Ableism in the time of...
March 25, 2020 9:59 PM Subscribe

As news of the toll that Covid-19 has brought and will bring, the fact that care might have to be rationed is on a lot of people's minds. Disability rights groups are worried that the rationing of care is a euphemism for eugenics. Already rights groups are bringing discrimination complaints against State policies- which would value the lives of the non-disabled as "more savable" then those without. The new laws in the UK also risk the rights of the disabled. Shockingly- Kaiser is telling its patients with autoimmune disorders that depend on Chloroquine to survive that their drugs won't be refilled- so that there will be more for Covid-19 patients. Chloroquine is not proven to work on Covid-19, while it is proven to work on conditions such as Lupus and RA.
posted by Homo neanderthalensis (98 comments total) 48 users marked this as a favorite

I read with interest the Washington State complaint, which is available here.

I'm sure it's impossible for me to understand what will be determined to be legal in this regard. So I can only think about what is desirable. As far as that goes, I think their thesis is roughly this:

- The Washington State policy very generally specifies that triage should be done to optimize for the "healthy, long-term survival" of as many patients in the region as possible, without prescribing how those decisions should be made.
- The complainants are maybe on board with that policy in a very abstract sense, if it were perfectly implemented, but:
- They think that health care providers will incorrectly assess that people with disabilities are less healthy and less likely to survive than they might otherwise be.
- And they think that health care providers will not assign as much value to the survival of disabled people.

It's not clear to me whether the complainants would be happy with a process that had the same policy, but with a lot of oversight and specific language to guard against the latter two concerns, or whether they would write a totally different-sounding policy that rationed care on some other basis.
posted by value of information at 10:47 PM on March 25, 2020 [4 favorites]

I think there are two strands here, but I'm not sure they can be entirely unwound from each other:
(1) Medical professionals often make incorrect and negative assumptions about the health/prognosis/etc. of a disabled person based on the person's topline diagnosis alone
(2) Even in a hypothetical world in which there are no such errors and "healthiness" is evaluated correctly for each individual based on their individual information, a system that prioritizes care for young and healthy people is still, by definition, discriminatory in a manner that the ADA and other statutes prohibit

Put differently, pervasive ableism shapes both the suggested triage algorithm and its inputs, with a cumulatively lethal effect for disabled people.
posted by Not A Thing at 11:26 PM on March 25, 2020 [31 favorites]

Quoting Gorsuch is a nice touch, but if this gets any traction with Trump's HHS I will eat a bug. (Gladly!)
posted by Not A Thing at 11:29 PM on March 25, 2020

Any system will prioritize the people most likely to survive when forced to triage, which with this disease is generally going to be younger people and those without comorbidities. It is, in fact, the very purpose of triage in an emergency situation. I sincerely doubt the ADA will apply as long as that is the criteria.
posted by tavella at 12:17 AM on March 26, 2020 [14 favorites]

Triage is inheritantly descriminatory. Any pre-existing complaints that it is biased against a particular group have whatever merit they had before, but new complaints triggered by the unavoidable increase in the need to triage are counterproductive.
posted by krisjohn at 12:33 AM on March 26, 2020 [6 favorites]

Thank you for the UK link - that is not something I'd seen covered elsewhere.
posted by paduasoy at 12:35 AM on March 26, 2020 [1 favorite]

This isn’t really triage. It’s more like a runway game of telephone where someone heard something about a small randomized trial to THIS THE CURE!!! As such we’re burning through antiviral drugs without any data that they even work at all. So conditions where drug is shown to work get cut out entirely needlessly.
posted by jmauro at 12:40 AM on March 26, 2020 [35 favorites]

There are multiple parallel conversations here, but with respect to triage specifically, it seems worth noting that there are lots of disabled and/or elderly people on Metafilter, and we can hear what you're saying about us.

It may, in particular, be worth reconsidering the wisdom of arguments that evaluate to "well obviously your life is of lesser value."
posted by Not A Thing at 12:44 AM on March 26, 2020 [72 favorites]

I explicitly did not say that, and triage using a pure most likely to survive standard makes no judgement about the worth of a life, just that if you have to choose who to put on a vent (and that is a choice we almost certainly will not escape), you choose those most likely to live, because you try to save as many people as possible with the resources at hand. It counts all lives as equally worthy, and if you can save 2 lives with the resources it would take to save 1, that is the moral choice.

Disabilities may or may not be relevant to that judgement -- missing limbs will mean nothing, chronic respiratory disease will be very relevant.
posted by tavella at 12:58 AM on March 26, 2020 [38 favorites]

There's a bit more about changes to the MHA in the UK here: Rethink blog and Mind response.

Also found a bit more on the possibility of suspending the Care Act 2014: Warning raised over Coronavirus bill impact on elderly and disabled. There are differing views across organisations about the latter. "I don't think it's a hideous plot," says Abrahams [from Age UK]. "I think it is a fairly sensible pragmatic response potentially to what might end up being an absolutely hideous situation. If you find that a third of your domiciliary care agency workforce just isn't there, what do you do?" Other commentators have highlighted that this potentially unravels some of the previous (intended) focus on prevention, so that people end up needing a higher level of service. The article ends "The Department for Health and Social Care insists these provisions are time-limited, and that it still expects councils to do everything they can to maintain existing services and meet the needs of as many people as possible, particularly those with the most acute needs".
posted by paduasoy at 1:19 AM on March 26, 2020 [2 favorites]

There are multiple parallel conversations here

I understand the idea of wrapping them together but I already have a feeling one of these conversations is likely to overshadow the others (by generating a lot more arguments).
posted by atoxyl at 2:24 AM on March 26, 2020 [3 favorites]

If you honestly disagree with pursuing a policy of maximizing probable remaining years times quality of life then you need to propose another metric for rationing scant resources when not everyone can be saved and explain why your metric is more justified. If you cannot offer an alternative metric that most people would consider more fair then it is difficult to fathom what possible selfless motive is driving your argument.

Hypothetical: me pushing 40 with serious asthma and a likely fatal Covid infection vs a 20-year-old person with the exact same chronic condition, general level of health otherwise and severity of infection. The other person should obviously get the remaining ICU bed and I should not, fucking duh. If I currently occupy an ICU bed and they show up, I should be removed from said ICU bed and they should take my place. Narrowing the hypothetical gap: someone else pushing 40 with a slightly better chance of surviving than me but still in need of an ICU bed should likewise be given my ICU bed, even if I'm already in it.

I would hope the medical worker making that decision would put in some minimal effort to not be a dick about it when breaking the news, but of far greater importance is that they ultimately make that call regardless of their remaining capacity for diplomacy (I'm assuming they've been going non-stop for 72 hours trying desperately to stem the flood of millions needlessly dying as a result of Trump's latest "plan"). I hope my wife shows them this comment to help them feel better about it.

And no, I'm not infected yet but I've been assuming this is what my future looks like for weeks.

Honestly though, how the fuck is any of this even in question? The greater good of humanity is you minimize suffering and maximize years of quality living, period. Even if it kills me. Calling it eugenics - a policy of discriminating against people nearly always along racial lines regardless of capacity for aggregate quality of life and usually with intent to needlessly murder them solely out of genocidal animus - is utterly disingenuous. Eugenics is a categorically different thing than triage and it is an outrage that people would deliberately attempt to conflate the two.
posted by Ryvar at 2:33 AM on March 26, 2020 [54 favorites]

After all this people are going to be wringing their hands and talking about the tough choices they were forced to make, but I bet nobody is going to be talking about the unforced choices they made which left us unprepared.

This feels a little unfair to me in that I think the people who are really going to be making tough choices are mostly not going to be the same people who made the choices that left us unprepared. But I might also be too much honed in on one of the issues being discussed here and a couple of particular perspectives on that. If you mean healthcare administrators will be congratulating themselves on making the tough decision to stop offering chloroquine to lupus patients and not thinking about the reserve resources they did not acquire then yes absolutely.
posted by atoxyl at 2:34 AM on March 26, 2020 [26 favorites]

Coronavirus: Malaria drug has no impact on treating Covid-19 patients, Chinese study finds (The Independent)

The malaria drug hydroxychloroquine might not be effective in treating patients with Covid-19, a new study finds.

The report published by the Journal of Zhejiang University in China tested if coronavirus patients who received the medication were more likely to recover than those who didn’t, and it found that was not the case.

