Transcript
Speaker: Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound Critical Care provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: In today's episode of the podcast, we will discuss ethical issues related to the COVID-19 pandemic.
Speaker: We are very fortunate and much honored to have Dr. Arthur L. Kaplan as our guest today.
Speaker: Dr. Kaplan is Director of the Division of Medical Ethics at New York University Langone Medical Center and School of Medicine.
Speaker: He is the author or editor of 35 books and over 700 peer-reviewed articles, as well as a frequent commentator in the media on bioethical issues.
Speaker: Dr. Kaplan is a recognized thought leader and expert in medical ethics.
Speaker: Art, welcome to Critical Matters.
Speaker: Thank you so much for having me.
Speaker: I think that, obviously, there's been a lot going on in the last several months in our country.
Speaker: I mean, I know that you're in the epicenter in New York, and I'm sure that you've been talking about ethical issues related to the pandemic with a lot of people.
Speaker: So I really appreciate you making the time to talk with us today.
Speaker: But I wanted to start maybe with a very basic distinction and get your thoughts on the
Speaker: the differences between what's legal and what's moral, especially during a pandemic?
Speaker: Well, you know, the ethics usually arrives, if you will, first.
Speaker: We debate what's right to do, what's wrong to do.
Speaker: And then when we agree, we put it into law.
Speaker: So you might say that ethics precedes the law.
Speaker: And then ethics is always around to critique the law.
Speaker: We've had bad laws, immoral laws, laws that we had to change.
Speaker: And so ethicists are constantly probing and examining the law to see whether it might be unjust or might be violating basic human rights.
Speaker: So it is both kind of ahead of the game, first on the beaches activity, ethics, and then it becomes a sounding board to kind of reform the law as we go along.
Speaker: Remember, too, ethics is often defined by personal conscience.
Speaker: by professional groups that have agreed upon rules that they will follow.
Speaker: The law is put in place, if you will, by legislators reflecting popular will or opinion.
Speaker: But that opinion can sometimes stray.
Speaker: Let's just think in areas like civil rights where we had laws that were biased against groups and so on.
Speaker: So the law isn't always ethical, even though it is the law.
Speaker: And that's what I mean when I say the ethicists sometimes have to challenge it or sometimes the profession has to say, look, the law is pushing things in a direction that's not right for our profession.
Speaker: Think about trying to censor what doctors can say to patients about various topics.
Speaker: That's an example where the ethics doesn't square with what the law might say in a particular state, say, about discussing guns in the home or abortion or some other things that are legal.
Speaker: to talk about, but a state might try to restrict speech.
Speaker: Absolutely.
Speaker: And I think that the other part that I think is very interesting is that as we progress in a health crisis, such as a pandemic, there are different stages that might alter not only the way we look at certain ethical issues, but also certain legal issues might be changed as things get more dire.
Speaker: Is that something that you can comment on?
Speaker: I think ethics evolves to context.
Speaker: The law is slow to change and often can't keep up.
Speaker: So that's a problem with the law.
Speaker: And then remember, too, there are situations where legislators and politicians and judges don't want to make the law.
Speaker: They steer away from controversial topics.
Speaker: You can think here about guidance on how to ration ventilators.
Speaker: Ethicists jumped in and had much to say about how best to approach that difficult subject.
Speaker: politicians, lawyers, legislators, not so much.
Speaker: They just didn't want to get into it.
Speaker: Yeah.
Speaker: And in terms of making decisions from an ethical standpoint, in terms of just some very basic principles for our audience, when you think about pandemics or a crisis like the one we're living right now, are there like basic tenets that are important?
Speaker: I know that some people have always argued kind of the John Stuart Mill approach
Speaker: the greatest good for the greatest people, as other people who might believe Emmanuel Cantin say every life is sacred.
Speaker: I mean, any thoughts in terms of how bioethicists think about this in general, specifically for pandemics?
Speaker: Yeah, so I think we normally are a little bit Kantian in our outlook, meaning we tend to try and respect the individual patient.
Speaker: We tend to try and do what their values and wishes are in ordinary circumstances.
Speaker: Patient autonomy, patient choice get a lot of weight.
Speaker: in driving care.
Speaker: In a pandemic, we shift over to much more utilitarian standards because we're trying to do what's best for the group, for the community, even in some sense for the population of the world.
Speaker: An individual autonomy has to yield.
Speaker: So were I to give instructions that if I'm dying, I want everything done for me, normally we would try to do what we can to respect that until we reach futility.
Speaker: But in a pandemic, you're sort of spreading resources around and you're thinking, I can't respect the do everything possible for me to the last minute because I need to shift resources to others who have a much better chance of doing well with them.
Speaker: So pandemics, I think, are more consequentialist or utilitarian and ordinary medical morality, much more individualistic and autonomy driven.
Speaker: And I think that it's also very interesting because
Speaker: That also plays in the way I think physicians treat patients without maybe thinking of it in a deep ethical sense, that we usually are very focused on the patient in front of us, like you said.
Speaker: And when things are normal, that's our modus operandi.
Speaker: When things get to a crisis and it's really out of control, kind of what happened in some hospitals, maybe in New York and Mobutin in Italy, it's a very different approach.
Speaker: But it seems that the middle is very messy.
Speaker: And I think it's very difficult sometimes for patients, for physicians and families to make that shift as we go along.
Speaker: Is that something that you've observed?
Speaker: I mean, in this pandemic?
Speaker: Absolutely, yes.
Speaker: So we're used to, well, let's put it this way.
Speaker: Over my career, I've spent a lot of time dealing with rationing because I've worked in transplant for more than three decades.
Speaker: We make rationing decisions there every day.
Speaker: People die every day because they can't get a scarce resource.
