In a Nightmare Scenario, How Should We Decide Who Gets Care?

Summary

Podcast Summary

Podcast: The Political Scene | The New Yorker
Episode: In a Nightmare Scenario, How Should We Decide Who Gets Care?
Date: March 23, 2020
Host: David Remnick
Guest: Dr. Philip Rossoff (Professor of Medicine at Duke University, Bioethics Expert)

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Main Theme & Purpose

This episode tackles the harrowing ethical and logistical dilemmas facing doctors and hospitals in the COVID-19 pandemic, especially when resources such as ventilators and ICU beds are scarce. David Remnick interviews Dr. Philip Rossoff, a specialist in bioethics, about how life-and-death decisions should be made—who gets care when not everyone can be treated? The conversation explores practical, historical, and moral dimensions around triaging care in crisis, and what it means for the healthcare system and society at large.

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Key Discussion Points & Insights

1. The Nightmare Scenario Unfolding (01:16–03:09)

• Comparison with Italy: Dr. Rossoff explains how overwhelmed the Italian healthcare system became, forced to ration ventilators and ICU beds.
• Triage Dilemmas: He describes the core decisions: if two patients need life-saving equipment but only one is available, or if a patient occupies a ventilator with little hope of recovery while others are waiting outside the ICU.
• Moral Weight: The difficulty of removing someone from life support to save another, highlighting the wrenching moral distress for clinicians.

2. How to Decide, and How NOT to Decide (03:09–04:33)

• Bad Practices: Dr. Rossoff insists, “The way not to make this decision is to make it arbitrarily, capriciously, unilaterally, and at the bedside in the moment.” (03:26)
• Institutional Guidelines Needed: He underscores the need for pre-established, institutionally-developed guidelines—“If we're smart, we would have institutional guidelines and plans in place ahead of time.” (03:26)
• Patchwork Guidance: The U.S. has guidelines, but they're inconsistent and vary by state and hospital, leading to unequal treatment depending on geography.

3. Principles of Triage and Rationing (04:33–05:55)

• Origins and Challenges: Triage comes from battlefield and disaster medicine but is different in a hospital ICU setting where decisions can’t just be “one and done.”
• Cultural Hurdles: “[We] are not accustomed to making these kinds of rationing decisions openly and certainly not as a society.” (05:22)

4. Previous Experience with Scarcity (05:55–07:55)

• Drug Shortages as Precedent: Dr. Rossoff recounts developing a transparent, fair policy for critical drug shortages, prioritizing proven efficacy and equal treatment for clinically similar patients.
• Quote: “We did not wish to use scarcity or the necessity to ration as a mechanism to exacerbate existing disparities and inequalities in our society and in our health care system.” (07:31)

5. Communicating Difficult Decisions and Emotional Toll (07:55–09:25)

• Delivering Bad News: Dr. Rossoff highlights the “moral distress” faced by clinicians, stressing that ethical rules do not make the human cost of withholding or withdrawing care any easier.
• Support Systems Needed: Emotional and psychological support for frontline healthcare workers are crucial.

6. Why Is the U.S. Running Short on Supplies? (09:25–12:13)

• Systemic Flaws: Emphasis on the healthcare system as a business, maximizing efficiency (and profits) leaves no surge capacity—“we have cut the system to maximum efficiency. Bone.” (10:07)
• Just-in-Time Logistics: Hospitals use just-in-time ordering, with no buffer stock. Suppliers themselves lack large reserves, making the system fragile during unforeseen spikes.
• Global Problem: Even well-funded, socialized systems in Europe face similar challenges; no system can afford idle beds/equipment “just in case.”

7. Vaccines, Treatment, and False Hope (12:13–14:16)

• Caution on Vaccines: Dr. Rossoff warns against relying on rapid vaccine development, referencing Margaret Heckler’s premature HIV vaccine promises.
  • “I think banking everything on a vaccine would be unwise, putting off current planning because a vaccine is going to happen at some point.” (13:05)
• Drug Therapies: He finds hope in the possibility of effective therapies being found among existing drugs.