I'm spluttering with anger, so find it hard to comment on the FPP.
Well, I'll try: what I find most infuriating is that the situation isn't really that bad yet. They are already planning inhumane practices before it is even necessary. I can see the importance of being prepared, but this seems like sadistic roleplaying.

Several years ago, a new directive was sent out to hospitals in my home region, where patients with COPD and other vulnerabilities should not, in general, be given ventilator treatment after surgery. This caused an outrage, until the underlying rationale was explained: these patients' lives could be saved at that point in time, but rarely without severe brain-damage, meaning they might never return to awareness. Also, the decision was supposed to be made together with the patients and their families. Actually my grandmother went through a difficult surgery at the time, and while she wasn't a COPD patient, she was vulnerable in other ways that were mentioned under the directive, and I experienced the procedure first hand as the next of kin in the conference. She chose to try for resuscitation including ventilator treatment, and it was necessary and she came out just fine. No one pulled the plug without our consent. Actually, I wept and wept not out of fear or grief, but because of the humanity and grace on the side of the anesthesiologist team.

I am thinking that something similar could apply for some groups in the context of the Covid-19 disease, if the sitation is managed responsibly. I'll admit that the situation in Northern Italy and the approaching chaos in the US and UK are more like the Raft of Medusa. But the solution to that is not to plan for bad choices, it is to man up and make real plans for flattening the curve and getting hospitals ready.
posted by mumimor at 2:36 AM on March 26, 2020 [24 favorites]

I should say someone I am close to is not only at high risk for the disease but has already been affected by the larger disruption to the medical system. Personally I am very mad about the big picture resource allocation issues, and at the same time pretty sympathetic to the point-of-care resource allocation strategizing. I guess primarily because from the perspectives I've been seeing from medical folks it feels like they are inevitably planning for situations that offer no good choices because they feel like all the stuff that can prevent these situations is not in their hands (oh and some of the patients are going to be their colleagues). But obviously I'm focusing on the way frontline providers are approaching these decisions, not the way administrators are.

(Person referenced above would probably want to acknowledge that the healthcare system has already saved his life a few times, which then gets into talking about all the other axes of medical discrimination.)
posted by atoxyl at 3:01 AM on March 26, 2020 [5 favorites]

you need to propose another metric for rationing scant resources

The alternative metric might be that everyone who’s ill gets an equal share of the available resources. Yes, that will mean fewer good life/years, but not everyone is a utilitarian. In fact I think most people believe that the ethical importance of equality trumps strict utilitarianism in at least some cases.

I just thank God I’m never likely to have to make these impossible decisions.
posted by Segundus at 3:11 AM on March 26, 2020 [8 favorites]

I do think there is an important ethical distinction between three related but separate things:

1) Triage based on pure likelihood of survival - If someone has 10% chance of surviving if given a vent and someone else has a 60% chance then in a resource constrained scenario, the latter should receive it. I think this one is easy.

2) Triage based on remaining years of life - This is one is trickier, if all other things are equal (same likelihood of survival) should the younger person get the ventilator? This might be a choice between a 50 yr old with asthma and a health 70 year old. I think this can be justified. All lives have equal worth and if we are all equally entitled to our lives, the person who has "used" the least of their lifespan should get it.

3) Triage based on quality of life based on existing conditions. If a choice has to be made between someone who already has a disability and someone who is has "normal" health going in, that is not a choice I think we can make because it means we are saying that one person's life is worth less because of a disability. I think that this is driving a lot of worry about what will happen when stressed and overwhelmed doctors have to make decisions.
posted by atrazine at 3:13 AM on March 26, 2020 [19 favorites]

everyone who’s ill gets an equal share of the available resources

In the most absolute basic example if you have 10 people who will survive if they receive one of five pills and give each one half a pill you have needlessly killed 5 people. That is neither fair nor even generally acceptable to the vast majority of the human race regardless of beliefs.

Real life is of course vastly more complicated and nuanced but the basic principle holds and we are definitely talking double-digit percentages of additional fatalities if we adopt that policy.
posted by Ryvar at 3:20 AM on March 26, 2020 [17 favorites]

I take that back: next week in NYC 5 ICU beds for 10 patients that will die without is going to become part of somebody's daily life. Real life is *usually* more complicated and nuanced.
posted by Ryvar at 3:36 AM on March 26, 2020 [7 favorites]

Triage is about lessening death. It is about choosing odds that are most likely to result in people living. That's the calculous.

Because if someone has three people and one ventilator , two people are going to die, this is a fact. in that situation people do want to pick the person who is most likely to live, because using a ventilator on a case with less chance means it's more likely that one has three deaths instead of two. But in reality, it's not a comparison between two people, it's a comparison between 10 or 20 or thousands.

More so, it's important to understand a ventilator is not a fix. It isn't a magic cure in cases of ARDS. It is an incredibly invasive procedure that can cause airway damage in addition to damage already caused by the virus. There is no guarantee any person on a ventilator is going to come off of it, but statistically we know from surguries and many other things that medical professionals have been using ventilators for a really long time that there is pretty good aggregate prognosis for a variety of people in a variety of circumstances because we've been using them without limitations. So we do know up front how likely a person will make it through.

When looking through a ablism lense yes it is awful, and cruel. No one wants to die. But the things to fix this aren't policies to save as many people in a wide scale crisis, it is about making those things available prior in in enough numbers that no one has to choose. And governments should produce enough of this equipment to deal with a surge of need so nobody needs to make these decisions. It's about sound public health policy across the lifespan and preventative care. That includes protections for disabled adults. It includes making sure nursing homes provide ample space to all of their patients regardless of income or need and staff appropriately . It's about increasing telehealth and ease of ways to get perscriptions and basic needs met. It's about the government spending money for testing regardless if someone looks sick or not because so many people are vulnerable to this .
posted by AlexiaSky at 3:58 AM on March 26, 2020 [22 favorites]

As another example of how these decisions might be made, New York has detailed ventilator allocation guidelines (PDF) with a much more readable 11 page FAQ (PDF).
posted by dragoon at 4:07 AM on March 26, 2020 [6 favorites]

There's an interesting BMJ blog article here which argues that how many likely bed days will be required per patient should be under consideration. The authors also suggest that the reality may well be 'first come first served' since this will be a difficult metric to break away from for a health service.
posted by biffa at 4:51 AM on March 26, 2020 [4 favorites]

God Doesn’t Want Us to Sacrifice the Old

We already are hearing talk about weighing the value of human life against the health of the nation’s economy and the strength of the stock market. It’s true that a depression would cause untold suffering for people around the world, hitting the poor the hardest. Still, each human life is more significant than a trillion-dollar gross national product. Stocks and bonds are important, yes, but human beings are created in the image of God.

We must also reject suggestions that it makes sense to prioritize the care of those who are young and healthy over those who are elderly or have disabilities. Such considerations turn human lives into checkmarks on a page rather than the sacred mystery they are. When we entertain these ideas, something of our very humanity is lost.

Social distancing and shelter-in-place initiatives are hugely disruptive; that is true. People who need to be working, and who cannot work from home, are suffering. That’s why we need both the government at work to enable us to help one another through this time, and why we need a vibrant civil society to empower people to care for one another.

posted by mumimor at 5:10 AM on March 26, 2020 [7 favorites]

I have a lot of complicated feelings about this: as someone who is disabled, in one of the hotspots, and who has been trained in triage. I don’t really know how to resolve those feelings.

I very firmly believe you should give scarce medical supplies/time to those most likely to survive, who would not be likely to survive without your intervention, thus maximizing the life you are able to save. So I think there’s probably some middle ground between “give everything to the young and healthy” and “give everything to those most likely to die”. I can’t chart it though - my knowledge of triage is so basic and immediate and I suspect this is a calculation that requires enormous amounts of data and math.

But also in this case the shortages are so dire that these triages may kill entire portions of populations. Does that affect those calculations? Should it? I honestly don’t know - and I say this as someone who is likely to be triaged, should I worsen, as “do not give care”. And quality of life calculus also seems impossible - who can judge how one enjoys the life they are given?

But also, doctors having to choose this on the fly seems likely to be discriminatory even if they don’t mean to.

I don’t really know what the answer is, and it bothers me.
posted by corb at 5:24 AM on March 26, 2020 [20 favorites]

If you honestly disagree with pursuing a policy of maximizing probable remaining years times quality of life then you need to propose another metric for rationing scant resources when not everyone can be saved and explain why your metric is more justified.