Speaker: I'm used to trying to think hard and
Speaker: about what rules are best with a scarce resource when you have many worthy candidates and many who might benefit, but you don't have enough hearts or livers or lungs or kidneys to help everyone with a cadaver donation.
Speaker: Obviously, one obligation there is to try and think about what individual patients want, but you're also saying, I've got this scarce resource.
Speaker: I have to maximize it.
Speaker: Some transplant surgeons will say, well, look, my patient failed.
Speaker: with their transplant and I want to get another organ.
Speaker: And we've set up the system so if we think a second transplant is just not going to work, even though the individual doc is fighting like crazy to get that next transplant to give their patient another chance, the system sometimes steps in and denies it.
Speaker: So that's a classic, if you will, challenge of the obligation to do what's best for my patient, which might be a retransplant versus a
Speaker: What's best for the overall population is to save the most lives, and we're going to discourage re-transplants in cases where there's been, say, acute rejection.
Speaker: And I think that when we walk into a pandemic like the one we're living, the numbers are logarithmically greater, and the exponential growth of number of patients obviously makes it even a more difficult situation, I'm sure, for everybody.
Speaker: Exactly.
Speaker: And, you know, there's also this additional factor of risk built in.
Speaker: Do you have enough protective gear?
Speaker: Even if you're wearing protective gear, if you're doing very dangerous intubations and so on, trying to split a ventilator, these kinds of things, even kidney dialysis, which can be dangerous.
Speaker: How do you weigh that?
Speaker: Would you take certain risks for your patient knowing they're not likely to survive, say an 87-year-old on a ventilator, that's a bad forecast, versus
Speaker: trying to shift resources to a 30-year-old who has a much better chance of survival and justifies perhaps exposure and risk if you don't have enough protective gear or even if you do have protective gear but you're still concerned that infection is a possibility.
Speaker: So you're weighing in a third factor, which normally isn't there.
Speaker: What's the risk to the healthcare provider of doing something?
Speaker: Absolutely.
Speaker: Art, as an ethicist, I mean, you've not only thought about rationing the transplant world, but you've probably thought about pandemics a lot more than most people who are listening to this podcast.
Speaker: What has been as expected with the COVID and what has been the least expected in your experience in the last several weeks?
Speaker: Well, I've had a chance to think about rationing with transplants.
Speaker: I was part of the WHO committee that thought about resource constraints with Ebola.
Speaker: And I've spent time running a committee that's been advising big pharma companies like Johnson & Johnson about how to give out drugs that are not yet approved by the FDA to desperately ill, dying people who can't get into a clinical trial.
Speaker: So a lot of experience in many ways in thinking about previous, if you will, demands on resources where supply just wasn't keeping up with or couldn't keep up with demand.
Speaker: What's left me surprised in this outbreak, first, I think we had a strong, virtuous response on the part of healthcare providers going in, facing risk, and saying, I'm going to do right by my patients.
Speaker: You know, that didn't have to happen.
Speaker: People could have called out sick.
Speaker: People could have said, I'm not facing that risk.
Speaker: I didn't see, I won't say I didn't see any of that, but I saw very little of that in every country.
Speaker: I think people can be proud that they're
Speaker: Doctors and nurses and technicians and food handlers and transporters went in there and said, we're healthcare providers.
Speaker: We're going to do right by our patients.
Speaker: We're going to help in this pandemic.
Speaker: I think in even the Ebola outbreak, there was panic on the part of many healthcare providers and they wouldn't do it.
Speaker: Second, I see something that disturbs me.
Speaker: In Ebola, we saw panic prescribing.
Speaker: People were using anything and everything to try and cure people.
Speaker: We tried to lay out rules and say, look, you've got to try experimental things in an organized way.
Speaker: I haven't seen that enough in the current pandemic.
Speaker: The president got up in the U.S. and said, you know, I like these anti-malarial drugs in combination.
Speaker: I think they work.
Speaker: All of a sudden, the entire supply of this drug is diverted over.
Speaker: to trying it out on people with no systematic organization, who knows what doses they got, when they got it, how sick they were, just throwing the kitchen sink in there.
Speaker: And I thought we weren't going to do that again once we'd learned from the Ebola outbreak that if you don't organize testing new agents in a systematic way, you're never going to know what's going on.
Speaker: Plus, you can do harm.
Speaker: And we saw some harm coming out of the
Speaker: misuse of these drugs, both in diverting them from people who were benefiting, people with lupus, for example, couldn't get this drug, and heart attacks and heart problems in older people who got the drug and then basically had to suspend the studies.
Speaker: Just one other quick area.
Speaker: I think people have been surprising to me a little bit that we focused on ventilators, ventilators, ventilators, and they're important.
Speaker: But I think most of the people on this podcast will know that if you need a ventilator, it's not a good sign.
Speaker: The outcomes are not great no matter who you are.
Speaker: But we didn't pay enough attention to rationing personnel and where would we deploy them best and how do we handle elective surgeries versus the need to staff up for acute emergencies.
Speaker: What should continue?
Speaker: What shouldn't?
Speaker: I saw a lot of yelling and screaming about pocketbook issues.
Speaker: That surprised me a little bit.
Speaker: Interesting.
Speaker: I think you touched on two things that we're going to dive a little bit deeper, but I want to start with basically physicians and healthcare workers.
Speaker: And if you could give us kind of your thoughts on the duty to serve in a pandemic, what guidance do we have?
Speaker: I know the AMA has talked about this in the past, and you mentioned, I mean, most healthcare providers have stepped up and really put themselves in the front lines.
Speaker: But tell us a little bit more in terms of how you think about the duty to serve from a bioethical standpoint.
Speaker: Yeah, well, we started talking a little bit about the difference between the law and ethics.