8. End-of-Life Care in Pandemic Triage (14:16–15:45)

• Dignity for the Dying: Dr. Rossoff stresses preparing palliative resources for those patients who cannot be saved, referencing his own published work.
  • “We need to have medications like morphine and benzodiazepines … to relieve respiratory distress at the end of life.” (14:42)

9. Hope vs. Despair—Learning from History (15:45–17:14)

• Character in Crisis: Reflects on America's history—sometimes rising to moral challenges, sometimes failing, as in the internment of Japanese Americans during WWII.
• Aspirations: “My hope is that when we come out of this, we will have medical and moral victories rather than medical and moral shame.” (16:55)

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Notable Quotes & Memorable Moments

• On Triaging Lives:
  “In the calculus of who shall live and who shall die, who prevails? The younger patient, the healthier one, the one that may know the cure to cancer, how do you make these decisions?”
  – David Remnick (03:09)

• On How NOT to Decide:
  “The way not to make this decision is to make it arbitrarily, capriciously, unilaterally, and at the bedside in the moment.”
  – Dr. Rossoff (03:26)

• On Principles of Fair Allocation:
  “There were neither VIPs nor what we also called VUPs, or very unimportant people.”
  – Dr. Rossoff (07:20)

• On the Emotional Cost to Providers:
  “The amount of moral distress and emotional psychological distress that could pile up on people at the front lines should not be underestimated.”
  – Dr. Rossoff (08:45)

• On Systemic Causes of Shortages:
  “We have cut the system to maximum efficiency. Bone.”
  – Dr. Rossoff (10:07)

• On Pandemic Preparedness:
  “Pandemics are not a remote possibility, but … an inevitability. … Luck runs out.”
  – David Remnick (11:11)

• On False Hope in Vaccines:
  “I think banking everything on a vaccine would be unwise…”
  – Dr. Rossoff (13:05)

• On End-of-Life Duties:
  “What do we owe those who can't be saved?”
  – Dr. Rossoff (14:34)

• On America’s Test of Character:
  “My hope is that when we come out of this, we will have medical and moral victories rather than medical and moral shame.”
  – Dr. Rossoff (16:55)

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Timestamps for Important Segments

• Start of main discussion / Introduction of Dr. Rossoff: 01:16
• Deciding who gets care in crisis (Italy context): 02:13–03:09
• The right vs wrong way to triage: 03:09–04:33
• Principles for allocation & prior experience with drug rationing: 05:55–07:55
• Psychological burden on clinicians, support needs: 07:55–09:25
• Why shortages occur (system-level analysis): 09:25–12:13
• Vaccine skepticism and the need for ongoing planning: 12:13–14:16
• Planning for end-of-life care: 14:16–15:45
• Reflections on societal response & hope: 15:45–17:14

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Overall Tone

The conversation is urgent, candid, and sobering, with Dr. Rossoff’s explanations combining practical bioethics with deep human empathy. Remnick’s questions guide the discussion to clarify difficult realities and spur reflection on both immediate decisions and long-term systemic reforms. There is an undercurrent of frustration about avoidable system vulnerabilities, but also hope that the crisis can bring about both moral clarity and necessary change.

Transcript

[A]

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[B]

This is the Politics and More podcast. I'm David Remnick. In northern Italy, doctors were forced to begin rationing ventilators and other equipment, scarcity of essential supplies, decisions about who gets resources and who won't. It's a nightmare scenario, and it could come true here, too. Last week, New York Governor Andrew Cuomo demanded that the Army Corps of Engineers begin building field hospitals in New York, essentially repurposing existing buildings, all out of the fear that ICUs in New York could soon be or overwhelmed. Dr. Philip Rossoff is a professor of medicine at Duke University and he specializes in bioethics. Dr. Rosoff, we've been watching as the Italian healthcare system has been absolutely overwhelmed by COVID 19. What kinds of choices are doctors there having to make when faced with so many patients in critical condition?

[C]

Well, a typical scenario where would be having a finite number of intensive care unit beds, a finite number of mechanical ventilators or artificial breathing machines, and also, by the way, a finite number of doctors and nurses and respiratory therapists who know how to operate these machines and having to make a decision about who should get put on a machine. The other wrenching decisions I think that they have to make is when they have the ICU filled with people potentially still having some sort of hope of getting better, but you have a line of people waiting to get in there. If somebody is in the ICU and not getting better, do you take them off the ventilator and make room for somebody who potentially could benefit more?

[B]

These are horrible questions to ask, but in the calculus of who shall live and who shall die, who prevails? The younger patient, the healthier one, the one that may know the cure to cancer, how do you make these decisions?

[C]

Well, I can tell you how not to make these decisions. That's probably an easier answer to go with. First, the way not to make this decision is to make it arbitrarily, capriciously, unilaterally, and at the bedside in the moment. If we're smart, we would have institutional guidelines and plans in place ahead of time.

[B]

Well, do we have such guidelines?

