413. Who Gets the Ventilator?

Should a nurse or doctor who gets sick treating Covid-19 patients have priority access to a potentially life-saving healthcare device? Americans aren’t used to rationing in medicine, but it’s time to think about it. We consult a lung specialist, a bioethicist, and (of course) an economist.

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:01Stephen J. Dubner?

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• 0:45Stephen J. Dubner?

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• 1:28Stephen J. Dubner?

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• 1:56Stephen J. Dubner?

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• 2:35Stephen J. Dubner?

  Here's a question for you. Let's say there's a pandemic, a fatal virus, working its way around the world. There's no therapeutic treatment yet, but there is one piece of equipment that gives critically ill people at least a chance to survive. And let's say the demand for this equipment outstrips the supply. There just aren't enough units for the number of people who need it. So how do you decide who gets priority? Should it be first come, first served? Should it be the very sickest people? Or perhaps the least sick of the very sick, since they'll have a better shot at survival? Should it be older people, who may be fragile, or younger ones with more life left to live and theoretically more to contribute to society?

• 3:19Stephen J. Dubner?

  Should the wealthy and powerful have privileged access to this life-extending equipment as they have access to most other resources? Or should it be reversed, with priority going to the poor and powerless? There's one more category I'd like you to consider. What about doctors and nurses and other healthcare workers? Since they're the ones treating the victims and putting themselves at higher risk of exposure, should they move to the front of the line if they get sick?

• 3:47Stephen J. Dubner?

  How you answer these questions probably says something about how you view the world generally. If, for instance, you're an economist, you think about the most efficient ways to allocate scarce resources. But if you're a frontline healthcare worker, you may think it's only fair to balance efficiency with some sense of reciprocity. And how do you think about this question if you're this person?

• 4:12Speaker 01

  My name is Parag Pathik. I'm a professor of economics at MIT.

• 4:16Stephen J. Dubner?

  Okay, that's the economist part, but also...

• 4:19Speaker 01

  So my wife is a physician and my sister is an emergency room doctor.

• 4:23Stephen J. Dubner?

  As it happens, Pathik's research specialty is particularly suited to this sort of dilemma. It's called market design.

• 4:31Speaker 01

  So that is a branch of microeconomics that tries to devise practical schemes for real-life resource allocation problems, like getting your kid into school, or how can you increase your chances of getting a kidney if you didn't have one? What I'm really excited about are situations where, you know, we have to be very precise about how things get rationed. Situations where supply and demand don't have the usual instruments for the market to clear.

• 5:00Stephen J. Dubner?

  The usual instruments, meaning prices.

• 5:02Speaker 01

  So like a situation where there's no price. Usually, you know, if there's more demand than supply, the price goes up. If there is not enough demand, the price goes down. But in a lot of the problems I've studied, we have to think about equilibrating the market in a different way.

• 5:18Stephen J. Dubner?

  So does this still feel like economics to you? Or does it put you into the realm of ethics, or philosophy, or something else?

• 5:27Speaker 01

  Well, a lot of the times when you can't use price, we have to ask the question, why? And that opens the door to exactly philosophy, ethics, considerations that I think are a little difficult for economists to wrestle with.

• 5:40Stephen J. Dubner?

  For instance, during this COVID-19 epidemic...

• 5:44Speaker 01

  I started to look at some of the guidelines about what do you do when there's not enough ventilators?

• 5:49Stephen J. Dubner?

  Ventilator, as you likely know, is a piece of hospital equipment that can help keep alive someone with respiratory failure. Pathic and some colleagues started reading different states' guidelines for how to prioritize ventilators in a potential shortage.

• 6:03Speaker 01

  And so there's some interesting tidbits in the New York document that really got us thinking. And one of the tidbits was a statement in that guideline that said, you know, we do not think that essential personnel or frontline health workers should be prioritized. And, you know, here I am talking to my spouse, who is trying to find a way to get N95 masks online, and my sister is looking at different face shields for welding from Home Depot before she goes into the emergency room. And I asked her, what do you think about this? And they both said, this is crazy. But New York's rationale was based on the idea that if we give essential personnel

• 6:43Speaker 01

  the highest priority, then we could be in a state where a hospital has 20 ventilators and they only go to essential personnel. And that got me thinking.

• 6:54Stephen J. Dubner?

  It got us thinking, too. Today on Freakonomics Radio, we'll speak with a medical ethicist about healthcare rationing.

• 7:03Speaker 02

  First come, first served is the absolute worst principle you can think of in this situation.

• 7:10Stephen J. Dubner?

  A leading pulmonologist on the need for a better principle, fast.

• 7:15Speaker 03

  The hospitals are bursting at the seams. I have friends who are writing their wills.

• 7:22Stephen J. Dubner?

  And The Economist on a potential solution.

• 7:25Speaker 01

  I think most of these plans would like to prioritize frontline workers. They just don't know how to.

• 7:45Speaker 04

  From Stitcher and Dubner Productions, this is Freakonomics Radio, the podcast that explores the hidden side of everything. Here's your host, Stephen Dubner.

• 8:02Stephen J. Dubner?

