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COVID-19 and the Titanic Dilemma: Which Patients Get Priority?

Read the latest blog post from Cureus Editor-in-Chief, John R. Adler, Jr., M.D. Passengers, frightened by the Titanic sinking beneath them and knowing that there were not enough lifeboats to go around, had mere minutes to prioritize who among them might be saved. Steerage passengers were largely left to fend for themselves. Among everyone else it was implicitly understood that children would be saved first. In fact, this necessity of sacrificing ourselves for younger generations is as old as humanity. This hierarchy of sacrifice for a “greater good” resonates deeply within all cultures and is part of why the movie Titanic is so beloved worldwide.   Fast-forward to Spring, 2020, where we find ourselves trapped on a metaphorical ship. This time we have tragically struck an invisible microbe precipitating the current Covid-19 pandemic. Starting first in Wuhan, then Northern Italy, Spain and France, and now bearing down with all its fury on the United States, Covid-19 is challenging the moral framework of our society, and even our identities as compassionate humans. At the heart of this calamity is a subset of very sick patients requiring prolonged respiratory support from a finite pool of ventilators. Anticipating a tragic necessity to ration these life-saving devices, a handful of US states, and most recently The University of Pittsburgh (UPMC), have developed a range of “guidelines.” Some states have chosen to consider age, advanced cancer and intellectual impairment as relevant considerations for rationing ventilators. However disability and elder rights groups, seeking to represent their constituencies, have recently and successfully pushed back hard. Specifically, these lobbying groups have raised objections to the US Office of Civil Rights, arguing that hospitals (via state guidelines) were being “ordered to not offer mechanical ventilator support for patients” with “severe or profound mental retardation,” “moderate to severe dementia,” and “severe traumatic brain injury.”  Memorializing these civil liberty objections, the ivory tower team of UPMC medical ethicists has developed their own set of “guidelines,” to which “100s of hospitals” are now poised to sign up. The group think, the politics, the idiocy of where we now find ourselves in this health rationing debate, leaves me dumbfounded. Mortified. Stupefied. What I am hearing is that society’s politically savvy actually subscribe to the notion that a 90-year-old Alzheimer’s patient, a vegetative head injury patient, or an end stage cancer patient should have the same access to a proverbial lifeboat as a healthy 18-year-old. How can our collective judgment now be so impaired? How is it that our ancestor’s self-evident notions have been washed away during the current panic? In no way do I wish to suggest a healthy Down’s Syndrome or vigorous cystic fibrosis adult not be given a fair shot at a life saving ventilator. However to not acknowledge that “fairness” can involve a hierarchy of intellectual, medical and “chronological” disability is beyond foolish. Hopefully such indifference to OUR collective future will not prove to be the final legacy of the “greatest generation”? Fortunately I am reassured by the many senior and disabled individuals with whom I have discussed the current intellectual brouhaha. Each of these many family members and friends are, like me, utterly dismayed that we are even having this debate.  So let me end by being thoroughly blunt. If at some juncture a medical team with only one ventilator needs to choose point blank between saving me, a healthy 65-year-old, and the life of a much younger and reasonably healthy patient, please do not hesitate - let me die. Does anyone want to live in a world that has forgotten the wisdom of the ages?

Apr 06, 2020

The COVID-19 Pandemic is Not a Surprise

Read the latest blog post from Cureus Editor-in-Chief, John Adler. If you'd like to leave a comment for Dr. Adler, please click here to comment on the post itself. John R. Adler, Jr., M.D. - March 2, 2020 Right now it is impossible to ignore the financial markets panicking, the breathless coverage by news media, the fearful buying at Costcos everywhere, and so many friends and family now worried about the emerging Covid-19 pandemic. Predictions of what might come next raise the specter of an historic pandemic that could literally kill millions or dare I say tens of millions before it runs its course. We are clearly living in an “interesting” time. Media often nurtures the collective myth that modern medicine is capable of miracles, and in recent years some in Silicon Valley even implied that humanity could be on the cusp of conquering death itself. Fueled by so much optimism, we, and especially the young adults among us, live in a world grown complacent about premature dying and now finds itself shocked at our shared reality; modern medicine has not solved the “death problem.” Philosophically speaking, and as a physician who has seen more than his fair share of deaths, I do not necessarily find our communal predicament tragic. Yes, it is quite possible that countless individual tragedies will abound in the months to come, However, as my neurosurgical profession taught me at a young age, death is never far away, even though we may have chosen to believe otherwise. What is not a surprise, or should not be a surprise, is that the Covid-19 pandemic is occurring in the first place. Human beings are merely one life form among many on earth. Why then should we think of ourselves as being exempt from the fundamental principles of biology? As human numbers approach 8 billion there is an increasing need for urbanization, and with urbanization massive densely populated cities have emerged. Not unlike the situation on factory farms, high population density of any life form is a set up for the rapid spread of infectious disease. It takes heroic and often unnatural public health efforts to compensate for such ecological pressures, much like the antibiotics used in animal feedlots. Meanwhile, modern medicine enables a continuously growing elderly or otherwise infirm population to keep on living and it is these individuals who are far and away the most susceptible to Covid-19. As a 65-year-old man, I am not unaware of the fact that 100 years ago life expectancy was little more than 30. The huge population of elderly and other individuals with compromised health who are alive today would not have lived a century ago, yet they are a natural target for infectious disease. There are reasons to celebrate urbanization and growing old, yet our species should not be unmindful of the infectious disease opportunities that these changes engender. If not Covid-19, other pandemics can and will emerge. That is our human reality that medicine will be hard pressed to ever “solve.” So what to do? Sorry to say, there is no solution. Rather my simple advice would be to use the present pandemic as a wake-up call to appreciate whatever life we have before us. As Steve Jobs famously once said, “Death is very likely the best single invention of life.” Let’s wisely use that which remains. And don’t forget to wash your hands!

Mar 03, 2020