Speaker: Legally, I don't think you can compel somebody to face untoward risk, meaning go in there without adequate PPE or reusing a mask or reuse a mask that we attempted to clean by procedures that we don't really know will work or won't ruin the mask.
Speaker: It's one thing to say the average healthcare worker has to face a little more risk being around
Speaker: the flu or infectious agents.
Speaker: It's a different thing to say, we know that this virus is virulent, highly infective, and we don't have the proper equipment for you.
Speaker: Legally, it would be very hard to say, I'm going to fire you if you won't do that.
Speaker: And I know some people have been threatened with that in different parts of the world, but I don't think it would stick.
Speaker: It's just, it's more asking unusual risk or distorted risk than trying to enforce it.
Speaker: That said, ethically, I think the medical groups, nursing, medicine, have said patients first, put your patients' interests first.
Speaker: That has been part of the code of ethics for a long, long time in many, many specialties in medicine and in nursing.
Speaker: Also, by the way, in pharmacy.
Speaker: And there, I think the call is ethically to try and assume more risk because that's what a professional does.
Speaker: That's what a healthcare professional does.
Speaker: So I think ethically, there's a little more of a duty.
Speaker: Legally, no.
Speaker: I don't think you can enforce it in the same way.
Speaker: So you're really calling on people's moral vision to say, take the risk, go in there, go to a risky environment.
Speaker: Also, you're putting potentially loved ones at risk or people you live with.
Speaker: And they didn't sign up for that if you bring the virus home or you get infected.
Speaker: But I do think it's a question of ethics.
Speaker: And I think the profession has risen to
Speaker: all the healthcare workers to really commendable levels of bravery and, if you will, heroism on ethical grounds.
Speaker: No, and absolutely.
Speaker: And that's, I think, exactly what I have seen.
Speaker: I mean, we have, obviously, colleagues all over the country, and some areas got hit harder than others, but some of the things that we've heard are things that are unprecedented and that I've never heard or experienced in previous disasters at that level.
Speaker: What about the whole topic of lack of proper PPE?
Speaker: I think that also part of the problem here has been that there's been, on one hand, real supply chain disruptions, real surges in volumes that have made this very difficult.
Speaker: But there's also been a tremendous amount of misinformation.
Speaker: And it's kind of like what people want, what they need, and what they have are not always aligned
Speaker: So how do you look at that in terms of proper PPE and where does that come into that duty to serve?
Speaker: Well, I think national government in the U.S. failed, let us down, did not have a supply, let the stockpile that was built up post-Ebola decline and rot away, shut down key CDC presence in other countries in office,
Speaker: The government under Trump has been particularly after the deep state thinking that's not what you need.
Speaker: But ironically, a plague is exactly where you need, quote unquote, the deep state, meaning CDC, NIH, FDA, the ability to ask manufacturers to shift quickly to making protective gear.
Speaker: We didn't have that fast enough.
Speaker: And it's not a state issue.
Speaker: Sometimes the federal government has kept saying it's a state issue and the state should go find their equipment.
Speaker: It's a federal issue.
Speaker: They're the ones who have the authority to step in and say, you start making shields, you start making gloves, you start making masks, and so on.
Speaker: So that is probably my number one criticism of how we've responded to this is inadequate protective gear.
Speaker: I see people stretching and trying, you know, we have people making masks at home.
Speaker: I saw companies locally just decide to switch over to making face guards.
Speaker: One area where PPE was particularly horrible, nursing homes, they had death pits because the staff is the only group that could be bringing the infection in.
Speaker: Got terrible numbers of people infected, very frail, and they didn't have equipment to do their job.
Speaker: The nursing home sector has always been the
Speaker: sort of poor child of healthcare, and it just showed up here again.
Speaker: So I know that's a long whine and a lot of complaining, but we really should have done better on PPE.
Speaker: And as long as I'm venting about that, we also should have done better on testing.
Speaker: Why we don't have testing as we speak today, still adequate to allow people to start to return to work, meaning we don't have quick turnaround testing of the
Speaker: same-day variety, spit testing, while we don't have more genetic testing, while we don't have more accurate serology testing.
Speaker: I think the federal government was in denial of this thing too long.
Speaker: Other countries did better, Taiwan, South Korea.
Speaker: They managed to test their way back to tamping down the epidemic faster by focusing their quarantine on
Speaker: So there's a lesson here for the future.
Speaker: We must always have an adequate reserve supply of gear to manage infectious diseases.
Speaker: We must always have a lab capacity to shift to different types of testing, whether it's for swine flu or Ebola or Zika or new coronavirus or whatever the heck is brewing out there, Marburg.
Speaker: Those things threaten the world and the cost of this
Speaker: towards any cost it would take to maintain that.
Speaker: And I think each hospital should be maintaining some sort of equipment reserve.
Speaker: This just-in-time idea that we'll maximize profits by getting our equipment only as we need it is not the best way for healthcare to operate, in my view.
Speaker: It's not the ethical way to be.
Speaker: Absolutely.
Speaker: And I think that, furthermore, I think that another change that is not, I think, a welcome change, I think it's just a sign of despair that you have talked about, is that
Speaker: I would imagine that in the next couple of months, a lot of physicians and nurses might procure their own N95s in mass to keep it just in case something happens again, which again is something that we have never even thought about in the past.
Speaker: Yeah.
Speaker: And, you know, I think there's been some warnings, I'll admit, having been around some of the response to prior infectious disease outbreaks in Africa or Zika, which mainly went into South America.
Speaker: Though we're not paying attention here, you know, again, people say, well, who could have anticipated this?
Speaker: Who could have known?
Speaker: There were warnings coming that we needed to be ready for infectious disease outbreaks, given what had happened, but they just didn't register.
