Rich hospitals get the bulk of government bailouts: It's the American way!

The world isn’t fair. The US isn’t fair. It isn’t equitable. It would be much better if things were more equitable, if everyone had the same starting line (or, to use a metaphor that might be more resonant with politicians and businessmen, started from the same tee), or if those who were starting from farther back got extra help to get them closer to being on a par. Par is another golf term, and actually in golf this is actually done. The “handicap” is an amount subtracted from the scores of weaker golfers (in golf, lower scores are better) to make the competition more fair. Unfortunately, it never occurs to the presidents and CEOs who play on the golf course to apply this same strategy to the actual world, to regular people and businesses.

In fact, it is those least in need benefit most from government policies. It has been clearly demonstrated that the 2018 tax cuts had little benefit for the middle class or working class, less yet for the poor whose incomes are so low they scarcely pay taxes, but was a bonanza for billionaires and mega-multi-national corporations. This is no less the case with the next multi-trillion-dollar coronavirus relief bills, where the richer you are the more you get. Nicholas Kristof points out that ‘a single mom juggling two jobs gets a maximum $1,200 stimulus check — and then pays taxes so that a real estate mogul can receive $1.6 million. This is dog-eat-dog capitalism for struggling workers, and socialism for the rich.' He is correct, and it is unconscionable. Franklin Roosevelt would certainly be appalled; I use a quotation from him that is inscribed in the FDR memorial in DC as the epigram for this blog.  By this measure we not only fall flat, we invert; you’d have to go back even before the “Roaring ‘20s”, at least to the “Gilded Age” of the 1890s to see such inequity enshrined. For a good, concrete, example of how MUCH a billion dollars is and how those who have multiples of it are so far from the rest of us, and how incomprehensible it is to expect working people to bear the brunt of need, Tom Lutz of the Los Angeles Review of Books writes:

In other culture news, The Atlantic laid off 68 people, and the LA Times made everyone take a 20% pay cut, which will save the paper $2 million in a year.

Patrick Soon-Shiong, who owns the LA Times, has a net worth of $7 billion, so one year's 5% return on his wealth would cover that $2 million savings for 175 years. Or he could just cover for this year and have a net worth of $7,348,000,000, instead of $7,350,000,000. Laurene Jobs owns The Atlantic. Her net worth is $23 billion; 5% return on that in one year would pay those 68 fired staffers $100,000 a year each for 169 years. Or she could just pay for this year, and not kick 68 human beings to the curb to face the worst unemployment in 70 years. If she did that, at the end of the year, instead of $24,150,000,000, she would only have $24,143,200,000. That difference is surely worth ruining the lives of 68 people for. Her Apple stock alone went from $7 billion to $12 billion over the last 12 months. That appreciation could pay the fired 68 staffers $100,000 a year each for 735 years. and she still would be one of the 40 richest people in the world.

FDR was famous for the “New Deal”, a mixture of programs to put Americans back to work and to bring us out of the Great Depression. Congress and the executive branch have, in response to the coronavirus pandemic, trotted out literally trillions of dollars, but unlike Roosevelt have done their best to ensure that the most goes to the least needy. It is not just regular people who are affected; bailout money intended to offer relief to small businesses (already generously defined as fewer than 500 workers) went largely to much larger businesses. Some of this was blamed on administrative mistakes in a rush to get the money out, but huge corporations did in fact get lots of money, and didn’t give it back. And, in case you were wondering when I was going to get to health care, the same dynamic is playing out for hospitals.

The pandemic has hit hospitals hard, particularly those in high-prevalence places (like New York City) and particularly public hospitals and others that care for the poor in the best of times. Although most rural areas have not had as high an incidence of coronavirus infections, rural hospitals were teetering on the brink before the pandemic, because a hospital is an expensive operation to run and rural areas have, well, less dense populations. And populations, also that are more likely to be old and poor. Which are two risk factors for getting and dying from COVID-19, but are also risk factors for a lot of other health issue. This is why such hospitals – small rural hospitals, overwhelmed inner city hospitals, hospitals with true need, should be getting the bailout money to help them in this crisis. But – and I doubt this will come as a surprise – they are not getting most of the help, and most of the help is going to big, money-rich, hospital chains, the hospital equivalents of billionaires and multi-national corporations.

A recent article in the New York Times, ‘Wealthiest Hospitals Got Billions in Bailout for Struggling Health Providers’, with the subhead ‘Twenty large chains received more than $5 billion in federal grants even while sitting on more than $100 billion in cash’, begins

A multibillion-dollar institution in the Seattle area invests in hedge funds, runs a pair of venture capital funds and works with elite private equity firms like the Carlyle Group.