We're talking about the USA here, yes? The usual USA metric is already being applied to allocation of scarce COVID-19 tests. Rich, powerful, and famous people can get tested, while poor or merely ordinary people are sent home to quarantine. The same metric will be applied to "triage," because it always is. If there are two beds available, and you, Mitch McConnell and Jeff Bezos need treatment, you're not going to get it.
posted by Kirth Gerson at 5:28 AM on March 26, 2020 [50 favorites]

The following article was incredibly difficult to read and made me weep, but it should probably be added to this discussion: Emanuel et al. (2020 March 23). Allocation of Scarce Medical Resources in the Time of Covid-19. The New England Journal of Medicine. DOI: 10.1056/NEJMsb2005114. (Open access.) The authors make several recommendations about allocating care in the section "Who gets health resources in a covid-19 pandemic?" which Dr. Esther Choo nicely summarized and commented upon in a thread on Twitter.
posted by k8lin at 5:50 AM on March 26, 2020 [6 favorites]

I've been teaching bioethics (a new course for us)for the past two years, and in fact there are all kinds of disagreements about how to perform an ethical triage.

As others have suggested, the main problem is this utilitarian notion of "Quality Adjusted Life Years" -- who will have the most years with a decent quality of life. And the problem here is that temporarily nondisabled people (as we able-bodied people mostly are) are terrible at estimating the quality of life of people with disabilities. That is why the patient needs to be involved in these decisions...

I know, there's no time, and this is a real emergency.

But remember that even the king of Distributive Justice, John Rawls, says that distributions that result in inequalities have to be reasonably justifiable to those who are in the least well-off position.

In short, the proper ethics of triage is not well established, and a just society would look very different, and very much better prepared for these events, than the one we live in.
posted by allthinky at 5:54 AM on March 26, 2020 [52 favorites]

Well, I'll try: what I find most infuriating is that the situation isn't really that bad yet. They are already planning inhumane practices before it is even necessary. I can see the importance of being prepared, but this seems like sadistic roleplaying.

Whenever I hear bioethicists talk about who's going to live and die in situations where it doesn't even seem like there's going to be a need to make those decisions, I am always reminded of the Onion classic In Retrospect, I Guess We Might Have Resorted To Cannibalism A Bit Early.

I don't want to say that these kinds of discussions are completely unnecessary, but they are also not free of downsides in terms of how they affect our perception of older people and people with disabilities.
posted by Ralston McTodd at 6:02 AM on March 26, 2020 [10 favorites]

As a healthcare system we have not prepared for this kind of thinking for ICU resources. ED have more practice for mass causality situations working on triage, but even then the fundamental assumption is stabilize and see if you can send them somewhere else. There is no where to hide right now. Every one of oursociety’s flaws are coming out in this crisis. Leadership at all levels(including hospital systems) has been fairly inept. Particularly when we have so many decision makers who are so far removed from the impact of their decisions.

I think a better thing would to have national conversation about advance directives. It makes it a hell of lot easier to make the decisions if someone said i would like to give a shot for a week on vent, but if I am going to be stuck on it for a month. I’d rather have the tube pulled. Then let everyone in their family know that and put it writing. Everyone above the age of 18 should have an advance directive if they have ever had a physical with a doctor. But our system doesn’t reward this kind of thinking.
posted by roguewraith at 6:10 AM on March 26, 2020 [3 favorites]

Allthinky, does the quality of life adjustment need to take into account anything not related to the current situation? It seems like the protocols could separate affects of covid - 19 from pre-existing life factors. So if someone comes in who is in a wheelchair or needs regular dialysis and the expected outcome of treating their covid-19 is that they would go home in pretty much the same state as they were in before they got covid-19, that seems different than if someone already has so much covid-19 related lung damage that even if you put them on a vent and save their life, they will always have significant lung function problems.
posted by jacquilynne at 6:10 AM on March 26, 2020 [2 favorites]

If you delay these decisions to next week - the likelihood is that worse decisions will be made and even more people will die.

What has been delayed, not for weeks but for months, is planning for the reality of a global pandemic. Coming at me with furrowed brows and talking about "decisions" is not going to calm me down. I understand that US politicians are ignorant and malicious. But US healthcare staff, at all levels, have known for ages that this would happen at some point, and yet they have been focused on their individual and corporate bottom lines.

I'm really, really angry, because someone I know is on the very front line of this, and I blame every single healthcare professional who has not worked towards universal healthcare in the US. Wether they work with care or admin or finance.

I know that a huge number of healthcare professionals have been working for a better system, and are working now to save lives. I respect them and hope they will carry through these dark times. But it doesn't change the overall situation.

I know that now we are here, and we have to deal with the reality that is given in the best possible way. And that involves triage. But how on earth do you expect the general public to trust a profession that has neglected the common welfare for generations?
posted by mumimor at 6:15 AM on March 26, 2020 [6 favorites]

Unless I'm misunderstanding things, it seems inappropriate in this instance to focus on "triage" in the distribution of Chloroquine. The drug has known efficacy in treating some conditions and if it is in short supply then it should be reserved for those people for whom it has been prescribed. The current shortfall is being caused by people purchasing it - with some anecdotal claims of doctors lying to obtain the medication for themselves and family members who do not have legitimate prescriptions - to treat conditions for which the drug is not known to work. Unlike the many heart-wrenching decisions that healthcare professionals and others have to make in determining how to distribute scarce resources, this seems like a pretty simple decision: Ensure the people who actually need (i.e., have legitimate prescriptions) the medicine receive it instead of allowing it to be siphoned off by people who are panicking and don't really need it. Kaiser Permanente needs to do what it can to make this happen, too, not just shrug its shoulders and say "oh well - that's capitalism for you!"

(And if the U.S. president continues to cause panic like this then we need our colleagues in the media to stop perpetuating his lies. Stopping real-time broadcasting of his speeches to ensure that only the true and helpful information is propagated would be a great start.)
posted by ElKevbo at 6:36 AM on March 26, 2020 [28 favorites]

Why will a health insurance company cover a drug for an off-label use? They never have in my entire adult life. Are the doctors prescribing chloroquine lying to get it for their patients? What exactly is going on here?
posted by Automocar at 6:43 AM on March 26, 2020 [6 favorites]

Look at what anem0ne posted over at the other thread: seems like the french scientist who published a study on the efficacy of chloroquine therapy on covid-19 patients... has faked data in the past and is super sketch.

posted by mumimor at 6:47 AM on March 26, 2020 [12 favorites]

And yes, the triage questions and Kaiser's unfounded decision are two different things, but they both point to the total failure of the US healthcare system, as it is exposed by the corona virus.
posted by mumimor at 6:49 AM on March 26, 2020 [1 favorite]

After all this people are going to be wringing their hands and talking about the tough choices they were forced to make, but I bet nobody is going to be talking about the unforced choices they made which left us unprepared.

This is already pissing me off. It's not even just 'what do we do when disabled people get the disease'; it's 'can we divert resources to allowing disabled folks to self-isolate and avoid the disease in the first place?'

One of my close friends is autistic, epileptic, and has a nasty heart condition and lives in an assisted living scheme with primarily old people. They work in the mail service, so their job is essential and won't be closing, but they are highly vulnerable to a COVID infection. They're young and otherwise able-bodied, though, so there will be no aid at all coming in to give them the financial resources necessary to self-isolate and prevent this hard decision from being made. Their fucking disability income was reduced several months ago, and like most disabled people they're pretty fucking poor; the only reason they're self-isolating is that a mutual friend is literally paying their rent right now to keep them from taking shifts, because otherwise they couldn't afford to.

This doesn't have to be a decision that gets made at the point of triage. For fuck's sake, providing resources to allow self-isolation to exist is a necessary component of stopping the spread of the disease especially among poor people with no financial padding, which is (surprise, surprise) the case for an awful lot of disabled folks. And in that absence, well, people get desperate.
posted by sciatrix at 7:26 AM on March 26, 2020 [26 favorites]

Lots of complicated feelings about triage and allocation of ventilators from this doctor, who takes care of cancer patients every day and who knows that if we run out of ventilators, my patients (who are not uncommonly in pretty good shape other than their cancer diagnosis) will be the ones who won't be offered mechanical ventilation. My mother, who is 60 and has a chronic autoimmune condition and a litany of other health issues, wouldn't be offered MV.

