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)
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.
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)
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)
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
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.