  There are so many unknowns about COVID-19 that it's hard not only to keep straight what's known, but we're constantly discovering that what we knew yesterday isn't quite so true today, and by next week, it may be totally invalid. One concern over the past couple of months is that many people will need mechanical ventilators to keep them alive, and that there aren't nearly enough ventilators to go around. Keeping in mind, these numbers are changing all the time, let's start with the current assumptions on ventilator demand and supply.

• 8:33Speaker 01

  The best numbers I've seen on this are aggregate numbers.

• 8:36Stephen J. Dubner?

  That, again, is the MIT economist, Parag Pathak.

• 8:40Speaker 01

  There are full-featured ventilators, there is about 70,000 to 80,000 of those, including, you know, 10,000 to 20,000 from the Strategic National Stockpile. And then there's a partial feature of ventilator, and there's about 100,000 of those. And if you think about the numbers from Italy, about 10% to 20% of those hospitalized require a ventilator. So that takes us to about 2 million at least.

• 9:03Stephen J. Dubner?

  And even if those are spread out over three months, the 100,000 or 200,000 numbers start to look pretty scary.

• 9:10Speaker 01

  It looks very scary. Also, just to mention, in terms of the supply-demand calculation is, a lot of the ventilators that we had in the United States were not just sitting idle, they were already being used for other types of ailments.

• 9:23Stephen J. Dubner?

  In New York State, for instance, about 85% of ventilators are typically in use during normal conditions, which makes sense. Ventilator is an expensive piece of equipment, hospital doesn't buy one just to have it sit idle. So a big share of those 100,000 or 200,000 existing ventilators were already in use. There's also the issue of whether the available ventilators are situated where they're needed.

• 9:47Speaker 01

  How those are split across states is a big, open question, and it's actually another area where economists have started to think, if only we had a national registry that said, you know, there's an excess supply of ventilators in Idaho. And there's a shortage in New York City. Why don't we transport some of those Idaho ventilators to New York?

• 10:06Stephen J. Dubner?

  And a national registry does not exist because why?

• 10:09Speaker 01

  I don't know. I think in part it's because medical services in the US are fairly decentralized.

• 10:14Stephen J. Dubner?

  The purchasing of ventilators, like most other expensive medical equipment, is often left to individual hospital systems. Capacity, therefore, varies from hospital to hospital. With COVID-19, the overall capacity is thought to be way too low, which is why the federal government and others have been frantically ramping up ventilator production. Will all those ventilators be needed? If needed, will they be effective? Those questions are unanswerable for now. In New York, it was predicted there would be a massive surge in ventilator demand, and therefore a massive shortage, thankfully, that hasn't come to pass, at least not yet.

• 10:56Stephen J. Dubner?

  But if there are shortages, the issue of how to ration a ventilator will be an incredibly difficult and important one. The idea of outright rationing medical resources may sound alien in the US, but that doesn't mean it hasn't happened.

• 11:12Speaker 02

  We have had clear situations where we, the United States, has had to allocate resources and ration.

• 11:21Stephen J. Dubner?

  That's the oncologist and bioethicist Ezekiel Emanuel.

• 11:25Speaker 02

  I am the Vice Provost of Global Initiatives, a university professor and director of the Healthcare Transformation Institute at the University of Pennsylvania.

• 11:34Stephen J. Dubner?

  Emanuel was an architect of Obamacare. He's now advising Joe Biden on COVID-19. He says there have been three major instances of medical rationing in US history. Number one.

• 11:46Speaker 02

  One is insulin for diabetes, when it was first discovered in 1920. And before it, we figured out how to mass produce it.

• 11:54Stephen J. Dubner?

  And number two.

• 11:55Speaker 02

  A second is penicillin, which was discovered in the late 1920s, but could not be produced in large quantity until the war, World War II, created a real imperative and they finally figured out how to produce it. But large quantities was not large enough for everyone who needed it. And so we had to ration who got it first during a war effort. And even though the vast majority, 90% of it, went to the military, within the military, there wasn't enough for everyone who could benefit from it. So we had to ration that.

• 12:27Stephen J. Dubner?

  And the most recent episode of rationing, a process to treat kidney failure.

• 12:31Speaker 02

  In the early 1960s, figured out how to do long-term chronic dialysis. There weren't enough dialysis machines. It was expensive and there was very substantial rationing there, picking the people who would get on long-term dialysis and the people who wouldn't, who would end up dying. That persisted until the federal government fully took over all the payment for dialysis, which continues till today.

• 12:55Stephen J. Dubner?

  While that kind of rationing is typically in the past, Emmanuel and his fellow bioethicists still have plenty to think about.

• 13:02Speaker 02

  You know, do you resuscitate this patient? Do you quote unquote, pull the plug on this patient? How do you use genetic tests? Do we permit embryonic stem cells or only other kinds of somatic stem cells? Do we use CRISPR technology?

• 13:19Stephen J. Dubner?

  But also, there are still serious shortages in medicine.

• 13:23Speaker 02

  We have a shortage of kidneys. We have a shortage of livers and you have to choose which patients get the organ that you have at any one time. There are rules. The rules are not without their contention and those doctors probably have thought about it more than any other, the transplant teams, any other set of doctors.