But it is not just another deep-pocketed investor hunting for high returns. It is the Providence Health System, one of the country’s largest and richest hospital chains. It is sitting on nearly $12 billion in cash, which it invests, Wall Street-style, in a good year generating more than $1 billion in profits.

And this spring, Providence received at least $509 million in government funds….

While all hospitals have taken a financial hit from the cancellation of high-profit elective procedures, some, like Providence (and there are many others) have big-to-huge cash reserves, while others can barely make payroll month-to-month. In the typical rich-get-richer scenario that characterizes the US all too often, those hospitals that have high profiles (read: take care of well-to-do people) not only do not have to make it on low-reimbursement uninsured and Medicaid (and even Medicare) patients, the get big donations, as detailed in “One rich NY hospital got Warren Buffett’s help. This one got duct tape”, NY Times April 26, 2020 (updated May 20). As all too often with “philanthropy”, the rich give to organizations that benefit the rich, and take a tax break for it. And so do the hospitals, most of which are organized as “non-profits” but act like for-profit businesses, but don’t pay taxes. Much of the data in the May 25 article comes from this Kaiser Family Foundation report. It documents that the biggest recipients of aid were for-profit and wealthy “non-profit” hospital systems. 

How does this happen? By intent or sloppiness? I don’t know.

While Health and Human Services also created separate pots of funding for rural hospitals and those hit especially hard by the coronavirus, the department did not take into account each hospital’s existing financial resources.

“This simple formula used the data we had on hand at that time to get relief funds to the largest number of health care facilities and providers as quickly as possible,” said Caitlin B. Oakley, a spokeswoman for the department. “While other approaches were considered, these would have taken much longer to implement.”

Most people are decent people; if a package is mistakenly delivered to your house but is addressed to someone down the street, you don’t keep it. If the person who was supposed to get it is aged, disabled, poor, or otherwise in need, and this package provides some relief – perhaps food, clothing, medicine, you are especially concerned to make sure they get it. This kind of morality does not apply to billionaires or to wealthy corporations, whose absolute greed to grab anything that they can get their hands on, no matter who else suffers, would make the highwaymen of yore, or Mafia dons, blush.

“If you ever hear a hospital complaining they don’t have enough money, see if they have a venture fund,” said Niall Brennan, president of the nonprofit Health Care Cost Institute and a former senior Medicare official. “If you’ve got play money, you’re fine.”’ Well, they’re fine. And I guess you’re fine if you can afford to go to one of them, not the hospitals that serve the people with the greatest need. And if you don’t think about it too much, you can probably sleep at night.

I don’t see how the CEOs and Boards of these hospitals do.

COVID-19 is hard and horrible and exposes existing gross inequities in our society. But don't drink the snake oil

The COVID-19 global pandemic is hard. It is just a little bit hard for those of us who can work from home or are retired, and live in lowish-incidence areas with a high outdoors/people ratio who can go for walks, and just have to worry about not going to the gym or our hair getting shaggy, or whether to try to go to the store to get things to cook or get takeout, or being able to see our children and grandchildren in faraway places. It is harder for those who live in more congested and affected areas, and really hard for those who have lost friends or family to the disease, or have had it themselves.

I read the NY Times, published at the epicenter of the US pandemic, and am torn up by the suffering of so many there. It is really hard if you are not any of the things I mentioned in the first sentence; if you have a very low-paying job and no savings and either cannot work and get paid or have to go to work because you are essential, despite the fact that no one ever told you that before – or certainly paid you as if you were. It is showing us not only which workers are essential even if very low paid, it is showing us which are absolutely not even though highly paid, like the manipulators of finance in the legal gambling casinos of Wall St. An article by a NYC subway conductor in the NY Times says “we are not essential; we are sacrificial”. It is really hard if you have pre-existing conditions such as diabetes, obesity, chronic lung disease, or all of them. Nursing home patients were the initial victims and remain the hardest hit.

It is really, really hard if all these things come together. If you are a low-wage health worker in New York, or a farmworker (documented or not) picking vegetables and fruit and living in dangerous conditions at the best of times, or a Native American on a reservation where services are meager and the virus is spreading. The two counties of Arizona including the Navajo reservation have just about 2.5% of the state’s population and 15% of its COVID-19 cases. If you are a racial or ethnic minority, whether Asian and being blamed by the President for the virus and harassed and worse by people on the streets, or Black or Latinx, and having your usual differential level of risk and harassment exacerbated, not mitigated, by the virus.