Speaker: I have to say, long-term planning has not been a great feature of our public health planning, of our hospital supply planning.
Speaker: And we've got to take that lesson home and start to really say, you know, we get ready for things like a big train accident or a terrorism attack, and we do some planning about triaging and handling an explosion or a chemical plant explosion.
Speaker: We have to really also add in the infectious diseases.
Speaker: In this day and age, for a variety of reasons, they're constantly going to be there.
Speaker: I'm even concerned that
Speaker: that we got to really build up a resupply in case this thing comes back in a big way on rebounds later in the year.
Speaker: And I think, like you said, people say, who could have predicted?
Speaker: And actually, anybody who thinks about this or reads history, I think would feel very comfortable saying that the biggest immediate threat to people and economies is a pandemic.
Speaker: I agree.
Speaker: I agree.
Speaker: You know, I'll just say personally, I know I've written...
Speaker: say in 2015, 2016, about the need to get ready for this, the failure not to take infectious disease outbreaks seriously, the notion even that we have in America that somehow the oceans isolate us, we're kind of fortress America, we're not going to get the problems that beset other parts of the world.
Speaker: And it's sort of, you know, did anybody remember like airplanes and cruise ships and the fact that a disease that's in the
Speaker: Sierra Leone one day can be over here in 24 hours.
Speaker: We're planning as if it was a 19th century, and if a disease broke out, we'll hold the boats in the harbor until we figure out who's got typhoid.
Speaker: I agree.
Speaker: So the other topic that you had touched on is one of the surprises related to treatment during the pandemic, and specifically during COVID-19.
Speaker: And I wanted to talk about two areas within treatment.
Speaker: One is that you already mentioned, but I wanted to expand a little bit further is with this pandemic, and I think what's unique about maybe COVID-19 that we've never seen before is the infodemic associated with it.
Speaker: Like every single minute there's something new being shared, viralized, posted.
Speaker: The quality of what's being shared is like very, very low from a scientific standpoint.
Speaker: But people seem obviously to be buying this magical thinking and snake oil and everybody wants a solution.
Speaker: And I have seen colleagues giving therapies with very little data, which, again, in some situations might be ethically appropriate, like you said, in Ebola in some situations.
Speaker: But what worries me is that there seems to be also a lot of research going on without any science, without any documentation, but also without any discussion with patients and families about risk.
Speaker: Could you comment a little bit more on what you're seeing and how you think about this particular issue of using all these medications that really are at the best experimental in a widespread use?
Speaker: Well, you know, what's going on is what I call panic prescribing.
Speaker: It's basically saying, I don't know what to do.
Speaker: Somebody told me that one of these antiviral drugs might work or one of these...
Speaker: Things that stop cytokine storms might work, and I'll try that.
Speaker: Or maybe convalescent plasma might help.
Speaker: Or I've totaled up, there are well over 200 different agents that are being proposed by people to help either kill the virus or overturn some of the side effects caused by the virus.
Speaker: People are looking at things that might stop you from seroconverting if you get near the virus all the way out to what can I do if the person's dying right in front of me on a ventilator?
Speaker: Can I throw something at them?
Speaker: No one ever learned anything by panic prescribing, ever.
Speaker: You just don't know what's going on.
Speaker: So even if you had something that worked,
Speaker: If you don't write down how sick the patient was, when you gave it, what the dose was, how frequently you gave it, how are we going to know either that it didn't work or that if you just gave more of it, it might have worked?
Speaker: And I'm not calling for waiting until we have full randomized placebo-controlled trials.
Speaker: By the way, we may see some of that with the vaccines because giving a vaccine out to the world is going to require
Speaker: a very high safety level, and some pretty solid demonstration of efficacy.
Speaker: But for therapy efforts, rescue efforts, salvage therapies, if we don't compare A to B to C and write down what it is we're doing, we're lost.
Speaker: We saw that in Ebola.
Speaker: People were throwing the kitchen sink at Ebola patients, and we never figured out until the thing was almost burnt out the fact that there were some drugs that helped a little, and most things didn't do anything.
Speaker: And that relates also to the consent aspect.
Speaker: There's no excuse, none, for not getting minimal informed consent when you're trying a novel agent on somebody.
Speaker: Even if you're using an approved drug for a different purpose, you should tell the patient or the patient's surrogate that that's going to happen.
Speaker: You should absolutely tell someone that you're going to try an experimental agent and get their permission.
Speaker: If they can't give it, then a surrogate is usually available to do it.
Speaker: So,
Speaker: Suspending ethics in the middle of a pandemic, there's no cause for that.
Speaker: There's no reason for that.
Speaker: Even if you have to do it retrospectively and say, you know, I couldn't find anybody and I wanted to try and save your loved one.
Speaker: Okay.
Speaker: We have retrospective consent in emergency situations.
Speaker: We've created informed consent in the ER.
Speaker: You know, we understand the ethics side that you can't always
Speaker: get a consent on the spot.
Speaker: Maybe someone's in there with an emergency and no relatives and no family and no one, but then you do it after the fact.
Speaker: So I do think abandoning the informed consent aspect is wrong.
Speaker: And also I think it's wrong not to report what you're doing to the research ethics committees or IRBs as they're called, just to let them know, again, you're not seeking approval.
Speaker: You're just coming after the fact and saying, I tried this, it was experimental.
Speaker: and I'm just notifying the IRB, they can help keep records too so that we can learn.
Speaker: Look, in a pandemic, the game is obviously to help someone with something.
Speaker: But if we don't organize it, if we don't do it in a systematic way, if we don't record what we're doing, how are we ever going to advance?
Speaker: We're going to miss the things that helped, and we're going to use things that maybe hurt or tip people over.