• 13:44Stephen J. Dubner?

  So how much discussion of rationing is there in medical schools?

• 13:48Speaker 02

  It's not really, you know, not really discussed and not a core part of the curriculum anywhere. And I think prior to COVID-19, despite some evidence, no one really thought that this was critical.

• 14:03Stephen J. Dubner?

  Emmanuel was one person who did think it was critical to think about rationing.

• 14:08Speaker 02

  I wrote my first paper about this in 2006, which was basically an analysis of the Department of Health and Human Services' plan for rationing vaccines and treatments if we had an influenza pandemic. So the government had been thinking about this way back in 2005 and they came up with an initial plan and I thought that plan was unethical because that plan said, "Our goal is to save the most lives."

• 14:37Stephen J. Dubner?

  And wait a minute, what's wrong with a plan where the goal is to save the most lives? The HHS plan made clear that older people were most likely to die in an influenza outbreak, and so.

• 14:50Speaker 02

  And so we should save them first. And that just struck me as wrong, because it emphasized saving the most lives, and it ignored saving the most life years, people who might, if you save them, live a long time.

• 15:04Stephen J. Dubner?

  If you read a lot of papers written by bioethicists and health economists, there's an initialism you'll often run across, Q A L Y. It stands for Quality Adjusted Life Year. One Quality Adjusted Life Year means you live a year longer at full health. If you live a full year at only 50% of full health, that's only half of a Quality Adjusted Life Year.

• 15:29Speaker 02

  One of the things we know from the influenza pandemic of 1918, it was people in the prime of life, young kids up until young adults, were the most likely to die in that episode. And so if you focused in on older people, you would end up, quote unquote, sacrificing younger people who had way more potential time to live.

• 15:53Stephen J. Dubner?

  But the HHS plan prioritized older people.

• 15:56Speaker 02

  So we wrote a paper criticizing it. And then it turned out, if you surveyed the public, they agreed with us that, you know, in a pandemic, you ought to save young people and not just old people. So one of the things we ended up doing is to think through what are the values that are really important to people in any kind of rationing situation?

• 16:18Stephen J. Dubner?

  Here's one value that's embraced by nearly all bioethicists. When it comes to rationing medical services, things like race, ethnicity, or socioeconomic factors should not come into play. This, of course, is not a universal concept. Consider Saudi Arabia, where several dozen members of the royal family are reported to have COVID-19. The hospital where royals typically receive treatment was instructed to not only prioritize those VIP patients, but to remove non-VIP patients from the premises ASAP. The US had its own brushes with privileged access. For instance, when many NBA players were given

• 16:58Stephen J. Dubner?

  COVID-19 tests despite showing no symptoms, while countless civilians with symptoms were unable to get tested. When you hear this kind of story, it may be natural to think that the fairest way to distribute medical care, let's say it's a ventilator, would simply be first come, first served.

• 17:17Speaker 02

  First come, first served is the absolute worst principle you can think of in this situation. It's biased in a number of ways. It's biased because people who live close to a health facility get priority. People who have traditionally been excluded from getting good health care, whether they're minorities or people in rural areas or others, they continue to get excluded because first come, first served emphasizes those people who are well into the system. Third, you might have someone who has a worse prognosis who happens to show up first. That's a relevant criteria, but it's hardly determinative. You know, someone with a better prognosis ought to get those resources. I recognize that if you say first come, first served doesn't have a role

• 18:02Speaker 02

  and someone happens to be on a ventilator, but someone else who has better prognosis comes in and you have no other ventilators, removing a patient from a ventilator to give it to someone else is psychologically traumatic. It's very hard to do, but I think it's very important to do because it's the ethical thing to do.

• 18:24Stephen J. Dubner?

  Before we go deeper into ventilator rationing, let's take a step back and learn exactly what a ventilator is.

• 18:30Speaker 03

  In order to talk about what a ventilator is, I think it's helpful to first discuss what normal breathing does for us.

• 18:38Stephen J. Dubner?

  That's Malan Han.

• 18:40Speaker 03

  So the most important things that it does is get oxygen in. That helps our cells and then get carbon dioxide out, which is the waste product. So when we think about a ventilator, it has to do those two things. Get the oxygen in and get the carbon dioxide out.

• 18:57Stephen J. Dubner?

  Han is an MD and professor of pulmonary and critical care medicine at the University of Michigan. COVID-19 is fairly widespread in Michigan.

• 19:07Speaker 03

  Within the last few weeks, the greater area of Detroit has been hit quite hard. My county was not hit quite so hard, but we have been trying to help by taking transfers from Detroit. The hospitals are bursting at the seams. They have opened up field hospitals. We are redeploying staff, but it's incredibly stressful on everyone. We have healthcare workers now that are sick. I have friends who are writing their wills.

• 19:39Stephen J. Dubner?

  Han is a big deal in the field of pulmonology. She's a journal editor. She sits on scientific advisory committees. In other words, she knows a lot about how we breathe or fail to.