The virus has not affected countries across the world, or parts of countries, or communities equally, but the pandemic is far from over. The rates of infection are not fading; the NY Times coverage frankly says ‘The reality of the coronavirus in the U.S. is an unrelenting crush of cases and deaths.’

More than a month has passed since there was a day with fewer than 1,000 deaths from the virus. Almost every day, at least 25,000 new cases are identified, meaning that the total in the United States — which has the highest number of known cases in the world with more than a million — is expanding by 2 to 4 percent daily.

Rural towns that one month ago were unscathed are suddenly hot spots. It is rampaging through nursing homes, meatpacking plants and prisons, killing the medically vulnerable and the poor, and new outbreaks keep emerging, an ominous harbinger of what a full reopening of the economy could bring.

As New York, which has the largest burden of cases, sees plateauing and even decrease it brings down the national rate, but if NY is excluded, the rate is continuing to rise, moving more and more into the rural states and counties who have seen the least, and, despite their frequently suffering from poverty and drug addiction and unemployment, have sometimes deluded themselves into thinking this was a big-city problem.

Both the Trump administration and independent (e.g., University of Washington) sources estimate that the deaths from COVID-19 in the US will be at least double what has been previously predicted, up to 120,000. This is not coincidentally associated with the relaxation of public-health motivated controls including social distancing mandates, business closures, etc. The states that are taking the “lead” in this regressive movement are mostly in the South and Midwest, have Republican leadership, and are creating a macabre natural experiment to demonstrate how bad public policy can kill.

Despite the morbid, if accurate, predictions that come from his own administration, and that the administration has set federal guidelines for reducing restrictions based on decreasing rates of cases and deaths and increased testing, the President himself has provided a different message. He has overtly lauded the “opening” of states that have not met these criteria, visited a mask factory in Arizona without wearing a mask. and encouraged the shocking, stupid, and dangerous demonstrations by overwhelmingly white, armed men against the appropriate restrictions in states with Democratic governors such as Michigan. These folks may think that they look cool and tough, but in fact what they look like is the yahoos they are. It is impossible for me to look at a photo like this and not imagine what would happen to these demonstrators if their skin were a darker color. It doesn’t take much imagining, and it is an awful reminder of our ongoing racism that they are allowed to do this.

With all of the hard-to-terrible impact of the pandemic, it is also hard to resist the temptation to latch on to hope in the form of new magical miracle treatments, cures, tests, vaccines. It is clearly hard for the President, who enthusiastically touted the wonders of hydroxychloroquine before there was real evidence of whether it was truly beneficial – and the evidence came in overwhelmingly negative. He also, of course, has suggested the benefits of “disinfecting” the body with chemicals or UV light. These would seem as ridiculous as they in fact are, except for the folks who drank fish-tank cleaner because it had chloroquine, or ammonia or bleach, or did Tide-pod enemas. As much as I rue it, there are a large number of Americans who view his pronouncements as gospel, and act on his every suggestion.

In addition, the complexities of the science are hard for most people to understand, and the uncertainties can seem unbearable. What level of antibodies are produced by natural infection? Do they protect against reinfection? If they do, how long will this immunity last? Can their antibody-containing plasma be used to effectively treat other sufferers? We don’t know, and won’t know, until we know. That takes time.

Another recent article in the NY Times, said

Researchers and politicians in China, the United States, Germany, Britain and beyond have latched onto antibodies as a potential solution to the virus and an outlet from containment measures. But that talk, always ahead of the science, has grown more muted in recent weeks. With the research refusing to cooperate, experts in Italy say the promise of antibodies may not be what people have imagined. At least for now.

This needs to become the new mantra for essentially every medical and scientific intervention for the novel coronavirus (officially “SARS-CoV-2”). Our talk can be ahead of the science when we are expressing our hopes and desires, but we cannot allow these hopes and desires to become something we act on until we have real evidence. Too much has already been disappointing, or misstated. “Compassionate” use is sometimes advocated, but we had better be sure that our compassion does not create more problems for people than they already have. Hydroxychloroquine does, certainly drinking disinfectants does; high-dose vitamin C is water-soluble and thus may not – unless you are a stone-former; vitamin D is fat-soluble and you can overdose on it.