Speaker: I think, just for one example, those that
Speaker: the drug that President Trump loves, the anti-malarials, not only did it divert the supply away from people who were benefiting from that drug, say who had lupus, it was using a drug in older populations who were prone to heart problems.
Speaker: They weren't in the sample that led to the drug being approved originally.
Speaker: It hadn't been given there.
Speaker: And we saw a number of countries have to stop
Speaker: their administration of that drug because they were giving people heart attacks and heart problems.
Speaker: Good intentions are great, but they shouldn't substitute for science.
Speaker: Yeah, and I think that you touched on, I mean, not only the substitution for science, but the substitution of appropriate ethics.
Speaker: And then I think that the one thing that I always worry as being part of a large group and making recommendations that affect a lot of patients is that
Speaker: Individual decisions with patients that are taken in the right way are different than saying everybody should do this.
Speaker: And then if you have harm, you've potentiated that harm by thousands of patients.
Speaker: And I think that the magnitude of that in a pandemic is something that people cannot take lightly.
Speaker: Specifically, I wanted to use an example that I see in critical care and just, I mean, get a little bit more of your thoughts.
Speaker: I mean, you've touched about it.
Speaker: already on the ethical needs to get that informed consent.
Speaker: But a drug that a lot of people are utilizing is the IL-6 inhibitors, which are drugs that originally were studied in septic shock with the same arguments that they're trying to use them in COVID, the cytokine storm and all that.
Speaker: And when they were studied, it didn't really work.
Speaker: And then they find their way into rheumatology as biological agents that do work for some diseases.
Speaker: But what's very interesting is that in current practice,
Speaker: If you're going to use an IL-6 inhibitor for a rheumatology patient, I know that in some places they do it under video consent.
Speaker: In other places, so they record the consent.
Speaker: In other places, they do it under written informed consent.
Speaker: And the reason is that these drugs have very powerful infectious disease complications that can be lethal.
Speaker: So that's a standard of care for patients who have approved indications and are not in the hospital.
Speaker: How can we walk away from that in people who are critically ill with this new disease?
Speaker: And I know that people have given this drug without getting that type of consent.
Speaker: What are your thoughts on that?
Speaker: Yeah, I'm just going to repeat.
Speaker: I think you must get consent.
Speaker: It's more, if you will, a notification.
Speaker: We both know, and most people listening to this will know, that people aren't going to say no.
Speaker: They're going to say, okay, try something.
Speaker: They hope.
Speaker: They wish.
Speaker: They put their faith in the doc and the remedy.
Speaker: It's psychologically understandable.
Speaker: If you're drowning, you'll take anything as a life preserver, piece of wood, anything.
Speaker: But sometimes you grab something that could hurt you, might be sharp edged or will just sink.
Speaker: So I think you might say what we want to do is notify people when we've used it.
Speaker: And then the other reason for consent is it's another way to track what the heck is going on.
Speaker: You start to have records that, you know, we used it here and we used it on this person.
Speaker: We tried it on an 87-year-old who had three underlying diseases.
Speaker: We tried it on a 30-year-old who didn't have any underlying diseases and seemed to have a very boisterous immune response.
Speaker: Part of the way to record all that is to keep tabs on the ethics end of it by recording the consents.
Speaker: So more information, even in a crisis, even when time is tight,
Speaker: and people are stressed and the workforce is overworked, that's the time to double down on trying to record what's happening.
Speaker: We want to make sure we're not making errors.
Speaker: We want to make sure we're not exposing people continuously to things that are tipping them over.
Speaker: You know the old rule.
Speaker: If a person gets better, it must be the drug I gave them.
Speaker: If the person dies, it must be the underlying disease that kills them, not the drug.
Speaker: And that's common.
Speaker: It's psychologically, again, understandable.
Speaker: but it's what medicine has to overcome in a plague if we're gonna advance.
Speaker: Absolutely.
Speaker: And I think that you kind of walked into the next topic I had regarding treatment, which is we obviously would benefit as society if we got good information of what works and what doesn't work and what causes harm and what causes benefit.
Speaker: And the best way to do that is through as rigorous as possible science, but we also have to balance that with the needs to do this
Speaker: in a rapid way while we have the patients coming at us at such a rapid pace.
Speaker: But what are the ethical issues regarding doing research?
Speaker: Because like you said, I have been part of research protocols in the past, and for a lot of these protocols, getting consent is not always easy.
Speaker: But I would imagine that if I were to approach any family member or patient with an experimental drug for COVID-19, they would just, before I even start, say, where do I sign?
Speaker: What are the ethical issues of doing ethically sound, rigorous science,
Speaker: in the midst of a pandemic such as this one?
Speaker: Well, sometimes I think people equate getting informed consent with getting legal immunity if things go wrong.
Speaker: I would not worry about that in a pandemic.
Speaker: For example, New York State passed a law providing immunity for going outside standard of care because they understood that more risks and more deviations from standard of care were going to happen in a pandemic, particularly if things got overly stressed.
Speaker: in a particular hospital setting.
Speaker: So I don't worry about legal liability.
Speaker: If someone wants to sue you after the fact for trying something that produced an adverse outcome, I'm going to say good luck to them in court because they're not going to get far.
Speaker: People understand desperate situations require desperate measures.
Speaker: So the reason you want to get the consent is not so much to respect the patient's choice because I agree.
Speaker: People are going to say, okay,
Speaker: If you throw anything at them, they'll try it.
Speaker: I don't think many people are going to say no.
Speaker: I can't imagine anybody will say no if a doctor comes in and says, I think this might help.
Speaker: Let's try it.
Speaker: But what we want to do is keep a record of what the heck is going on.
Speaker: So think more notification and record keeping.