• 19:52Speaker 03

  A patient can end up on a ventilator for a huge variety of reasons. Essentially, anytime the lungs are failing to do one of its two key jobs. That could be due to pneumonia. That could be due to heart failure in some cases. Ventilators are only used in intensive care units. It actually requires an incredible amount of resource utilization from a human perspective to keep a patient on a ventilator. Usually, we have physician teams that are going around and doing constant tweaking of the ventilators.

• 20:26Stephen J. Dubner?

  A ventilator is meant to help the lungs do their job, but it doesn't work the way lungs work.

• 20:32Speaker 03

  A ventilator actually induces something we call positive pressure breathing. The air is essentially being blown into you. If you think about how you normally breathe, normally your diaphragm fires. The lungs expand and actually air rushes in because of the negative pressure generated. So it's very different and actually uncomfortable for patients to go from their normal negative pressure breathing to positive pressure breathing. If you can imagine what it would all of a sudden feel like to have someone just blasting you with air, and that's how you're supposed to breathe. So one of the reasons why we have to sedate patients in the ICU,

• 21:15Speaker 03

  and in some cases, we actually have to paralyze them. Because otherwise, you get significant desynchrony between the patient trying to fire their own diaphragms to breathe and the ventilator trying to deliver breaths. That's one of the things I think a lot of people don't realize. You don't just put a patient on a ventilator and walk away. Things could be good one second, and you get a call from the respiratory therapist or the nurse that all of a sudden, the settings that were working 15 to 20 minutes ago are no longer working. So it requires really close attention to detail, a lot of tweaking and experimentation to really optimize each patient.

• 21:55Stephen J. Dubner?

  When a patient comes to the emergency room in respiratory distress, let's say it's a COVID-19 patient, a ventilator is not necessarily the first step.

• 22:04Speaker 03

  Often, they have low levels of oxygen. So the first thing to do if it's not life critically low would be to put the patients on some kind of supplemental oxygen.

• 22:15Stephen J. Dubner?

  There are a few options.

• 22:16Speaker 03

  This has actually been an area of significant debate among the medical community. But one of these options is something called high-flow nasal cannula.

• 22:29Stephen J. Dubner?

  That's administered through a thin, clear tube into the patient's nose. But for the most serious cases, supplemental oxygen won't be enough.

• 22:38Speaker 03

  When we look at that on a chest X-ray or we look at that on a CT, sometimes we call it white-out. So instead of the lung being nice and black, which is the color of air on a radiographic image, all of a sudden, we just see these white infiltrates everywhere.

• 22:54Stephen J. Dubner?

  At this point, a patient is often put on a ventilator. They are likely to be suffering from ARDS, acute respiratory distress syndrome.

• 23:02Speaker 03

  And prior to COVID-19, we've done tons of research studies on how best to treat ARDS, regardless of the cause. And so there are certain protocols that we have in place, like keeping the size of the breaths that we deliver on the ventilator low. One of the things that people may not realize is that oxygen itself is toxic in high levels. The other thing people may not realize is that the amount of air that we push into the lungs, beyond a certain point, is actually harmful. And it can actually cause lung injury.

• 23:39Stephen J. Dubner?

  Because COVID-19 is a new disease, doctors around the world are frantically trying to work out how to best use ventilators against it.

• 23:49Speaker 03

  You know, there's no time for a randomized trial of how to ventilate patients. Everyone is just doing their best.

• 23:56Stephen J. Dubner?

  There are a few different views.

• 23:58Speaker 03

  One camp of thought is that we should be treating COVID-19 just like any other ARDS that we've seen and follow the same protective protocols that we would normally follow. There is this other camp of thought that maybe this isn't really like ARDS and maybe we should be using larger lung volumes.

• 24:23Stephen J. Dubner?

  Some researchers suspect that COVID-19 is attacking the lungs of some patients in a manner more similar to high-altitude pulmonary edema, where the problem has to do more with how the lungs' blood vessels regulate blood flow. This would mean that using a ventilator on COVID-19 patients in the way it's used to treat ARDS may be suboptimal at best.

• 24:48Speaker 03

  Maybe the normal rules don't apply. There certainly do seem to be certain aspects of the patient physiology that seem a little bit strange.

• 24:58Stephen J. Dubner?

  One thing that doctors around the world are noticing, the way ventilators have been used to date on COVID-19 patients, isn't working very well.

• 25:07Speaker 03

  Roughly 67% of patients in one UK database that received mechanical ventilation still died.

• 25:18Stephen J. Dubner?

  In New York City, more than 80% of coronavirus patients who were put on ventilators still died. Now, keep in mind, if you need a ventilator, you're already in very bad shape. In fact, roughly half of all patients with severe respiratory distress who go on a ventilator in normal times will die. So how does Malan Han see the role of the ventilator in fighting COVID-19?

• 25:42Speaker 03

  It's not going to be the panacea necessarily to get us all through, but for the patients that are severe, it is our only hope.

• 25:53Speaker 03

  Ultimately, if we're going to beat this, we are going to need better proven treatments. The ventilators are life sustaining, but honestly, that's while we wait for either drugs to work or for the patient to heal themselves.

• 26:06Stephen J. Dubner?