A moving article in the NY Times about Rep. Alexandria Ocasio-Cortez, whose district includes the hardest-hit areas of the hardest-hit city (including, with sad irony, the neighborhood of Corona in Queens), addresses the challenges of the community and the sadness it engenders in her, in her constituents, and in us. It says ‘The wreckage in her community has made a darkly eloquent case, she said, for her agenda of universal health care and less income inequity. “This crisis is not really creating new problems,” she said. “It’s pouring gasoline on our existing ones.”

She is correct. We need to move forward not following snake-oil salesmen but resolving to address the structural problems that have made this crisis worse than it had to be.

Pandemic mismanagement: Fear, inequity and -- maybe -- hope?

Like almost everyone else, of all political persuasions, I imagine, I am furious. What and whom we are furious about or with varies, of course, with how we see the world, what we value, and whether we have a “reality-based” outlook. To a great degree our perception is affected by what we want to be true, rather than what necessarily is true, and our short-term desires rather than any long-term sense.

As a physician with a great interest in and concern for public health, I am very concerned (!!) about the horrible way that President Trump and his administration prepared for a pandemic (not at all), reacted to the first evidence of one (denial), finally moved into a response (incompetently), and have yo-yo’d (good word for them) back and forth between making tentative positive moves and stepping back. Trump’s own statements are pretty accurately parodied by a meme making the rounds with him as Captain of the RMS Titanic. But we now have a response team, headed by Ivanka and Jared, with folks like Mark Meadows, Wilbur Ross, and Steven Mnuchin, so everything should be OK. Or not. We will, as Masha Gessen tells us in the New Yorker, not know the moment when democracy dies. We can have armed rallies demanding ‘reopening of the economy’, and even calls for insurrection if he loses the election, by folks like Franklin Graham.

So far, the coronavirus does not appear to be intimidated.

Predictions for the duration of this pandemic and the way in which it will change society and human behavior in the US and around the world are both dire and probably accurate. The most distressing news has been the unsurprising degree to which it has had its greatest negative impact upon the most vulnerable: the poor, minorities, elderly, and those who cannot afford to not go to work. The most inspiring aspect has been the degree to which it has highlighted the contributions of not only heroic health care workers, but all essential workers, the majority of whom are women, especially non-white women, and are generally underpaid. Among the essential workers are NOT included CEOs, hedge fund managers, political pundits, and other mostly-male, mostly overpaid roles. Walter Scheidel gives us mixed news in his New York Times piece ‘Why the Wealthy Fear Pandemics’; back to at least the 14^th century, it brings about social disruption and tends to increase the relative power of workers to demand better wages and working conditions. However, he cautions, that while “more often than not, repression failed…none of these stories had a happy ending for the masses.”

But it is not just the far-right, the GOP, and Trump who are not responding well to this crisis. The Democrats have been much better, but that’s a low bar. They still insistently miss the point that a national health program would have put us in a much better position to respond to this pandemic, and at the very least have eliminated the probably of bankruptcy for many of those receiving treatment. It almost certainly would have decreased the number of people staying away from treatment because of fear of the cost. Bernie Sanders said this throughout his entire campaign, and has just said it again in a NY Times Op-ed:

We are the richest country in the history of the world, but at a time of massive income and wealth inequality, that reality means little to half of our people who live paycheck to paycheck, the 40 million living in poverty, the 87 million who are uninsured or underinsured, and the half million who are homeless.

These ideas are absolutely as correct now as they were before he left the race. We need a national health system.

Most recently (April 18, 2020) the case is made by economists Anne Case and Angus Deaton, who continue to be amazed at the fact that ‘America can afford a world-class health system: Why don’t we have one?’. They note that

In March, Congress passed a coronavirus bill including $3.1 billion to develop and produce drugs and vaccines. The bipartisan consensus was unusual. Less unusual was the successful lobbying by pharmaceutical companies to weaken or kill provisions that addressed affordability — measures that could be used to control prices or invalidate patents for any new drugs.

The notion of price control is anathema to health care companies. It threatens their basic business model, in which the government grants them approvals and patents, pays whatever they ask, and works hand in hand with them as they deliver the worst health outcomes at the highest costs in the rich world.

And make this blunt and totally accurate statement:

The American health care industry is not good at promoting health, but it excels at taking money from all of us for its benefit. It is an engine of inequality.

It is not good at promoting health. That is a bad thing. It is good at taking money from all of us for its benefit. That is a corrupt and inefficient, as well as bad, thing. It is an agent of inequality. For most of us, that is a bad thing.