Speaker: I gave it to Mr. X. Permission was impossible to obtain at the time.
Speaker: I'm going to get that later.
Speaker: Mr. X was an 87-year-old with three underlying diseases.
Speaker: He had no relatives around.
Speaker: He was on a vent and had been on for four days.
Speaker: That's it.
Speaker: Let's keep that side of the record keeping going, partly for the science.
Speaker: Remember, good ethics, good science mix.
Speaker: It isn't just that who cares about what's going on in a desperate situation.
Speaker: You care more
Speaker: because you're trying very hard to learn when you can't do the usual clinical trials, the usual controlled studies.
Speaker: You're basically trying to do either patient observation or adaptive trials, testing A against B against C and then dropping A if nothing seems to happen and doing them for shorter periods of time and having less evidence, but at least you got something.
Speaker: Use the ethics to let that happen.
Speaker: Absolutely.
Speaker: And I think that the other issue that I think sometimes gets obscured in these situations is that there is also a lot of other agendas going on in terms of what's being published, what's being proposed.
Speaker: I know that for some companies, if it seems that they have a promising drug, all of a sudden there could be benefits in their stock, even though there's maybe no real proof that that is true.
Speaker: I also think that from a scientific perspective,
Speaker: We've always been very, in academia, very heavy on the interests and biases that pharma might have in the industry.
Speaker: But there's also investigator agendas, and people are publishing low-quality stuff, sending tons of letters to the New England Journal of Medicine.
Speaker: I think that I saw one that was really remarkable because it had described one patient out of China with one cardiopathy issue.
Speaker: but the paper was a letter, it had 32 authors.
Speaker: I mean, what's going on here, right?
Speaker: So I think a couple of things also need to be kept in mind.
Speaker: Look, I lived through Ebola.
Speaker: Every antiviral agent known to humankind was trotted out and touted, some by people who had a financial interest.
Speaker: They wanted to sell their drug, and they didn't really care.
Speaker: Obviously, they hoped it would work.
Speaker: But if they could get you to buy a lot of it and administer it, they were coming out way ahead.
Speaker: Let's not forget that in addition to science, there are different people, investors and others who have financial goals that they hope something will get picked up and used by a lot of people.
Speaker: And then there are just outright quack people and hucksters and frauds.
Speaker: I think the first publication that came out of France about the anti-malarial drugs was retracted as bogus.
Speaker: And that might have been
Speaker: put out there by someone with good motives, but maybe not the best researcher, or maybe they got sloppy.
Speaker: So there's, if you will, money, there's error, hopeful observation, and then there's just quackster stuff.
Speaker: People come in and say, try this, try that.
Speaker: I saw that if you drink bleach or diluted bleach, it will help me.
Speaker: That's all over the internet.
Speaker: People are yakking on about use vitamins in big doses, as I always do, by the way, whenever there's a virus, like the virus cares about vitamins.
Speaker: There are many claims about immune boosters.
Speaker: So in sorting through this maze of claims, you need to first make sure you ask a patient, are you taking something that you saw on the internet?
Speaker: You may want to get them to stop drinking silver solution.
Speaker: That might not be the best thing to be doing.
Speaker: And then, again, we've got to have more systematic assessment of what's going on because you can't just trust somebody from a bio company or a startup saying, hey, I got this great antiviral.
Speaker: It showed real activity against the virus in vitro, right, in a dish.
Speaker: I'm going to tell you, like that paper that came out of China, I got one from China that said they tried a drug, and it showed that the drug had real effect in killing the virus in a lab study.
Speaker: And then we looked at the dose that was being used, and it was about 300 times the weight of a human being.
Speaker: There's no drug that won't show some effect against the virus at some dose.
Speaker: So, again, you've got to watch out for bad science, hype-y science, crackpot science, and financially driven science.
Speaker: And so we've got to lean back hard on trying to stay organized and not just panicking,
Speaker: in the middle of either this crisis or should the virus hopefully not recur.
Speaker: Yeah, I think that clearly, I mean, not only like the panic prescribing or panic-based medicine, but social media-based medicine has also, I think, taken flight.
Speaker: And it's amazing how many colleagues just post and repost things that they see on social media as being science.
Speaker: And that is a little bit disconcerting and scary when so many people are really dying and at risk.
Speaker: Yeah, the only thing you want to be reposting, I think, are opinion pieces.
Speaker: They're fine and you can criticize them or agree with them and that sort of thing.
Speaker: Yeah, but not as science.
Speaker: I hate it when somebody says, I heard that there was a study out of Sweden where 10 people did X. It's like, oh, if you don't have the paper, don't repeat that.
Speaker: If you want to say, I saw Art Kaplan's opinion piece and it struck me as exceedingly stupid,
Speaker: And here's why.
Speaker: You can retweet that.
Speaker: I agree.
Speaker: So the last part of our conversation, I wanted to go into a bit of the rationing of critical care.
Speaker: And like you, we talked a little bit at the beginning.
Speaker: Most people are very in tune into this right now related to ventilators.
Speaker: But like you said, I mean, we've been rationing resources for decades with transplants.
Speaker: And people do die because they cannot get access to an organ because they don't have enough.
Speaker: But the two areas that I wanted you to give us your thoughts on is first is the rationing of other types of care because of potential risk for healthcare providers.
Speaker: And I think that specifically how that plays into cardiac arrest and thoughts that people have talked about, well, I mean, should we code these patients, not code these patients?
Speaker: Does it depend on their success, potential for success, et cetera?
Speaker: But just, I mean, maybe we could talk at that first and then talk about the scarcity of resources if you can.
Speaker: Well, the policies that I've seen, and I will also say that I've contributed to a little bit, including at my own NYU Langone Health System, you face the question if someone were to come in, in a hypothetical scenario, and into the ER and get triaged out saying, we don't have enough ventilators or we don't have enough dialysis,
Speaker: This person isn't going to make it relative to others.