  That said, a ventilator can keep a COVID-19 patient alive. It can potentially help them recover, which means there will be competition for the units.

• 26:19Speaker 03

  Yesterday, I was chatting with a friend of mine who is a pulmonologist in New York, and he told me that they were down to six ventilators and had 20 patients who needed them. So it is definitely a crisis in some hospitals.

• 26:35Stephen J. Dubner?

  And how does a doctor like Han think about handling a shortage like that?

• 26:40Speaker 03

  No one physician, no one nurse, no one respiratory therapist wants to be the one to say, "Well, patient A gets something and patient B doesn't." We certainly have our own way of thinking about the likelihood of benefit. And while we don't usually like to think about that in prescribing a treatment, we are now forced to think about that. But I think what most healthcare teams that I've been working with really want are ethics boards from the hospital to come in and use ethical principles, but a team-based approach to try to decide if it comes down to it, whether this life-saving treatment should be given to patient A or to patient B.

• 27:28Stephen J. Dubner?

  Coming up after the break, what hospital ethics boards and their state overseers have come up with, what those guidelines say and don't say, and two completely different ways of looking at the very same patient. That's coming up right after this.

• 27:48Stephen J. Dubner?

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• 28:33Stephen J. Dubner?

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• 29:16Stephen J. Dubner?

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• 30:01Stephen J. Dubner?

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• 30:12Stephen J. Dubner?

  Before COVID-19, many states had formulated guidelines for hospitals to follow if they were faced with a shortage of ventilators. It was those guidelines that got the MIT economist Parag Pathak interested in the subject.

• 30:26Speaker 01

  So, most of the ventilator protocols we've come across are based on a points system, where, you know, medical ethicists and different stakeholders, doctors, legal scholars, basically take ethical principles and map them to numbers.

• 30:41Stephen J. Dubner?

  For instance?

• 30:42Speaker 01

  So, there's a thing called a SOFA score. A SOFA score stands for the Sequential Organ Failure Assessment. And if your organs are more likely to fail, then you get a higher score. If it's less likely to fail, you get a lower score. So, they take that and they sum it up with another ethical criteria, which is, we want to save the most number of years of life. Not the most number of lives, but the number of years of lives. And there again, they take categories, like, do you have a lot of comorbidities, or do you have few comorbidities? Assign a number. And when all is said and done, they just sum everything up, and whoever's got the lowest score gets the ventilator first.

• 31:22Stephen J. Dubner?

  This is a pretty standard way of prioritizing scarce medical resources, like organs available for transplant.

• 31:30Speaker 03

  I mean, one thing I do do is lung transplant.

• 31:33Stephen J. Dubner?

  Malan Han, again, from the University of Michigan.

• 31:36Speaker 03

  So, I'm very familiar with the allocation systems for lung transplants. And they used to be based on how long you'd been on the list, and there was no prioritization of persons. But they realized then, that means that the least sick patients are all getting transplanted because the only ones living long enough to get a transplant. So, they changed that system to it being risk-based on your diagnosis. But then they added to it the patient's numbers, this massive calculation, and the patient gets a score.

• 32:09Stephen J. Dubner?

  How does this kind of calculation work for ventilators? We asked Pathak to walk us through the New York State guidelines, which were written in 2015.

• 32:18Speaker 01

  So, the highest priority patients are those who are most likely to recover with a ventilator. They call those patients RED. Next come patients who are very sick and whose prognosis is a bit uncertain. So their likelihood of survival with a ventilator is in the intermediate range. So they're yellow. Then come blue patients. Those are patients who have a low likelihood of survival with ventilators. And finally, you have green patients. These are, you know, green means go. These are patients who don't need ventilator support. So even if we had a ventilator, we wouldn't give those patients a ventilator.

• 32:55Stephen J. Dubner?

  This priority point system is similar to what most states recommend.

• 32:58Speaker 01

  Now, where states can differ is what are the ethical principles that they entertain? And so some of the principles are, you know, things like saving lives or saving life years.

• 33:10Stephen J. Dubner?

  Again, that's the notion of quality adjusted life years that we mentioned earlier.

• 33:14Speaker 01

  Other principles include reciprocity. So someone who has put themselves at risk should get priority.

• 33:20Stephen J. Dubner?

  That might include ambulance and fire department and grocery workers as well as doctors, nurses and other frontline healthcare workers.

• 33:28Speaker 01

  There's also a concept of instrumental value, which is if we don't have enough members of society of this particular type, say doctors or respiratory therapists, we're in trouble. So they need to be prioritized.

• 33:41Stephen J. Dubner?

  Meaning they are the instrument, a doctor in this case, would be the instrument that would create value down the line. Is that the correct interpretation of that phrase?

• 33:49Speaker 01

  That's absolutely right. So there is just direct benefit, instrumental value, they call it, for having enough medical personnel because if we didn't, then the crisis is just going to get worse.

• 34:00Stephen J. Dubner?

  So you could see how a given state might consider the reciprocity idea and the instrumental valuation idea and conclude that doctors and nurses should be given priority ranking if they get sick and need a ventilator. And that's exactly what some states have done. Michigan, for instance, where Malon Han practices medicine. But other states, as Pathic found, don't prioritize healthcare workers, including New York State.

