There are people trying to manage people who don't want to come to work. Somebody who's pregnant and just afraid. A nurse or a social worker. How do you get them to come? And what do you say?
Wells: Have you had experience with this kind of pandemic situation before?
Caplan: I'll tell you what's different about the situation now. We make rationing decisions all the time. For example, I've been working for decades on the system we use to distribute scarce organs for transplants. Every day many people die who don't get a transplant because we don't have enough.
Here's what's different. First, many of the people, doctors and nurses, social workers, techs, they've never faced rationing, even transplants. They have not impacted most health care workers. So they've never faced the possibility that they could be involved in rationing. That ups the ante and makes the tension and the emotion and the fear much greater within the hospitals.
The other difference is that most people never worried about getting rationed—because they didn't need an organ, and they weren't sitting near an Ebola outbreak. Tell a rich person or well-insured person that they could face rationing, they've never faced that so they get nervous about it. The pandemic has raised the scope where rationing has to be considered to include everybody, even worldwide.
Wells: What do you think the hardest ethical questions we have right now are?
Caplan: How long is this podcast?
James Hamblin: There was discussion over the weekend about making sure that there not be discrimination against elderly people, against chronically ill people. There is that tension, which is similar with organ donation, where you have to think about the utility of how many “quality life years” does a person have if they receive an organ.
So it seems like there is discrimination against elderly and chronically ill people built into so many rationing decisions. How do you navigate that in a way that if, say, if it comes to ventilators, is as nondiscriminatory as possible—while making decisions that are, by definition, discriminating who gets what?
Caplan: When I look at policies, including my own institution’s, the first thing you have to commit to is that you won't discriminate. I'm looking for a statement that says everyone will be considered. That includes elderly people, the chronically ill, the disabled, and also would include no discrimination by gender or race or culture. We're trying to lead with the principle, and this is what I would call fairness, that everybody has a shot. Everybody has an opportunity.
That's somewhat true in transplant rationing, and it's somewhat true with emergency medicine rationing. You begin by saying in order to get support for rationing, you have to make people know that the squeaky wheels won't have an advantage, the rich won't shove aside the poor, the disabled just won't be killed. We're not going to have hard and fast age boundaries.