I called my MIL last weekend to remind her to get her Plaquenil filled - she is supposed to be on it for an autoimmune condition - and she told me that she had stopped taking it a few months ago because of concerns for a possible arrythmia. But then she asked me if I thought she should get it filled "just in case" because she, my FIL, or someone else in the family might need it. I tried to talk her out of it, but I'm pretty sure she got it filled anyway.

I'm in several facebook groups for COVID19 and health care providers - a fair number of people asking about antimalarials and prophylaxis, but more doctors shouting them down. Doesn't stop people from writing prescriptions for it, but hopefully we can shame enough people into doing the right thing. I haven't been super-impressed with the data that I have seen, and am not writing for or recommending it. And although Texas has really done a pretty crappy job of responding to the pandemic, the pharmacy board has instructed pharmacies not to fill scripts unless for a documented autoimmune condition (which of course inspired the ire of a whole lot of HCPs screaming about "what right do they have" - you numbskulls, they're trying to keep us from doing harm).

We haven't even seen the full force of this yet in TX. The last thing we need to have are runs on currency and ineffective therapeutic agents.
posted by honeybee413 at 7:27 AM on March 26, 2020 [9 favorites]

The US's largest healthcare system, the Veterans Healthcare Administration (VHA/VA), in 2010 developed guidelines for allocation of scare resources in a pandemic. These guidelines have been affirmed as what VA will use in Covid-19.

The guideline has goals of being consistent and fair and seeks to do the most good for the most people. A "Scare Resource Allocation" team who aren't doing direct patient care makes the decisions about who gets the scarce resources. Excluded from such care are people with pre-existing limited life expectancy (e.g. metastatic cancer), advanced dementia, and persistent vegetative state. Those excluded, those who choose to forego critical care, and those triaged (literally: sorted) out of it are to be given good palliative care.

Triage of sick patients is based on SOFA score, a measure of illness severity. Age isn't a criterion; older patients will tend to have worse SOFA scores based on their chronic illnesses and aging physiology. Access to scarce given is given to those who need it who have a better prognosis, which is what SOFA predicts. Patients with equal SOFA scores are treated on a "first come, first served" basis. The process in the guideline is to be used only when a "crisis standard of care" is invoked [nationally, I think].

Patients' SOFA scores are updated every 48 hours. Covid patients in respiratory failure tend to take a long time to recover and be weaned from mechanical ventilation. If ventilators are taken from patients too soon, there will be few survivors. The makes the SAR team's job trickier.

I'm a doctor at a small, rural VA hospital which doesn't yet have any Covid patients, in a state with relatively few cases. Our hospital has no ventilators, having closed our ICU a few years ago. We hope that patients who show up here sick can be sent to the private sector hospitals who do have ICUs, but I fear that those hospitals will overfill and refuse transfers. Then we will be in a hard spot.
posted by neuron at 7:34 AM on March 26, 2020 [30 favorites]

If we're being strictly utilitarian then we should take into account life expectancy by group. If group A lives longer than group B then it makes sense to give resources to a group A person over a group B person if they're the same age.

This article says that LGB people in high stigma areas have a 12 year shorter life expectancy than LGB people in low stigma areas. So if you're an LGB person, I hope you're getting triaged in a coastal city instead of the rural interior. And obviously this sort of thing is partly why there's a different life expectancy in the first place.

This is wrong. People should be entitled to the same level of care, as equal human beings. Triage should be based on stuff like what medical resources does this person require and are they responding to treatment. In extreme cases, such as we might unfortunately soon face, we can consider things like the stuff neuron mentioned, such as late-stage cancer. But we shouldn't play musical beds and ventilators with the broad mass of humanity in the middle. That's just opening the door for people to start indulging their worst prejudices.
posted by bright flowers at 7:41 AM on March 26, 2020 [5 favorites]

the triage questions and Kaiser's unfounded decision are two different things

I respectfully disagree- in both cases it's exposing how the medical system devalues the lives of the disabled. RA and Lupus and the other chronic conditions that Chloroquine can treat are inherently disabling, and by taking those drugs away from those patients Kaiser is prioritizing Hypothetical sick abled people over Real sick (and treatable) disabled people. This sort of treatment from the medical community is EXACTLY why various disabled groups are upset about the triage orders- because WE KNOW how doctor's value our lives and therefore any triage order that isn't EXPLICITLY non-discriminatory is going to value abled lives over disabled lives.
posted by Homo neanderthalensis at 7:41 AM on March 26, 2020 [20 favorites]

I'm an old guy in the crosshairs. I concentrate on what I can do and try to ignore the rest. I can stay factually informed. I can practice science-based hygiene. I can avoid humanity obsessively at every given opportunity. But should I catch it anyway, I'll be grateful for any help and comfort offered. The rest is beyond my control...
posted by jim in austin at 7:45 AM on March 26, 2020 [2 favorites]

Do bioethicists recommend prioritizing women over same-age men in a triage situation like this, since they live longer on average? Or are only older people and people with disabilities judged to have fewer quality-of-life-adjusted years for the purpose of rationing? (I really don't know the answer to this, I'd be interested to hear, though.)
posted by Ralston McTodd at 7:50 AM on March 26, 2020 [10 favorites]

mass causality situations

That's the kind of typo from which science fiction trilogies are born.
posted by thatwhichfalls at 8:09 AM on March 26, 2020 [15 favorites]

Scoring systems like SOFA don't explicitly take the patient's sex (or age) into account. But if on average men are less healthy and have a worse score and thus worse prognosis, then it follows that women would receive more care. However, this paper says "There were no gender-related differences in mortality or length of stay. [...] In this cohort, gender was not associated with increased mortality during a 2-year follow-up period. SOFA score at ICU admission was a stronger risk factor for hospital mortality for women than for men." So it's not clear that the assumption that men have a worse prognosis is true.
posted by Kadin2048 at 8:09 AM on March 26, 2020 [4 favorites]

After n+3 years of arguing about trolley problems in the context of self driving cars, the internet discovers triage...

If I recall correctly, the correct answer is "fuck Elon Musk."
posted by kaibutsu at 8:10 AM on March 26, 2020 [16 favorites]

I'm also squarely in the "won't get a ventilator" category. I'm 61 and have a cancer that is considered incurable, though without a pandemic, I could live for decades. I don't want to die, but I accept that I shouldn't get a ventilator over a healthy 25-year-old. I'm not sure if I should get one over a healthy 80-year-old, but it's not going to be a decision I can do anything about.
There is unfairness in the situation that irritates the shit out of me. I know old, rich, famous people will get the best medical care that exists. If you want to know when I lost faith in the system, it was in 1995. Look up "Mickey Mantle liver transplant." Here's a piece on it.
But the thing that angers me the most is that this whole shitshow didn't have to happen this way. And I wish there were a way the people who voted that jackass into power would reap the consequences of their actions.
posted by FencingGal at 8:18 AM on March 26, 2020 [17 favorites]

I seriously thought the Kaiser letter was a fake, especially with the "do not contact your doctor". It makes no sense. But Buzzfeed confirmed it directly. It certainly provides more evidence that scientists, medical professionals and doctors can panic and make bad decisions, too.

I'm holding out hope this will be overturned.

Coronavirus: Malaria drug has no impact on treating Covid-19 patients, Chinese study finds (The Independent)

Chloroquine's effectiveness is totally speculative at this point but that is a bad article. It was a small study with almost 100% recovery in the control arm. Once that happened you couldn't have had a positive outcome even if it were a "miracle drug." The study didn't find anything, positive or negative. (The term of art here would be the study was "insufficiently powered.")

I will reiterate that the attention the drug is getting is insane. If Trump were a pharma CEO talking about a drug in the terms he used, he'd be facing an FDA fine and SEC investigations.
posted by mark k at 8:23 AM on March 26, 2020 [11 favorites]

There’s a scene in the sci-fi series The Expanse, when the subject of Are we gonna toss someone out the airlock without a suit or not? is under discussion:

Kenzo: It must be nice, having everything figured out like that.
Amos: Ain’t nothing to do with me: we’re just caught in the Churn, that’s all.
Kenzo: I have no idea what you just said.
Amos: This boss I used to work for in Baltimore, he called it the Churn. When the rules of the game change.
Kenzo: What game?
Amos: The only game. Survival. When the jungle tears itself down and builds itself into something new. Guys like you and me, we end up dead. Doesn’t really mean anything. Or, if we happen to live through it, well that doesn’t mean anything either.