• 34:30Speaker 01

  So if I compare New York to Michigan, in Michigan, they say we want to prioritize essential personnel. And, you know, they give this rationale based on reciprocity. They're taking on a high risk, saving others. We've seen with COVID-19, a large fraction of those who got sick are actually these frontline healthcare workers. Minnesota, on the other hand, they've said, like New York, we should not treat frontline health workers any differently than any other patient.

• 34:59Stephen J. Dubner?

  And how many states do prioritize essential personnel?

• 35:02Speaker 01

  We don't know the answer to that. So Michigan is a state that does. Massachusetts just released their standard yesterday.

• 35:09Stephen J. Dubner?

  And?

• 35:09Speaker 01

  So they have the same priority point system. The two ethical criteria they have are saving the most lives and saving the most life years. And then they have a kind of footnote or a paragraph below their table saying, and we think that essential personnel should get heightened priority. And it's a bit interesting because this table is very concrete and mathematical. It's taking, you know, these debates that the great philosophers have had and putting them onto a numeric scale. And then, you know, there's this comment, oh yeah, and by the way, these guys should get a heightened priority without explaining, does that mean they're at the front of the line or are they're at the end of the line?

• 35:45Stephen J. Dubner?

  Right. So it's math, math, math, math, and then, you know, do what you think makes sense.

• 35:50Speaker 01

  Yes.

• 35:51Stephen J. Dubner?

  And that strikes you as woefully inadequate, it sounds like?

• 35:56Speaker 01

  Well, I mean, what's the point of specifying your values in this super concrete way and then saying, oh, it's inadequate, like we need to protect our frontline workers?

• 36:04Stephen J. Dubner?

  We should note that we interviewed Pathic on Friday, April 10th. By Monday, the 13th, doctors in Massachusetts were pushing back against the state's murky ruling, saying they should be given priority access to ventilators if needed. In any case, some states have decided to give doctors and nurses priority, while others have decided not to. I asked Pathic to play the role of disinterested scholar and explain the logic behind each position. First, states like New York and Minnesota, where healthcare workers don't get priority.

• 36:39Speaker 01

  So I'm not an ethicist, but I can try to guess what the ethicists were saying. At core, their principle is a non-discrimination idea. So everyone should be treated equally. That's our collective values as society. And if we prioritize someone based on their occupation, there's two issues. One is, why one occupation versus the other? So if I say frontline healthcare workers are taking on greater risks, we could also say that there are certain types of jobs that are more valuable to society that should be prioritized as well. A second thing is actually defining what a frontline health worker is. So is that a respiratory therapist? Is that an ER doc? What about a dermatologist? Do they count?

• 37:22Speaker 01

  And it's possible that that category gets very large. What they're worried about is that the key workers would use all of a supply up, and that's going to deprive all of the other groups, people like you and me, Stephen, from getting access.

• 37:35Stephen J. Dubner?

  And now, let's hear you argue, let's say, the Michigan side. What are the good reasons why healthcare workers should be prioritized?

• 37:41Speaker 01

  You know, healthcare workers are heroes in this situation. They're putting their lives on the line. If you don't prioritize them, you know, you could create some problems, things like sick outs or absenteeism. If I'm putting my life on the line and I could get exposed to COVID-19 trying to help someone else, maybe I decide not to show up. Or another thing could be, you know, ethical dilemmas that a healthcare worker themselves faces. If they have to decide, should I give the ventilator to my colleague, who's a healthcare worker, or another patient who's not, what do I do? So rather than force them to make those trade-offs, we should prioritize healthcare workers first.

• 38:19Stephen J. Dubner?

  So that's Pathic playing the disinterested observer. What does Zeke Emanuel, the medical ethicist, think of the New York position versus the Michigan position?

• 38:29Speaker 02

  I think New York is wrong and Michigan's right.

• 38:32Stephen J. Dubner?

  Emmanuel and several co-authors recently made their position clear in a New England Journal of Medicine article.

• 38:38Speaker 02

  I think the logic is pretty simple and pretty widely endorsed in the sense that in an emergency, like a pandemic, where the health system is working flat out to care for people, you want the healthcare providers who are providing that care to get the first treatment and keep them alive because they can save additional people. So, one phrase that has been used is they're force multipliers. You know, one doctor, one nurse, one respiratory therapist can care for many other potential patients, and so you want to save them first.

• 39:13Stephen J. Dubner?

  Here's what Parag Pathak came to think about the states like New York that don't prioritize healthcare workers.

• 39:23Speaker 01

  You know, my, my feeling about this actually, Stephen, is I think most of these plans would like to prioritize frontline workers, they just don't know how to.

• 39:31Stephen J. Dubner?

  And so Pathak and three fellow economists set out to help. They applied some of the principles of market design that have proven helpful in allocating kidneys for donation, in matching medical residents to hospitals, in distributing visas to immigrant workers. They quickly wrote an academic paper. It's called "Triage Protocol Design for Ventilator Rationing in a Pandemic: Integrating Multiple Ethical Values Through Reserves," and the key word there, "reserves."