And yet it persists. And its enablers include the Democratic leadership, which resolutely continues to refrain from challenging the profits of the insurance and pharmaceutical industries. They sometimes talk about how it’s a bad thing, but then so does Trump, and sadly it seems that Trump is often more sincere. The latest proposal for spending money on protecting people by the Democratic leadership is to pay for people’s COBRA (this is where you can continue to keep your former employment-based health insurance for a time when you are laid off by paying the whole premium yourself). A good thing if you were going to lose your health insurance, for sure, especially if now, not working, you can’t afford to pay not only what YOU were paying but also your employer’s contribution. Not a bad start. But, somehow, one would hope for a better, more proactive, more comprehensive, and most important more effective solution to this crisis than just paying money to insurance companies!

The media has talked about the Democratic Party and its presumptive nominee, Joe Biden, coming a bit closer to the universal health, single-payer, Medicare for All (#Medicare4All) proposals endorsed by Sen. Sanders; a recent NY Times article tells us that ‘Biden's new proposals include expanding Medicare, government insurance for Americans over 65, to those 60 and older.’ Bold! Not! Yes, it is good that people who are 64 years old will not have to risk their lives waiting to turn 65 – that would become the province of 59 year olds! It certainly would not begin to solve the problems of the health system that are apparent to all of us, not just to Case and Deaton. It leaves the uninsured uninsured, the underinsured underinsured, the folks bankrupted by co-pays, deductibles, and surprise bills (especially those from catastrophic costs, mainly a problem for the middle-income with employer-based health insurance, per the Commonwealth Fund) bankrupt, and the insurance companies fat and happy.

It is not a solution, and the only thing audacious about it is that Biden and his campaign even dared to put it out there. We are told, by all the candidates who have dropped out, by all the liberal pundits, even by progressives, that if we want to defeat Trump and incipient fascism, we have to all come together and vote for Biden. If we do, we need to see meaningful movement to put the interests of the people ahead of those of the healthcare-industrial complex, as leaders like Alexandria Ocasio-Cortez have called for.  We need to see meaningful proposals from the Democratic standard-bearer.

In fact, we need to see him. Anyone seen Biden recently?

COVID-19 and protecting healthcare workers

The world, and the US, have entered unchartered waters in recent history as a result of the COVID-19 epidemic. Obviously, the deaths of people who would not otherwise have died is the most important. The real economy (forget the stock market) is a disaster; in this country 3.3 million people applied for unemployment insurance benefits one week only to have it double to 6.6 million the next – the previous high was less than 700,000. The responses of governments – national, state, local – to the epidemic, and the degree to which they rely on actual science, is another huge issue.  Here I seek to address one part of the crisis, one tension, the protection of health care workers, including doctors and nurses.

For starters, we have the issue of the actual health of these individuals. The reason for placing special emphasis on the protection of them is not because they are better or more important people than others, but because we need them to care for the sickest of us, those whose illness means that they cannot safely “shelter in place”, and need to come to urgent care centers, doctors’ offices, emergency rooms, and hospitals. Health care workers, particularly in hospitals, are personally more vulnerable because they have ongoing, repeated exposures to the virus. Greater levels of virus, from one or multiple exposures, increase the risk that a person will not only become sick, but become sicker, as discussed in ‘These Coronavirus exposures might be the most dangerous’ by Joshua Rabinowitz and Caroline Bartman in the NY Times April 1, 2020, and healthcare workers in hospitals have repeated exposures.

In addition, of course, we need these people to care for the sick, because they are the ones with the skills and training to do so. Thus, they need to be protected as much as possible. The news has been full of stories of this not happening, of hospitals not providing necessary Personal Protective Equipment (PPE) to its providers, and even punishing those who bring their own (with the bizarre idea that it is not fair to the other workers who do not have it). Our healthcare providers need to be protected, not punished for identifying flaws in the system (Nicholas Kristof, April 2, 2020, ‘”I Do Fear for My Staff,” a Doctor Said. He Lost His Job.’). Doctors, nurses, and other healthcare workers have often been lauded by the public (the practice of applauding out the window, begun in Italy, is especially touching), but punished by their employers. (Others, such as Capt. Brett E. Crozier of the aircraft carrier USS Theodore Roosevelt, are also being punished by their bosses for doing the right thing.) And these people are, although health professionals, also people, with families and with risk (Sandeep Jauhar, ‘In a Pandemic, Do Doctors Still Have a Duty to Treat?’. Heroes are great, but dead heroes are still dead, fired heroes are still fired, and dead or sick healthcare workers cannot provide care to others.