Speaker: We're not going to be able to do that.
Speaker: Should we then automatically DNR them and say, if they then arrest, we're not going to put risk and resources into that person because they're not coming back due to resource constraint, let's say, to the kind of technological support they might need.
Speaker: I support that.
Speaker: I think you may have to do some unilateral DNRs in a complete crisis where you say, I can't discuss this or I'm not waiting for patient permission.
Speaker: If you're not going to be eligible for a vent or dialysis and a bed in the ICU, then there's no point resuscitating you because where are you going from there?
Speaker: We've hit futility and we've hit it earlier.
Speaker: Similarly, let's say you're failing on high-tech support
Speaker: either because you had the new coronavirus or you're just failing, as people do, from other terrible injuries or diseases or heart attacks or whatever.
Speaker: I think if you're resource constrained there, you may decide to stop care and not do the usual resuscitation efforts you might try because you know that there are, let's say, 1 in 10,000 chances of doing anything, and even the thing that you might produce might only give days
Speaker: hours more function.
Speaker: So while in ordinary circumstances we might say we're going to call the code and stop only when we've tried three, four times to resuscitate, I can imagine in dire circumstances saying in the ICU, this person just isn't flourishing.
Speaker: The experienced ICU person looks at them and says they're never going to recover.
Speaker: What is the point of risking further exposure?
Speaker: and futile use of scarce equipment and protective gear, let's stop now and we'll stop sooner than we would have normally because we know we've reached futility sooner.
Speaker: So those are really hugely troubling and awful ethical scenarios, both the, if you will, unilateral DNR off to sending over to palliative care and giving up perhaps sooner than one might have under
Speaker: normal circumstances with some resource abundance.
Speaker: But I think both make moral sense if you need the resources, so to speak, and you're trying to control healthcare worker exposure and burnout.
Speaker: So those are scenarios that I would argue that's not business as usual.
Speaker: And I think that that's also a very important point that when you have a pandemic worldwide, you might be, let's say, in Texas,
Speaker: and you're seeing what's happening in New York, and you're seeing what's happening in Italy, and that informs the way people start thinking, but the reality is it can't inform the way you start acting because your situation is not the same.
Speaker: You have not reached that crisis level yet, right?
Speaker: Yeah, you know, it's funny.
Speaker: A number of places in the U.S. and Canada, I've seen their rationing policies, but some of them did not rule them out.
Speaker: When you make a policy,
Speaker: The next step is to train people in it and let them discuss it and accommodate to it.
Speaker: You know, you don't want to just say Tuesday at three o'clock, we start rationing everybody on board.
Speaker: You know, you want to discuss it and teach it.
Speaker: It takes at least a little bit of leadership and so forth to do it.
Speaker: But we never actually got to it.
Speaker: Even at NYU, we were stretched then.
Speaker: We had a lot of people working together.
Speaker: extraordinary hours, but we didn't get to rationing the ventilators.
Speaker: And I don't think that happened in almost any place that I know of.
Speaker: There were places that get overwhelmed with patients and had to move them because they just didn't have beds.
Speaker: But you don't want to roll your rationing policy out because you don't want people to use it before they need to.
Speaker: You know what I mean?
Speaker: It's sort of, there's a fear that if you release it, then people are going to say, well, you know, I'm not going to try to save this guy.
Speaker: He's too old.
Speaker: He doesn't meet the rationing criteria.
Speaker: And you're sort of like, no, no, no, we still have enough resources, we don't have to ration yet.
Speaker: So the most immoral thing you can do is ration when you don't have to.
Speaker: And I think that led some hospital systems around the country to not release the rationing policies for fear that it would trigger, I'll call it premature rationing, you know, unneeded rationing, and you don't want that.
Speaker: Yeah, and I think that's a very valuable point, and I think worth, I mean, reemphasizing
Speaker: because I think that people, obviously as they see what's going on, are very geared in going that route.
Speaker: But if you do it, like you said, at the wrong time, which is too early, clearly that presents even a bigger ethical dilemma and a moral issue.
Speaker: Yeah, yep, absolutely.
Speaker: So I know that we're coming up on time, Art, but are there any general recommendations?
Speaker: I know that, obviously,
Speaker: There's a lot of issues when if you were to decide a rationing protocol or policy, there's a lot of things that are very important in terms of using obviously sound, ethical basis, understanding what community, what the community believes in.
Speaker: I think it's very important also.
Speaker: Furthermore, putting things, the decisions outside of the hands of the people who are actually taking care of the patients is also probably very important.
Speaker: But could you just give us like maybe a couple of pointers in terms of what are
Speaker: basic things that should be present there?
Speaker: Well, I'll say this.
Speaker: Look, first, let's not abandon core ethics.
Speaker: Even though we're starting to, in a plague, practice with an eye toward the community, not just the individual, the individual still deserves the respect of knowing what's going on or their surrogate if they're too impaired, either by cognitive impairments if they're elderly or just because the sickness makes it difficult for them to communicate.
Speaker: But we shouldn't ever abandon that right to know and respect for the dignity of the person to know what's going on, whether it's treatment or research or desperation.
Speaker: We should always still respect that principle.
Speaker: I think it isn't just a matter of the law.
Speaker: It's a matter of respect ethically for dignity.
Speaker: There's not much we may be able to do in terms of actually having cures.
Speaker: And people may always say yes to whatever it is in a dire situation.
Speaker: that people are proposing to try on them, but I still think there's intrinsic merit in having that conversation, that permission, that consent.
Speaker: It shows dignity to people, many of whom may not make it.
Speaker: So we can at least give them that.
