under 1%… When you add the millions of ppl who get it and get better, we’re substantially under 1%.” This is, obviously, a bunch of lies

    None of this fucking matters when hospitals are overwhelmed. That mortality rate will shoot up far above 1%. “Bunch of lies”. I want to scream.

  61. 61.

    japa21

    I am pissed.

    Got my mail today and there was a mailer from the CDC titled PRESIDENT TRUMP’S CORONAVIRUS GUIDELINES FOR AMERICA.  As if he came up with the guidelines.  It is, in effect, a campaign flyer.

    I let the CDC know my displeasure, not that it will mean anything.

    BTW, all the guidelines were standard issue that we have been hearing.

  62. 62.

    Ohio Mom

    Orange is the new red: I’m old and asthmatic too, we also have that in common.

    How old is your kid, does he/she live at home, how do they occupy their days?

    Ohio Son is 22, on the higher-functioning side, taking classes at the community college (with the help of a tutor and his parents), had a job as a supermarket shopper but I won’t let him sign up for shifts anymore. That’s all we need, a vector in the house.

    My long range plan is to sell this suburban ranch (now that we are done with the superb school district) and buy something in Cincinnati proper, on a bus line, and along the lines of a fourplex. Install Ohio Son in one of the apartments and eventually leave the building to one of the local disabled housing nonprofits., with the stipulation he stays.

    I used to have a day dream that when Hillary was president and all was running well and we Juicers did not have so many pressing issues to discuss, we’d have a thread about supporting our disabled family members. There are a lot of us here.

  63. 63.

    West of the Rockies

    @Miss Bianca:

    There is an end to his support.  Not sure where yet, but it is there.  If someone is slapping you in the face nonstop, you might for “reasons” take it for ten seconds, a minute, ten… But at some point you leave and/or hit back.  His supporters aren’t domestic violence victims who for psychological or economic reasons put up with it.

    We may at last see the end of his 42% approval.

  64. 64.

    Elizabelle

    WaPost breaking news:

    Terrence McNally, a prolific, much-honored playwright who rose to the forefront of American theater with a humane and lyrical style in works such as “Love! Valour! Compassion!” and “Master Class,” died March 24 at a hospital in Sarasota, Fla. He was 81.

    The cause was complications from the coronavirus, said his press agent Matt Polk, adding that Mr. McNally had chronic inflammatory lung disease.

  65. 65.

    Chyron HR

    @West of the Rockies:

    There is an end to his support. Not sure where yet, but it is there. If someone is slapping you in the face nonstop, you might for “reasons” take it for ten seconds, a minute, ten… But at some point you leave and/or hit back. His supporters aren’t domestic violence victims who for psychological or economic reasons put up with it.

    We may at last see the end of his 42% approval.

    Have… have you seen the “Mr. Trump, my wife is dying of cancer, please give her the cure that you in your infinite wisdom are hiding from the American people” tweet?

  66. 66.

    Jim, Foolish Literalist

    Susan Simpso @TheViewFromLL2 2h
    Trump: “[Cuomo] should have ordered the ventilators…” He pulls out a paper: “This says Cuomo refused to buy the ventilators. … So he had a chance to buy ventilators at a low price and he turned it down.” Trump is very mad that Cuomo criticized the fed govt’s response

    Tom Nichols @RadioFreeTom 1h
    Birx describing testing problems, mentions New York high transmission rates.
    Trump interjects: “Do you blame the governor for that?”
    Birx completely ignores him and keeps talking as if Trump said nothing at all.
    Fox cuts to commercial the moment Birx is done.

  67. 67.

    Ohio Mom

    Goku: I think DeWine knows which side his bread is buttered on. He’s not going to badmouth Trump, the people who elected him also in large part are Trump supporters.

    He’s not that different in this respect than a lot of other Republicans. I assume Portman thinks Trump is awful but he has no pride or ethics, just goes along to get along.

  71. 71.

    James E Powell

    @West of the Rockies:

    There is an end to his support.  Not sure where yet, but it is there.

    Not so sure of that. Their love for Trump might wane, but their hatred of us never dies.

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