[C]

Sort of. There are guidelines that have existed since 2007 to 2009 that were originally created in anticipation of a bird flu pandemic. They have been dusted off and updated, but there are lots of them. There are many individual state plans. There are many individual hospital plans. The problem exists certainly in this country, that depending upon what state you're in, where you get very sick and might need these resources, you might get treated differently than if you were someplace else.

[B]

Give us a sense of the priorities, the way triage is done in the most basic way.

[C]

So I think that some of the origins of triage are from emergency or disaster medicine. One of the classic triage situation is on the battlefield, you have two wounded soldiers who come in and you only have one surgeon or one bed. And how do you prioritize which soldier to take care of first? That has been adopted with multiple changes, of course, to the emergency room setting for various disasters. Mass casualty incidents from mass shootings, for instance, or mass car accidents on the highway. But those are one and done situations. Applying that upstairs from the emergency department to the ICU is a radically different medical and psychological situation. We are a society of go for broke. A lost life is when we've lost the battle. I mean, those types of language exist throughout medicine. And we are not accustomed to, to making these kinds of rationing decisions openly and certainly not as a society.

[B]

You've recently retired, and I wonder if in your long career you've ever been in a situation even remotely like this, where there simply aren't enough Resources to go around and you have to make decisions.

[C]

Yes. So I can think of a couple. There is an ongoing crisis in which only every once in a while reaches the level that people in the media pay attention to it, of critical drug shortages. And 10 years ago, we were, I believe, the first institution in the country, and we published this about how to go about effectively, fairly and openly with rationing these drugs that were scarce. And so I dealt with that for 10 years and it actually worked out quite well.

[B]

Well, how did you work it out? How did you make your decision?

[C]

Well, we created a policy that was open and available to everyone. We decided that the first order of priority should be that any allocation of drugs should be based upon proven clinical efficacy. So the analogy would be to a ventilator, you don't give a ventilator to somebody who's clearly dying and can't benefit from it. You give it to somebody who potentially has the ability to benefit from it. Same thing with drugs. The second thing is it was open and transparent. The third thing was that we decided that clinically similar patients should be treated the same, so that there were no both. There were neither VIPs or what we also called VUPs, or very unimportant people. We did not wish to use scarcity or the necessity to ration as a mechanism to exacerbate existing disparities and inequalities in our society and in our health care system.

[B]

Do you have advice for doctors who have to deliver this kind of news to patients and say, look, we have to. We have to let your mother go because we don't have a ventilator for the person three beds down.

[C]

I think that is an extraordinarily good point that is often overlooked, is that we assume that once we have rules and guidelines, let's assume for the sake of argument that we actually have these rules and guidelines, that it should be relatively easy. It's actually not easy even under normal circumstances, when somebody is clearly not benefiting from advanced care and everybody's on the same page, to have someone die or turn off a ventilator. But under these circumstances, what is now what is called moral distress of doctors and nurses and respiratory therapists and other people involved in caring for these patients, either saying no to somebody up front, we're not going to start this, or after somebody is getting treatment, saying, we're going to stop. The amount of moral distress and emotional psychological distress that could pile up on people at the front lines should not be underestimated. And I think we need to put into place support systems for people in those situations.

[B]

I think a lot of people don't understand certainly I don't understand why the richest country in the world is going to find itself short by thousands of ventilators and other equipment. I mean, I know some really, really well who's an emergency room doctor, and he's telling me that already he's worried that he's going to have to use disposable masks all day instead of change with each period patient that just ordinary things are in short supply. What is going on?

[C]

Well, our healthcare System is a $3 trillion business and I want to emphasize business. And the way places stay in business is by controlling expenses and maximizing intake of money. Having empty hospital beds is a waste of money. Having too many doctors and nurses sitting around waiting for patients to come in and is a waste of money. It's an inefficiency. And so we have cut the system to maximum efficiency. Bone. Here's another example. Just like any other business that relies on continuing use of consumables, we our healthcare system, hospitals particularly run on just in time ordering. So they have computerized system. And when your level of let's say face masks gets to a certain level, a computer signal goes out to one of the healthcare supply places, Cardinal or McKesson or one of these big places, and they deliver the mask the next day. They don't have huge backlogs either. And so then they put it in order to wherever they get their mask from, et cetera.

[B]

But this is outrageous. We have been reading books, studying history. We know that pandemics are not a remote possibility, but I'm afraid to say an inevitability. And sometimes you get away lucky as we have. We did maybe 2007, 2008, but luck runs out.