One of the most elementary pieces of PPE is in great shortage: the effective N-95 masks that every healthcare worker, certainly those in the hospital, should have on all the time. Some of this is because our overall national response has been anemic, and production has not ramped up quickly enough, and some is because hospitals have adopted the “just in time” approach to acquiring equipment popularized by corporations like Toyota and Ford. It may work for cars, and it may be profitable and efficient for hospitals in normal times, but like so much of our “normal” capitalist system it is fatally (quite literally) flawed when stressed by a real crisis. This fault has been augmented by individual profiteering -- well over a month ago the staff in my local Home Depot laughed when I asked about them; they told me they had all been bought up when COVID-19 began in China, by “entrepreneurs” who sold them to Chinese on eBay. True? I can’t know, but there sure were none available. One thing that the rest of us can do is to ensure that essentially ALL new N-95 masks should be available for healthcare workers, especially those in hospitals. Other people should not be wearing, not to mention hoarding or scalping them. Don’t get some to wear when you go out. Stay home. Especially if you’re symptomatic. Stay away from others. Social distancing is something we can practice, and healthcare workers cannot. What about other masks, “surgical masks”? They won’t protect you much if at all from acquiring the virus, but may help (if you can find them, or else use a bandana) protect other people from getting the virus from you if you are infected but asymptomatic. Of course, if you are symptomatic, you should not be going out at all -- unless you are so sick and short of breath that you urgently need to go to the hospital, in which case, wear a mask.

Sometimes this balance between our own self-interest (I need to go out and an N-95 mask protects me) and society’s interest (healthcare workers need the N-95 masks) is difficult, but it is decision that should not be hard. You, me, or our family members, may be the ones who would have been cared for by that doctor or nurse if they weren’t lying in the next bed because they didn’t have the mask we wore to the grocery store.

But some other decisions are harder, like deciding who should get access to a ventilator when there are far too few for everyone who needs one. In their generally good opinion piece (April 1, 2020), Protect the Doctors and Nurses Who Are Protecting Us: They need immunity from lawsuits and prosecution for triage decisions, Cohen, Crespo, and White argue for laws to protect doctors making difficult decisions protection from lawsuits or criminal charges for making them. This is a very good idea. They make two very important points. The first is that there need to be formal criteria established for triaging access to scarce resources so that we do not just have individual doctors making individual decisions, but rather following well-thought-out guidelines. The other is that those decisions need to be legally protected. They cite   

A Maryland statute [that] makes health care providers “immune from civil or criminal liability” for actions they take “in good faith” during a declared “catastrophic health emergency.” According to the Maryland Attorney General’s Office, this statute immunizes clinicians who follow state-approved ventilator allocation protocols, “regardless of the negative consequences arising from the withdrawal of a patient’s ventilator.”

This is a good idea, and one that should be adopted by all states.

But these writers also note that “Denying some patients short-term ventilation, against their wishes, will probably cause them to die when they might have gone on to live long and healthy lives with the treatment. But it will also make limited numbers of ventilators available to other patients who are more likely to survive.” Fortunately, this is not yet really the situation we are in, having to decide which “people who might have gone on to live long and healthy lives with treatment” should be left to die. But we will be, and are in places like New York, in a situation in which decisions will have to be made that deny some patients who would NOT have gone on to lead long and healthy lives ventilation to allow their use for other patients who are more likely to survive.

People who have pre-existing terminal diseases from which they would have died anyway, or those with dementia who are never going to have normal healthy lives (and cannot make their own decisions) will be, and should be, the last people to receive ventilator treatment. Hopefully, this will not be “against their wishes” (or those of their family, if their dementia makes it impossible for them to express those wishes), because they recognize the sense of this. When people have a terminal disease, and/or are suffering from dementia, coming to grips with dying and when it is time to say “enough” even if there WERE sufficient ventilators, is something that should have been addressed already, by the patient, family, and physicians. Of course, none of this argument should suggest that criteria other than pre-existing health status and the likelihood of a full recovery should be considered in allocating resources; certainly not income, wealth, insurance status, race, disability of any kind that is not associated with an expectation of dying soon, or even age in and of itself.

COVID-19 has affected, or will affect, (as the southern hemisphere enters winter) the whole world. We are all in it together. In fact, of course, we are always all in it together, but the pandemic has exposed the flaws in individualistic arguments. I am not going to write that we can “beat this” because I don’t know, but we can behave in wise and responsible ways to keep the terrible consequences a little less terrible.