• 40:04Speaker 01

  Our proposal here is to think about an enhanced priority point system where you take the ventilators and you split them into categories, or what we call reserves, where a fraction of reserves can have one priority order, the remaining ventilators can use another priority order.

• 40:21Stephen J. Dubner?

  Imagine, for instance, we're talking about one hospital.

• 40:24Speaker 01

  Let's say you have a 150-bed hospital, and they have 20 ventilators. Our proposal is the following, right? Take the 20 ventilators, put them into two categories, okay? Five of them are going to be ventilators that are going to prioritize essential personnel. 15 of the ventilators are just going to take the ethical principles of saving the most lives and the most number of life years. We have these two groups, 48 hours in, there's 20 patients on ventilators. Imagine we have- Thirty patients show up who are frontline medical workers who need a ventilator. Okay. And there are an additional 60 patients who are not frontline medical personnel.

• 41:07Speaker 01

  What we need to do is take the 30 doctors or respiratory therapists or nurses who are on the frontline and try to allocate them a ventilator that's reserved for their group.

• 41:17Stephen J. Dubner?

  Uh, let's back up for a second. You said the 15 ventilators from the general pool are being used and the five from the reserve pool are also being used. Are we to assume that all five of those reserve ventilators are being used by frontline medical personnel?

• 41:34Speaker 01

  It need not be, Stephen. Actually, suppose only three essential personnel had showed up. So then the remaining two would go to the general community.

• 41:42Stephen J. Dubner?

  Let's say I'm a doctor that comes in and I'm qualified for the reserve pool of ventilators. And there are two people on those five ventilators that are reserved for the reserve pool who are not from the reserve pool. They're from the general population. What happens? Do they need to get booted off their ventilator to accommodate me?

• 42:04Speaker 01

  That could be possible. We would potentially boot them off. So the New York standard actually talks a bit about moving people off of ventilators. That's typically done when someone's status changes. So if two of those people, if their sofa score deteriorates, then one of the ventilators becomes free and that would be the case in which you would potentially be booted off. It could be possible that the patient who would get displaced by the frontline medical worker would then actually qualify for the general pool, in which case they wouldn't need to be booted off. But what they would do is displace a general pool person who maybe has deteriorated and freeze up a general pool ventilator. So key principle number one, no ventilators unused.

• 42:50Speaker 01

  Okay. Key principle number two, the categories can overlap. So a frontline medical personnel, he could qualify for the first bite at the apple or he could qualify for the general pool. Right? So his priority may be high enough that he gets a general pool ventilator. Just having two separate priorities or three or however many you wish for different categories of ventilators, partitioning all ventilators into these groups and using a different priority order for those ventilators.

• 43:19Stephen J. Dubner?

  Might I not say, well, let's talk about instrumental value on a much larger canvas. So there's one doctor who might be able to treat over the course of the next month, I don't know, 2, 3, 500 people. But what about a cancer researcher whose work might affect millions of people? What about an entrepreneur whose inventions might affect billions of people? So I understand why it resonates on an obvious dimension, why healthcare workers should be given priority. I'm not disputing that. But doesn't it feel like a fairly slippery slope? And if so, can you persuade me that you're not starting us on this slope primarily because you are married to a doctor?

• 44:03Speaker 01

  Oh, sure. Well, let me give you another instrumental category that I think is important. And that is patients who sign up for a clinical trial on a COVID treatment. So we need patients to do that if we're ever going to find a treatment for this. If we don't have patients who do this, then the pandemic might last a longer amount of time. So they should also have some kind of consideration. You could call that kind of a good Samaritan category. I would not say, however, that all of the instrumental value cases should trump these other considerations, because that's what I'm worried about. I mean, I don't think we can say that the person who's delivering groceries to a folk's house

• 44:46Speaker 01

  or running the subway system or the bus system, they're also keeping society going, right? So you're absolutely right, there's a slippery slope. So that's exactly the reason why we should not have a bang bang, is what we say in economics, a zero one type solution. We should have some set aside that respects instrumental value or reciprocity, and some set aside that has non-discrimination. I think the main reason our proposal improves the current situation is we can accommodate frontline personnel and we can also accommodate non-discrimination. What we offer is a midpoint. So there's really no right answer here, right? It's about equity, it's about distributive justice, it's about what's the appropriate kind of normative standard that we want to have here.

• 45:31Stephen J. Dubner?

  Now, what about a flip side? What about a stick instead of a carrot? Should people who get caught violating social distancing standards get demerits so that they don't have the right to a ventilator?

• 45:42Speaker 01

  You know, that's a possibility, Stephen. I think there's going to be a lot of implementation challenges there. I will say, however, I think a lot of frontline medical personnel are annoyed when they see people not following the guidelines. So I could see some sentiment in favor of that, but that's a tricky one.

• 46:02Stephen J. Dubner?

  Pathik and his co-authors have already had one fruitful conversation with a bioethicist who was involved in setting up the Massachusetts standard for prioritizing ventilators. They plainly hope to influence the general conversation. To that end, it may be helpful to point to some other scenarios that use a reserve system.