[C]

Yes, it does. And people play the odds. I think you know, this is not just profit, by the way. You can take a look at socialized medical systems or public private universal health care systems in Europe and they have just the same problem. France has an excellent medical system which is socialized medicine, but they are not going to be able to afford to have an ICU just in case there's a pandemic at some point have an ICU with 50% of the beds unoccupied all the time.

[B]

Now, Tony Fauci says that a vaccine is at least a year away, but when it does come, and hopefully it'll come soon, who should be the first to get it?

[C]

Okay, so do you mind if I pop somebody's balloon? I was Talking about with my wife this morning about this very same thing. I'm old enough that I remember who Margaret Heckler was. Remember her?

[B]

I do.

[C]

Okay, so Margaret Heckler was. She was the Secretary of Health and Human Services when HIV AIDS first hit.

[B]

The fan under Ronald Reagan.

[C]

Under Ronald Reagan in the mid-1980s. And she got up with a press conference and I believe it was Bob Gallo, co discoverer of the HIV virus and promised a vaccine, and I believe it was in a couple of years, as well as a cure. We know where that went. I am not saying that COVID 19 is the same thing as HIV, but I think banking everything on a vaccine would be unwise, putting off current planning because a vaccine is going to happen at some point. And I would listen to Fauci about when a vaccine might be available versus his boss. And I'm not talking. I'm not talking about his boss at the nih. I'm talking about his boss. Boss. Yeah, I think it's very hopeful. There was a great article in the Times about this international collaboration of hundreds of scientists looking to see if there are potentially already available drugs or soon to be available drugs that could have activity against this virus. I think that would be fantastic. If we found something that we could pull off the shelf, particularly if it wasn't very toxic to be used to intervene and perhaps stop transmission of the virus, as well as to treat people who are already sick, that would be great.

[B]

Now many people under the best case scenario are going to die from COVID 19. And end of life hasn't always been a priority for doctors or hospitals. What should they be doing?

[C]

So I actually wrote a couple of papers about this 10 years ago, and I asked the question then, hypothetical, if we can't save everybody who possibly could be saved, what do we owe those who can't be saved? Taking a patient who is in respiratory distress in front of us and saying, I don't have enough ventilators, what do I do for you? One of the things I argued 10 years ago was that we need to prepare for this, so we need to have medications like morphine and benzodiazepines like lorazepam and Diazepam, Valium, Ativan, those kinds of drugs to relieve respiratory distress at the end of life.

[B]

Now, given how bleak the situation is, do you see any reason for hope here?

[C]

It depends on what you hope for. In past crises that threaten national integrity, if not international integrity, we have seen both rising to the challenge and leaving us proud of how we acted as well as moments of. Of despicable behavior when decisions were made out of desperation and in crisis. My wife is Japanese American. Her parents were born in this country. But after December 7, 1941, when that infamous order from President Roosevelt was issued, they were ripped from their homes. My father in law was taken out of graduate school one month short of getting his degree and locked up in internment concentration camps. That is a sad, sad reaction to a crisis. My hope is that when we come out of this, we will have medical and moral victories rather than medical and moral shame.

[B]

Dr. Rostov, thank you so much.

[C]

Mr. Renner, thank you very much. This has been a real privilege, a.

[B]

Pleasure to talk to you, sir. And we may darken your doorstep again soon. All right, you be well.

[C]

Good luck.

[B]

Thank you.

[C]

Take care.

[B]

Take care.

[C]

Bye.

[B]

Dr. Philip Rossoff is a professor of pediatrics and medicine at Duke University. He's a resident scholar of the School of Medicine's Trent center for Bioethics, Humanities and History of Medicine.

[D]

What the hell is going on right now? And why is it happening like this? At Wired, we're obsessed with getting to the bottom of those questions on a daily basis. And maybe you are, too. I'm Katie Drummond, the global Editorial Director of Wired, and I'm hosting our new podcast series, the Big Interview. Each week I'll sit down with some of the most interesting, provocative and influential people who are shaping our right now. Big Interview conversations are fun.

[C]

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[D]

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[C]

So in a lot of ways, I try to be an antidote to the unimaginable faucet of reactionary content that you see online.

[D]

To the best of my ability, every week, we're going to offer you the ultimate luxury of our times. Meaning and context. True or false. You, Brian Johnson, the man sitting across the from me. One day, at some point, as of yet undefined in the future, you will die. False. Tell me more. Listen to the Big Interview right now in the same place you find Wired's Uncanny Valley podcast. Subscribe or follow wherever you get your podcasts.

[C]

From. Prx.