Welcome to the Churn, folks.
The rules that govern the Game of Survival are undergoing rewrite.
posted by Pirate-Bartender-Zombie-Monkey at 8:27 AM on March 26, 2020 [9 favorites]

what I find most infuriating is that the situation isn't really that bad yet. They are already planning inhumane practices before it is even necessary. I can see the importance of being prepared, but this seems like sadistic roleplaying.

NYC-area hospitals seem to be on the verge, if not this week then soon. The only reason it hasn't happened yet is because they are working as hard as possible to increase capacity to keep up. It's not roleplaying for the physicians staring down the barrel of this thing.
posted by BungaDunga at 8:35 AM on March 26, 2020 [14 favorites]

Welcome to the Churn, folks.
The rules that govern the Game of Survival are undergoing rewrite.

Triage is not new. It just feels new, because in the modern US, we have always had enough capacity to take care of everyone (in theory). Now we are facing a situation where we very well might not. The rules are about the same as triage always has had. It's just that it's here, now, rather than somewhere else.
posted by BungaDunga at 8:47 AM on March 26, 2020 [19 favorites]

Actually, thinking more about organ transplant (see my earlier fury about Mickey Mantle), that is one area that affects people in the US now, but those of us who don't know anyone waiting for an organ can easily not have to think about it. Steve Jobs worked legally within the system (at least we are told that), but he gamed it because he could jet to whatever city in the US had an organ for him.

Twenty people die every day waiting for an organ transplant. We can't manufacture organs (and someone I knew who had a liver transplant told me that auto airbags have reduced available organs). Obviously, this is a smaller number of people than we're looking at here, but this means that triage happens in the US every day.
posted by FencingGal at 9:10 AM on March 26, 2020 [11 favorites]

This thread isn’t about “the churn” or any other scifi nonsense- it’s about actual real deal ableism in the here and now.
posted by Homo neanderthalensis at 9:10 AM on March 26, 2020 [13 favorites]

Couple comments removed. Folks, please try to aim more for the specific subject of the post and not just free-wheeling tangents.
posted by cortex (staff) at 9:13 AM on March 26, 2020 [4 favorites]

this seems like sadistic roleplaying

NYC is rapidly approaching the point where this kind of triage may become necessary (and indeed NY state already has guidelines on care allocation written several years back). Nonetheless, you can definitely tell the people who take a sort of grim relish in "having" to "make the hard decisions." Those fuckers are dangerous.
posted by praemunire at 9:30 AM on March 26, 2020 [10 favorites]

The post was originally about withholding a drug from people who need it because there MAY be benefit for those with COVID-19.

I don't see that it has been well established that chloroquine is effective, and that means rationing in advance is not yet called for.

I fall VERY strongly on the "save the one who has better odds of living" side of the ventilator shortage issue. The chloroquine shortage issue is nowhere near as clear cut, and it does the whole discourse a profound disservice to conflate these two things.
posted by tclark at 9:33 AM on March 26, 2020 [3 favorites]

I fall VERY strongly on the "save the one who has better odds of living" side of the ventilator shortage issue.

Ok. Healthy 20 year old versus not-so-healthy 50 year old. 50 year old is able bodied- 20 year old has downs. Without an EXPLICIT directive from the state banning taking disability status into triage account- Very good chance the nurse/doctor making the decision makes the decision to pull the vent from the 20 year old. After all- the 50 year old is "healthier". The pulling of chloroquine from disabled patients who need it IS THE SAME ISSUE. Doctor's are telling them, their actual lives are worth less then hypothetical lives. Triage will be necessary- but with the ableism present in this country as evidenced by the Kaiser letter- if the triage directives aren't made in concert with disability activists quite a lot of "triage" is going to be murder.
posted by Homo neanderthalensis at 9:42 AM on March 26, 2020 [12 favorites]

The actual issue, as shown in Italy isn't "Healthy 20 year old with Down's syndrome vs Not-so-healthy 50 year old without it."

It's five people dying, and one ventilator. This is what is happening in the world. Today. Right now. In Italy. Bodies stacked in ice rinks in Spain.

I get it, shitty ableism will inform the decisions doctors make, and that should not be tolerated. But the days of hypotheticals are over. I still contend that the ventilator issue is NOT the same as the chloroquine issue.
posted by tclark at 9:50 AM on March 26, 2020 [17 favorites]

The doctors and nurses working on the front lines of COVID and the insurance administrators making insane decisions about rationing chloroquine are technically both part of the medical community, but they're very much not the same people.
posted by BungaDunga at 9:54 AM on March 26, 2020 [8 favorites]

Crossposting: “I expect that there will be much higher rates of infection and death in low-income communities and even more so in low-income communities of color because of all the pre-existing conditions—both medical and social conditions,” Mark Mitchell, an associate professor of climate change, energy, and environmental health equity at George Mason University and chair of the National Medical Association Council on Medical Legislation, told Earther.

These social conditions include higher rates of poverty, inequalities in healthcare, and disparities in access to paid leave. There are also lifestyle practices, such as multi-generational housing where grandparents, their children, and grandchildren may all live under the same roof. This is more common among immigrant families and people of color. So is the regular use of public transit.
--
DoD to Provide 5 Million Masks, 2,000 Ventilators to States from Strategic Reserves (Military Times, March 17, 2020)
More lifesaving ventilators are available. Hospitals can’t afford them. (Washington Post, March 18, 2020)
--
(I agree, the ventilator issue isn't the same as the chloroquine issue, except for how they're both being withheld from the people who need them.)
posted by Iris Gambol at 9:56 AM on March 26, 2020 [6 favorites]

Chloroquine issue is extronidarily important because it isn't even a thing that is even proven to be helpful, but Kiaser isn't a government. What it is a heath system and insurer which runs on profits. We desperately need a fix to how much for profit companies can impact out heathcare in the US. iSo that when a drug siupply uns low it doesn't mean that the price can be hiked orb the insurance company can change the medicine. Or deny the treatment for a unique thing, or create hurdles to make it harder to get the care needed.Ultimately, the Chloroquine issue is a sign of the systemic problems in the health system, but it really isn't unique to this crisis. It definately needs to be changed.
posted by AlexiaSky at 10:07 AM on March 26, 2020 [7 favorites]

NewYork-Presbyterian is doubling up some people on ventilators. Two people on one ventilator.
posted by BungaDunga at 10:07 AM on March 26, 2020 [3 favorites]

(this does not double ventilator capacity because you have to very carefully match patients, and also it's never been done before long-term, so nobody knows how well it will work)
posted by BungaDunga at 10:10 AM on March 26, 2020 [7 favorites]

For the record, Kaiser is a non-profit. They are my health insurer, and they have always seemed very focused on evidence-based medicine and providing the best health care-per-dollar to their patients. I have no idea what they are thinking here, taking drugs away from people that need them to give to people that the drugs apparently won't even help. I am pissed and will be sending them some angry emails.
posted by agentofselection at 10:13 AM on March 26, 2020 [14 favorites]

I blame every single healthcare professional who has not worked towards universal healthcare in the US

I'm a registered nurse and I don't spend all my days off working towards universal healthcare, so I guess you're talking to me?

These are terrifying times for everyone, and if blaming me helps you manage your anger and fear, so be it. It's always been part of a nurse's job.
posted by jesourie at 10:47 AM on March 26, 2020 [39 favorites]

For the record, I'm not thinking about people who go on with their lives, but about those who have been actively fighting against better healthcare in the US, in spite of the fact that every single developed country has better outcomes and less expense. If you are one of those people, yeah, you need some meditation time.
If you are just a normal hardworking nurse, thanks for your service.
posted by mumimor at 10:54 AM on March 26, 2020 [1 favorite]

doctors having to choose this on the fly seems likely to be discriminatory even if they don’t mean to.

Yes, this. This applies to both medicines of the might-work-for-COVID-19 variety and for ventilators.

In the first case, we have a system: Give the meds to the people for whom they are prescribed, and DO NOT pull them away for the maybe-chance that they'll work on some other condition; this system does not change for a pandemic. If there were existing proof that the medicines worked on COVID-19, we'd have a different issue, similar to the ones hospitals are facing with masks, gowns, and gloves: Do we use resources as normal, and COVID-19 gets whatever's left (or whatever can be produced quickly), do we prioritize the pandemic, or do we juggle between them? But the drugs ARE NOT guaranteed useful against COVID-19 the way that masks are.