Speaker: I think palliative care and support, emotional support, very important for patients and families.
Speaker: If we say there's no more we could do,
Speaker: have to quickly tell them that we're going to be there for them.
Speaker: You know, in a lot of places, people have had to die alone.
Speaker: They can't get in their family members or anyone because the unit is infected.
Speaker: I'd like to see people reassured that we'll have someone there, nurse, chaplain, in protective gear to hold hands, talk.
Speaker: If possible, we should start to set up
Speaker: electronic ways for families to be present with iPads and cell phones and so on.
Speaker: I don't think we did that enough.
Speaker: I think we should do that more.
Speaker: No one should have to die alone if the technology will help us work it through.
Speaker: I think understanding that the usual ethic of fight for my patient and be the best advocate I can be gets shifted in a pandemic or a plague to I have to take into account
Speaker: the best use of scarce resources.
Speaker: Now, happily, hopefully, we don't get to that.
Speaker: We saw some of it in Italy where the system got overwhelmed.
Speaker: We may still yet see it in some other parts of the world, but it's keeping in mind that it's not wrong to shift focus the plague, the pandemic, whatever it's caused, forces ethical adjustment in order to do the best you can now, not just for your patients,
Speaker: but for many patients.
Speaker: And that's hard because we've spent so much time stressing and teaching the importance of being a good advocate.
Speaker: But I do think in public health emergencies or in disasters, we have to change the ethic toward doing the best we can for the most people we can.
Speaker: That's, as I say, I understand that's difficult since I
Speaker: Myself, I've spent many, many years trying to advocate good advocacy as best you can do for your patient, even with fiscal constraints or resource constraints in ordinary times.
Speaker: But I do think that has to adjust.
Speaker: And the last thing I'd say is I think we should praise and support our peers.
Speaker: There are people working their butts off.
Speaker: There are people taking risks.
Speaker: There are people not just...
Speaker: at the bedside but supporting the infrastructure, making the food, cleaning the rooms, doing the laundry, affording security, transporting people.
Speaker: We got to bolster each, help one another, bolster one another.
Speaker: I try whenever I can in the hospital setting to tell people how much I admire what they're doing.
Speaker: I have many of my students that are now out there on the front lines and I try to encourage them and reinforce
Speaker: their bravery and their selflessness, and even the people listening to this who've been out there doing things.
Speaker: It's important to say I appreciate it.
Speaker: I admire it.
Speaker: I hope that if you're feeling anguished or overwhelmed that you seek out some support.
Speaker: There's nothing wrong with that.
Speaker: It's tough, tough duty in a miserable situation.
Speaker: And so support is something we should all extend and something we should seek when needed.
Speaker: Absolutely.
Speaker: And I think that I really appreciate those words, Art.
Speaker: And usually, I mean, we could probably go on for a lot more, but I want to be respectful of your time.
Speaker: So maybe we could close the podcast with some questions that are unrelated to COVID-19.
Speaker: Would that be okay?
Speaker: Sure.
Speaker: So what book or books have influenced you the most or what book have you gifted most often to others?
Speaker: Two books.
Speaker: Um,
Speaker: One, I'm a big fan of Socrates, the philosopher Socrates, Plato's dialogues, or Socrates talking to people about many different issues.
Speaker: And I am a fan of Socrates.
Speaker: You know, I have a philosophy degree, and I think that his model of going into the marketplace out in public and trying to do ethics in an applied way is really admirable.
Speaker: Plus,
Speaker: I think the Platonic Dialogues, which are really about what his teacher Socrates said and did, there's just a lot of wisdom there.
Speaker: If you want, I'll cheat and say I sometimes recommend reading a little Aristotle too.
Speaker: As classic insights into tough ethical dilemmas, Aristotle's very good on virtues and calling upon people to be brave but not stupid, for example.
Speaker: So he doesn't think that taking any risk is...
Speaker: necessarily brave, but he does a good job of carving out what's courageous versus what's foolhardy.
Speaker: And then I'm a fan of Ben Franklin.
Speaker: He's one of my heroes, a scientist, a legislator, an inventor, and I like his biography and I like his writings also.
Speaker: There's this sort of poor Richard's almanac kind of summary of
Speaker: extortations to be good.
Speaker: And I think Franklin was brilliant and underappreciated.
Speaker: We tend to think of him as kind of a chubby figure getting involved in signing the Constitution.
Speaker: But he was a deep, deep thinker and almost, I'm going to say, a pioneering American philosopher, very American.
Speaker: So he speaks to our times.
Speaker: Absolutely.
Speaker: I do polymath.
Speaker: And I think that with the dialogues, Plato's dialogues, I agree.
Speaker: I think that I am particularly fond of reading a
Speaker: stoic philosophers and especially during these times i i do find that it's very interesting that one of my favorite reads is meditation which was written during a plague and uh that lasted 13 years so a lot longer than covet but uh but clearly a lot of a lot of uh truth to power and also a lot of things that i think have to be true because they can send time right
Speaker: So I have to excuse myself because I just looked at the time and I got another call coming.
Speaker: That's a class of mine.
Speaker: So I'm going to have to jump.
Speaker: Absolutely.
Speaker: So thank you so much for your time, Art.
Speaker: And I really hope that you stay safe and hope that we have a chance to talk again soon.
Speaker: Very good.
Speaker: And if you get this on a link, send it to me.
Speaker: I'll post it.
Speaker: Absolutely.
Speaker: Thank you very much.
Speaker: All righty.
Speaker: Take care.
Speaker: Bye-bye.
Speaker: Thank you for listening to Critical Matters, a Sound Critical Care podcast.
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Speaker: Sound Critical Care is transforming the way critical care is provided in hospitals across the country.
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