• 46:21Speaker 01

  So one reserve system that we studied recently is the H1B immigration visa system. So H1B visas are visas for highly skilled employees.

• 46:33Speaker 05

  This year, H1B visas are allocated in the following way.

• 46:38Stephen J. Dubner?

  That's Typhoon Sunmez, one of Pathik's co-authors.

• 46:41Speaker 05

  There are 65,000 H1B visas which are open to all qualified candidates, and there are 20,000 additional visas which are exclusively reserved for holders of advanced degrees from American universities.

• 47:01Speaker 01

  So it's a situation where someone who's got an advanced degree can qualify for more than one type of slot.

• 47:07Speaker 05

  Advanced degree holders correspond to essential personnel in our way because they are the ones who have these reserves.

• 47:15Stephen J. Dubner?

  But there's one crucial difference between the H1B visa reserves and the medical personnel reserves the economists propose in their new paper.

• 47:23Speaker 05

  In the paper, we distinguish between two cases: hard caps, soft caps. So the ventilator application is what we refer as a soft cap. So preferential treatment is given, but otherwise, everybody is eligible for all units. Whereas H1B visa application is an example of hard caps.

• 47:48Stephen J. Dubner?

  A hard cap because members of the general population do not have access to the reserve slots.

• 47:55Speaker 05

  Actually, we are now...

• 47:58Speaker 05

  Talking to doctors, you know, medical ethicists, lawyers, and they are very much interested in this idea, but they are a little bit worried about the reserve terminology. The phrase "reserve" might give people the wrong idea. These are soft reserves. No unit is ever left unused.

• 48:24Stephen J. Dubner?

  So as we speak, there's some evidence that the COVID-19 curve is flattening in New York State, which has been, you know, the epicenter. So let's say, God willing, this trend continues and repeats itself elsewhere in the US and around the world. And let's say that ventilators will not be as scarce a resource as predicted. What kind of value will your model or idea still have?

• 48:50Speaker 01

  You know, we all hope that we don't need to ration and we get, you know, out in front of this, the curve is flattened. But I think there is a ton of value here in thinking about what we've, as a society, think about rationing and who's more deserving. So as I read the documents that exist from 2015, I mean, you could have asked the same question back then. Why did they write those documents? There was no influenza pandemic in 2015. It was all anticipating the future. And if our documents say certain groups are excluded or there's no priority for people who take risks, I think that's a dangerous situation.

• 49:32Stephen J. Dubner?

  You could also imagine that COVID-19 itself will present further rationing necessities.

• 49:38Speaker 02

  We're not going to be able to get back to, quote unquote, "normal" until we have a vaccine, which is about 18 months from now.

• 49:44Stephen J. Dubner?

  That again is Zeke Emanuel.

• 49:45Speaker 02

  There will doubtlessly be vaccine rationing and maybe even therapeutic rationing, depending upon which therapeutics seem to be effective against COVID-19.

• 49:56Stephen J. Dubner?

  Thinking about rationing is a form of preparation that is in short supply.

• 50:02Speaker 02

  We didn't prepare for, obviously, surge capacity. We didn't prepare for how do we rapidly develop and distribute a test. We didn't prepare for the idea of contact tracing and working with the tech companies to develop a robust system for tech-enabled contact tracing. Obviously, we didn't prepare for enough ventilators.

• 50:22Speaker 03

  We were woefully underprepared.

• 50:25Stephen J. Dubner?

  Melan Han again.

• 50:27Speaker 03

  It turns out our national stockpile was not adequate. It turns out that even, for instance, some of the equipment in the stockpile, the ventilators, were not working. And really, we don't have a centralized system to get needed medical supplies and equipment distributed evenly across the country. And what we are now left with is each state sort of fighting for itself, each health system fighting for itself, each healthcare worker fighting for their own personal protective equipment.

• 51:10Speaker 03

  And to me, it just seems such a waste and such a shame that a nation with the resources that we have can't figure out how to use and mobilize those resources in a crisis like this.

• 51:26Speaker 01

  Ventilators are really concrete, but the principles that we're articulating apply to any, I think, indivisible resource that's in short supply. So let's imagine we have a vaccine for COVID-19. There's still a question of who gets the vaccine. So we have a rationing problem yet again, and we need to think carefully about who's going to get it and how it's going to be allocated.

• 51:50Stephen J. Dubner?

  Thanks for listening. We'll be back next week. In the meantime, take care of yourself and someone else, too, if you can. Freakonomics Radio is produced by Stitcher and Dubner Productions. This episode was produced by Zach Lipinski. Our staff also includes Alison Kreglo, Greg Rippon, Matt Hickey, Daphne Chen, Harry Huggins, and Corinne Wallace. Our intern is Isabel O'Brien, and we had help this week from James Foster. Our theme song is "Mr. Fortune" by The Hitchhikers. All the other music was composed by Luis Guerra. You can get Freakonomics Radio on any podcast app. If you want the entire back catalog, use the Stitcher app or go to Freakonomics.com, where we also publish transcripts and show notes.

• 52:33Stephen J. Dubner?

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• 52:52Speaker 06

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