In the second... we're going to see a lot of innovative and risky techniques like 4 patients on a ventilator, some of which are going to work and some of which are going to end in 4 deaths instead of 2 or 3. We're going to see some vile examples of discrimination of many sorts. We're going to see heroism from both medical staff and patients.

And we cannot possibly have too much talking about this, because there's the off chance that some of those random conversations here or on Twitter or Facebook or Tumblr or in some hospital break room are going to result in an "aha!" moment that saves thousands of lives. And we need all of those "aha!" moments that we can possibly create.
posted by ErisLordFreedom at 11:05 AM on March 26, 2020 [10 favorites]

Does anyone have reliable statistics on how many people with COVID-19 are actually saved by going on ventilators? I found an unsourced quote on another site I'm on that said, worldwide, 86% of people who go on ventilators die anyway and that in Seattle it's been 70%.

My mom was on a ventilator before she died from complications of cancer, and it did not do anything but keep her technically alive a little longer. She never even regained consciousness and died when we had it turned off.

(Since I'm not getting a ventilator if theres a shortage, maybe part of this is trying to make myself feel better. But I feel like there's sometimes a sense that getting a ventilator or not means life or death, and that seems like it's way too simplistic - like the chance of living if you get to that point is not great anyway. And are there issues besides ventilators and chloroquine that are going to make more of a difference? That's why I'm thinking this is pertinent, though of course, mods can delete if it's not.)
posted by FencingGal at 11:08 AM on March 26, 2020 [6 favorites]

Yeah, the ventilator issue is extra complicated because it's not "with ventilator, the patient lives." It's "without ventilator, the patient definitely dies. With ventilator, patient might live. Not quite sure what changes the odds for that."

That makes all the decision-making more fraught, because in many cases, there's not going to be any confirmation that they made the "right" call.
posted by ErisLordFreedom at 11:11 AM on March 26, 2020 [4 favorites]

Does anyone have reliable statistics on how many people with COVID-19 are actually saved by going on ventilators? I found an unsourced quote on another site I'm on that said, worldwide, 86% of people who go on ventilators die anyway and that in Seattle it's been 70%.
Someone asked this question on our local public service ask site (in Denmark) a week ago, and the doctor answering said that most people on ventilators survive. (There have been thousands of questions since, I can't find it again). It's been a week, everything may be different now.
That said, US hospitals have different general rates from other countries' hospitals, for a number of reasons. But I don't think general statistics are relevant when it comes to the coronavirus.
posted by mumimor at 11:19 AM on March 26, 2020 [1 favorite]

Wow. I'm pretty cynical but I never expected this would happen so fast. It took less that two weeks of inconvenience to awaken America's inner Nazi and turn 35% of us into eugenicists for the stock market.
posted by Everyone Expects The Spanish Influenza at 11:21 AM on March 26, 2020 [14 favorites]

Just wanted to add to Neuron's excellent comment that the broad strokes of the VA's guidelines are also in effect elsewhere. Here are NY's ventilator allocation guidelines, which were mostly modeled for influenza epidemics. It is a long document, but is reassuring when I did quick skim of the adult ventilator guidelines, which seemed to state that they wanted to make sure they were trying to not discriminate as much as they could and focus on the clinical presentation of each patient. They also describe various ways that they considered triaging and why they weren't pragmatic or as ethical. The doc also has some ventilator statistics, although pre-COVID-19, if you were curious. (Shorter FAQ)

As with most of these kinds of rational systems that we put into place, they are flawed and can never truly retain the humanity and compassion that we desire.

I wish we were in a society where we could have easier conversations with loved ones as to what their end-of-life plans would be, and whether it'd be best to have a do-not-intubate/do-not-resuscitate plan in place. Most of the time, I think we would like to make these decisions for ourselves and not have to put the onus on others, if we knew what intubation would really do and how it'd affect our survivability and quality of life. Unfortunately, there are some more unknowns here with COVID-19, but perhaps is worth talking with anyone affected or on the front lines.
posted by sincerely yours at 11:24 AM on March 26, 2020 [5 favorites]

But going back to the original post -- I agree it's fucked up and a bad medical choice. Certainly Kaiser should be refusing to fill any spurious new prescriptions, and I think it is valid to not fill extra stocking up prescriptions while the medication is under study for effectiveness against COVID-19, but they certainly should continue to fill the normal prescriptions for sick patients. Autoimmune disorders are no joke.

I'm wondering how high up this came from -- Kaiser has a new CEO, after all. They've been an excellent health care provider for me for decades, I hope this is not an opening sign of them being run into the ground.
posted by tavella at 11:25 AM on March 26, 2020 [3 favorites]

In cases of acute disease, saving the one who you think has the highest chance of making it through is often going to be at odds with what would normally be considered able-ism.

Note this is not "quality adjusted life years" or whatever. This is short term decision making. Someone generally considered non-disabled but with asthma, or just someone in their fifties having a really hard time, would not be preferred over someone "disabled" but with healthy lungs.

Personally I think my preferred triaging in terms of acute emergency care is the doctors delivering it on the scene make the decisions they think will have save the most lives over the next 3-5 days. (The whole chloroquine rationing is a different case.)

I'm not saying the discussion is about non-issues or implicit bias is not a concern.

Does anyone have reliable statistics on how many people with COVID-19 are actually saved by going on ventilators? I found an unsourced quote on another site I'm on that said, worldwide, 86% of people who go on ventilators die anyway and that in Seattle it's been 70%.

Access to well resourced intensive care in general seems to make a 5x to 10x difference in survival rates based on comparing Italy, South Korea, early China, late China reported numbers. Assuming triaging ventilator use is a stand-in for triaging this kind of expensive care in general, I think that is the sort of number to consider.

I'll assert data is not be collected at this point to make meaningful claims about 10% changes in survival rate relating to specific treatments and around subgroups. I'm seeing more of those floating around my circle (which is mostly scientists) but there's no way there are currently the data sets to reach valid conclusions.
posted by mark k at 11:26 AM on March 26, 2020 [4 favorites]

Meanwhile, on the chloroquine thing, here's a well referenced blog post citing whether the research on it is correct. Specifically Trump seems to be taking directions from a small study published by Didier Raoult; this blog post is about bad science published by Raoult in the past. More on Twitter. I'm not equipped to verify the original paper or this critique but it seemed interesting and, like I said, well referenced.
posted by Nelson at 12:00 PM on March 26, 2020 [2 favorites]

Deciding who to put on a ventilator is a numbers game. You are taking various variables into account and saying "okay, we think this person is more likely to survive, based on these various characteristics" but we don't KNOW. Plenty of people with at-risk conditions survive, and completely healthy people die. The truth is, without extremely complicated calculations that we do not even know how to do, we have no way of definitively saying, "This individual person is more likely to survive than this other individual person." There are just too many other variables that go into survivability and quality of life.

Per this systematic review, men are more likely to die from community-assisted pneumonia after hospitalization. Worse outcomes are also found for people with lower education, lower income, and who are unemployed (though to be clear: not higher mortality--just risk for relapse and readmission, which would still be a problem in this scenario). So why aren't those people being considered "less savable"? (To clarify: I don't think they should be.)

Anyway, if you stand by the numbers game, a good way to help is to put yourself at risk delivery groceries for disabled people. Since you have a lower risk of needing to use hospital resources, and all.
posted by brook horse at 12:21 PM on March 26, 2020 [6 favorites]

*Community-acquired, though community-assisted is not necessarily far off...
posted by brook horse at 12:30 PM on March 26, 2020

Stockpiling Ventilators for Influenza Pandemics (CDC.gov, Volume 23, Number 6 -- June 2017)[...] the United States has stockpiled mechanical ventilators in strategically located warehouses for use in public health emergencies, such as an influenza pandemic. The Centers for Disease Control and Prevention (CDC) manages this Strategic National Stockpile (SNS) and has plans for rapid deployment to states during critical events.

However, SNS ventilators might not suffice to meet demand during a severe public health emergency. In 2002, the SNS included ≈4,400 ventilators, and 4,500 SNS ventilators were added during 2009 and 2010. The American Association for Respiratory Care suggested the SNS inventory should increase to at least 11,000–16,000 ventilators in preparation for a severe influenza pandemic . The American Association for Respiratory Care and CDC (11) provide training on 3 types of SNS ventilators—LP10 (Covidien, Boulder, CO, USA); LTV1200 (CareFusion, Yorba Linda, CA, USA); and Uni-vent Eagle 754 (Impact Instrumentation, Inc., West Caldwell, NJ, USA)—to ensure proper use nationwide. In addition to the nationally held SNS, some US states maintain their own stockpiles. [...]

As a case study, we considered the US state of Texas under mild, moderate, and severe influenza pandemic scenarios. Based on the Texas Department of State Health Services (DSHS) response to the 2009 influenza A(H1N1) pandemic and planning efforts for future pandemics, we considered stockpiling across 9 sites: a centrally held state stockpile and local stockpiles in each of Texas’ 8 health service regions...
posted by Iris Gambol at 12:35 PM on March 26, 2020

It took less that two weeks of inconvenience to awaken America's inner Nazi and turn 35% of us into eugenicists for the stock market.

if the discovery of this kind of ableism is legitimately brand new information to you then i don't even know what to tell you
posted by poffin boffin at 12:45 PM on March 26, 2020 [8 favorites]

"Per numbers from the Society of Critical Care Medicine, U.S. hospitals have a total of 160,000 ventilators—62,000 modern units immediately available and 98,000 obsolete ones that can be pulled out of storage in an emergency situation. The Centers for Disease Control and Prevention Strategic National Stockpile has an additional 13,000 ventilators, which can be accessed by request from state health officials and deployed within 36 hours. Like the CDC, states can order and maintain their own stockpiles of ventilators for emergency deployment. Yet, as American COVID-19 case numbers track just days behind those of Italy, the American Hospital Association estimates that up to 960,000 patients may need ventilatory support. Our current supply is woefully insufficient... But here are some options for what the federal government could do to help." (Slate, March 18, 2020)
posted by Iris Gambol at 12:56 PM on March 26, 2020

I'm not quite as relieved by those NY Guidelines. At first blush (and a quick ctrl-f) there will already be systemic differences in treatment based on the evaluation methodology.

Data point:

From New York State Task Force on Life and the Law: VENTILATOR ALLOCATION GUIDELINES:

"A patient is assessed initially for inclusion and exclusion criteria; if inclusion criteria are present and exclusion criteria are absent, patients are then evaluated using a clinical scoring system to determine whether the patient should receive a ventilator therapy trial."

"The SOFA score adds points based on clinical measures of function in six key organs and systems: lungs, liver, brain, kidneys, blood clotting, and blood pressure."

And why, as it reads, it creates treatment disparities:

In particular, African-Americans present a unique public health challenge, with high rates of airflow-limitation and restrictive-pattern being associated with increased mortality but not respiratory symptoms.

African Americans are 3 times more likely and Hispanics are 1½ times more likely to have kidney failure compared to White Americans.

African-Americans are More Likely to Develop High Blood Pressure by Middle Age

African-American patients have a significantly higher rate of incident VTE... African-Americans are more likely to be diagnosed with pulmonary embolism (PE) than deep-vein thrombosis (DVT) compared to Caucasian and other racial groups

I'm of the perspective that these negative health outcomes for Black people is due to their systemic oppression in the U.S. The resultant health-related disabilities are then also the result of said systemic oppression.

Considering that those identified as disabled by the CDC are about twice as likely to be obese, smoke, have heart disease, or have diabetes I'm of the mind that the same is true for those with disabilities.

And that's the grossest thing to me. Those whom capitalism has pressed upon the most now exhibit resultant symptoms that will exclude them from care. Care that will need exponentially more rationing due to capital's insistence on biological/human life taking a backseat to market valuation. Healthcare practitioners are only in the position to make heinous decisions because capital has forced them into this position. Capital decided the answer to the trolley problem was to turn towards the 5 people tied to the tracks and now we're angry at nurses and doctors for triaging the victims that capital turned the train towards? Capital is the perpetrator!

A truly utilitarian approach would consider the future harm committed by the individuals chosen for care. Those with the most wealth should be the last treated, as the diffusion of their wealth nets positive for biological life IMO. Seeing as profits are necessarily theft from the resources of biomes/communities, the more investors, the worse for biological life. That's utilitarianism. You think saving the Bezoses and Bloombergs means more people won't be harmed as a result of their continued life's work? Please please please save anyone else.

Additionally, those who have made political decisions in defense of their 401ks, in my opinion, should come after any historically oppressed identities as well (sorry Dad!). Those choices have netted further negative for biological life than any purported valuation of life-quality that will be used to withhold care for those who deserve it the most. If you've voted with your market portfolio, and you're arguing for preservation of life in this thread, please live your truth and abstain from even going to the hospital if the time comes. I fear your continued contribution to future crises like the current one.
posted by avalonian at 1:28 PM on March 26, 2020 [18 favorites]

The Kaiser letter did say that chloroquine builds up in the system, so it's still going to have an effect for 40 days. They're just trying to not fill any prescriptions for a while, because they're getting flooded with them. People are scared and desperate, and looking to this because of Donald Trump's lies. He's boosting the chloroquine story because he wants to look good for 5 seconds, and he doesn't care how many people it kills. A guy died from taking aquarium chloroquine! There's a national plan for pandemic communication, and it's the opposite of Trump.

Today when the numbers are released, the US will leapfrog Italy and China to become the country with the most cases in the world. Just the 12,000 case increase yesterday would push us over, and we're nowhere near peak new cases per day. It's entirely possible we'll stay #1, depending on how countries like India fare. This situation was completely preventable. Look at South Korea.: through aggressive testing and tracing they kept their total to 9,200 cases. They peaked in new case rate about a month ago, so they have it well under control. That's not the only success story, and the US used to be one of the best at this. This time the whole system was frozen from the top, and we're getting the worst outbreak in the world.

100% of anger should be at Donald Trump and all the idiots in his administration. They fired the pandemic response team in 2018, and didn't replace them. They let this incredibly stupid situation with test approvals play out for week after week. They got briefings in how bad this would be in January (that's why they were selling stocks), but they pushed a "this is just the flu" narrative instead of getting ready. There are well thought out plans for this, collecting dust. Even now they're not invoking the defense production act, and touting this ridiculous "churches packed for easter" narrative that's influencing states like Texas and Florida to not shelter in place until it's too late. This is a tragedy on the scale of hundreds of 9-11's, and it's completely their fault. This is why everyone felt so gut-punched in 2016: this could happen.
posted by netowl at 1:29 PM on March 26, 2020 [12 favorites]

The Kaiser letter did say that chloroquine builds up in the system, so it's still going to have an effect for 40 days. They're just trying to not fill any prescriptions for a while, because they're getting flooded with them.

That's a justification for refusing to fill brand new prescriptions. It is no excuse for not filling long-standing prescriptions for patients who have depended on it for years. It is not the place of the pharmacy to decide for a physician whether their patient can go without their medication, and blithely announce that all such patients will be totally fine going cold turkey for 40 days.
posted by tavella at 1:37 PM on March 26, 2020 [20 favorites]

Now, if eventually there ends up being solid evidence of chloroquine being lifesaving for COVID-19, then reprioritizing distribution may become necessary. But withholding treatment for seriously ill individuals on speculation is malpractice, IMHO.
posted by tavella at 1:48 PM on March 26, 2020 [6 favorites]

The way for Kaiser not to get flooded with new prescriptions for speculative uses of chloroquine is to tell their doctors not to write prescriptions for that purpose.

The "40 days in your blood" sounds like a rationalization. I'm sure it's narrowly true, and I was trying to get details on the PK but need to get back to work. So I'll just stay going without for weeks to let other people stockpile probably means you're below the preferred steady state dose. This isn't necessarily catastrophic but seems exactly the sort of thing you should discuss with your doctor.

He's boosting the chloroquine story because he wants to look good for 5 seconds, and he doesn't care how many people it kills. A guy died from taking aquarium chloroquine

What Kaiser is doing is the HMO equivalent of taking mega doses of aquarium cleaner because you heard on the TV it's a miracle drug.
posted by mark k at 1:52 PM on March 26, 2020 [5 favorites]

Fox News picked up the Buzzfeed story two hours ago, as "Woman denied Lupus medication, thanked for 'sacrifice' for coronavirus patients"
posted by Iris Gambol at 2:48 PM on March 26, 2020 [1 favorite]

A truly utilitarian approach would consider the future harm committed by the individuals chosen for care. Those with the most wealth should be the last treated, as the diffusion of their wealth nets positive for biological life IMO.

So much this.

When I posted my pretty full-throated defense of utilitarianism upthread I was actually very afraid people were going to respond with “well what about rich people who claim their quality of life is intrinsically higher such that in addition to their already greater access to medical care they claim that favoritism for them is morally justified?”

To which: if you’re the sort of rich person who truly believes that or would even just advance that argument then your quality of life is actually a lot lower than you think because everyone around you correctly regards you as a ginormous gaping asshole and they’re just wearing fake smiles so they don’t become your next victim.

I have an excessive amount of lived experience with that exact type of rich person.

But just to be clear, my original comment upthread wasn’t about how the system *will* inevitably ration care, but rather whether there is a more ideal metric than aggregate years of quality of life... which is a metric where I fall in the lower middle of the pack and fully expect to be deprioritized. I can’t say I had a good run but it was at least an interesting one in deeply weird ways.

Apologies to those who find my views offputtingly logical or devoid of emotion: that is, ironically, the most outwardly visible aspect of my own disability.
posted by Ryvar at 2:51 PM on March 26, 2020 [1 favorite]

Boy am I glad I got my hydroxycholorquine prescription refilled before Trump opened his mouth.

I went to my rheumatologist this week to go over my blood test and eye exam results - hydroxychloroquine can built up in your eyes and cause liver damage so I get tested at least annually. The rheumatologist cryptically told me "you're one of the lucky ones. You've heard the news, haven't you?" Their office is getting constant requests for refills and new prescriptions.

My handy Davis' Drug Guide for Nurses tells me that the half life of hydroxycholorquine is 72-120 hours so I don't really understand where Kaiser is getting their claim that it lasts 40 days (from the Buzzfeed article).

I've been taking it for over a decade to control my autoimmune disease. Once I can refill my prescription, I sure hope there's some around for my refill.
posted by BooneTheCowboyToy at 3:18 PM on March 26, 2020 [9 favorites]

Hypothetical: me pushing 40 with serious asthma and a likely fatal Covid infection vs a 20-year-old person with the exact same chronic condition, general level of health otherwise and severity of infection. The other person should obviously get the remaining ICU bed and I should not, fucking duh. If I currently occupy an ICU bed and they show up, I should be removed from said ICU bed and they should take my place. Narrowing the hypothetical gap: someone else pushing 40 with a slightly better chance of surviving than me but still in need of an ICU bed should likewise be given my ICU bed, even if I'm already in it.

This utilitarian analysis ignores that you have received 40 years of societal investment and are likely a more valuable member. 20 year olds have only received 20 years of investment and are generally fuckwits. When people bring up utilitarian analysis I always like to say "OK lets murder infants first because we can make more very easily in short order" and then people look at me horrified like I am a sociopath in their midst.

Which I would be if I were actually a utilitarian.
posted by srboisvert at 4:06 PM on March 26, 2020 [25 favorites]

srboisvert, Becky Chambers's The Long Way to a Small Angry Planet has a species who functions according to that perspective. Reading it made for some really interesting thoughts and re-examining of my own assumptions.

Especially given years of life left is a complete unknown, whereas past personality and behavior is a known and should theoretically predict future actions.

The assumption that someone who has more (assumed) healthy years left is better for society and should always be saved over others is an assumption without necessarily conclusive evidence.
posted by brook horse at 4:18 PM on March 26, 2020 [10 favorites]

I think our worst instincts come to the fore when we contemplate suffering from anticipated shortages. In contrast, our best selves often emerge in the moment. From what I understand, triage or no, ventilators simply will not help many sufferers. It may be better to simply act with compassion in the present moment rather than attempt to engage in some hedonic calculus. I suppose I'm not likely to be one of those making decisions, but I don't think I could live with myself knowing that I had withheld medical care from a patient in front of me to benefit another one who had died anyway.

What got me thinking along these lines was this report on one nurse's experience with Israel's first corona virus casualty, 88-year-old Aryeh Even, a Holocaust survivor from Jerusalem: Nurse in virus isolation ward describes patients’ touching farewell to dying man.

More on anticipated medical shortages in Israel:
In Israel, where preserving life is core medical ethos, wrenching dilemmas loom

[...] Channel 12 reported on Wednesday afternoon that the price of ventilators has risen from $20,000 to $70,000 and Israel is competing for their purchase with wealthier nations.

Once a patient is on a ventilator in Israel, it is illegal for doctors to switch off the machine. “Regardless of who says what, we cannot stop it,” said Weissman. “We have no say and the family has no say; it’s just down to nature.”

This contributes to a situation in which, even as the coronavirus influx to hospitals starts to grow, the majority of ventilators nationwide are routinely in use[....]

Contrary to that last paragraph, another report says that Of a total 2,173 machines in medical centers, 708 are currently in use and another 28 are not working[....] Regardless, there's a strong possibility that Israel will be forced into some form of triage.
posted by Joe in Australia at 7:35 PM on March 26, 2020 [4 favorites]

Boy am I glad I got my hydroxycholorquine prescription refilled before Trump opened his mouth....I've been taking it for over a decade to control my autoimmune disease. Once I can refill my prescription, I sure hope there's some around for my refill.

Yeah, me too - and for the same reason. I'm also super glad I get mine 90 days at a time. The idea that my health insurance plan could arbitrarily decide I shouldn't get the meds I've been taking for years out of real and documented medical need -- all because a hypothetical person might hypothetically need it more at some point in the future -- is both terrifying and infuriating.

To be clear, if it were proven that hydroxychloroquine could save someone with COVID-19, I would happily hand over a few weeks' supply to make that happen. Hell, if I could even be reasonably sure it would help, I would. But that is not a choice I want an HMO making on my behalf in the absence of evidence.
posted by invincible summer at 8:45 PM on March 26, 2020 [9 favorites]

It’s hard also because this is - we know so little. I use a CPAP and I got fresh supplies and someone tried to make me feel guilty and said that CPAPs are used when ventilators run out. But is that true, or is it just someone who’s never thought I really “needed” this machine just getting a chance to make a casual dig?
posted by corb at 7:14 AM on March 27, 2020 [5 favorites]

I've never heard of a CPAP being a replacement for a ventilator. That's not to say that CPAP might not be useful for someone with pneumonia, but by the time you get to needing a ventilator, I can't imagine much else is going to suffice.
posted by Kadin2048 at 7:17 AM on March 27, 2020 [1 favorite]

A bunch of people on CPAP forums are busily trying to figure out if there's some way to rig up CPAPs to be of help when a ventilator is not available, but that's all people in their homes hacking away hopefully - there's no actual, current use of CPAPs in that way, to the best of my knowledge. Using your machine as prescribed to you, with the supplies you need (which is what I'm doing too) is a way of keeping yourself healthy and out of the medical system, which does not need you in it right now. Breathe and sleep in good health, and whoever said that to you deserves a sharp swift kick.
posted by Stacey at 8:25 AM on March 27, 2020 [9 favorites]

CPAP helps with breathing in some situations; COVID-19 causes problems with breathing; CPAP may sometimes be a way to address that. But they also come with increased chance of spreading the disease by aerosolizing (is that a word?) the virus. They aren't a substitute for a ventilator if that's what's needed.

They were used in Washington state before some patients were ID'd as having COVID-19, but that was stopped based on the fear of infection (and presumably, the realization that "positive airflow" is not going to cover the patients' needs).

Nobody needs to give up their CPAP to COVID-19 patients. And if hospitals get desperate enough that they're looking for "any and all help-the-breathing-tech," they'll let people know--but right now, it looks like the benefits aren't enough to balance the increased risk of spreading infection.

There are doctors looking into adapting CPAP machines for COVID-19, but all the attempts are still experimental.
posted by ErisLordFreedom at 12:33 PM on March 28, 2020 [3 favorites]

Despite scant evidence, the F.D.A. granted approval to use two malaria drugs. (NYT, March 30, 2020) The decision by the F.D.A., issued on Saturday but announced by the Department of Health and Human Services on Sunday, will allow hospitals to use the drugs on patients when enrolling them in clinical trials is not possible. Doctors must report on how they were used, including documenting any harmful side effects. Patients and doctors will also receive a fact sheet explaining that the drug’s efficacy in treating coronavirus is not known.

By restricting hospital use of the drugs to those taken from the national stockpile, the move also eases pressure on the rest of the supply chain. Both drugs have recently gone into shortage, making it difficult for patients who rely on them for other conditions to get access.
posted by Iris Gambol at 7:44 PM on March 30, 2020 [2 favorites]

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