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Should Age be Used To Ration Scarce Resources? Podcast with Tim Farrell and Doug White



We are rationing in the US.  We may not be explicitly rationing, as we're going to discuss on this podcast, but we are rationing - in the way we allocate fewer tests and less PPE to nursing homes compared to hospitals, in the way we allow hospitals and states to "fend for themselves" resulting in those hospitals/states with better connections and more resources having more PPE and testing availability.

And in some parts of the world, ICU and ventilator resources are scare, and they are rationing by age.  We talked on our last podcast about decisions Italy made to ration by age, and on this podcast we talk about two countries in South America we have heard are using age as a criteria for rationing ventilators.

In this context, we are fortunate to welcome Tim Farrell, Associate Professor of Geriatrics at the University of Utah and Vice Chair of the American Geriatrics Society (AGS) Ethics Committee, and returning guest Doug White, Vice Chair and Professor at the University of Pittsburgh School of Medicine.

In our prior podcast with Doug we talked about his University of Pittsburgh (and colleagues) policy for allocation of scarce resources that has been adopted by over a hundred hospitals.  Today's podcast is focused on the release of the AGS guidelines for allocation of scarce resources and the accompanying paper that explains the ethical rationale behind the AGS ethics committee's decisions.  Both papers are available now on the Journal of the American Geriatrics Society (JAGS) COVID19 webpage.  We talk about how the AGS and Pittsburgh guidelines are far more similar than different, and the ethical principles that led them to make the choices they made, and how these choices have evolved over time.

The two issues we cover in depth are: (1) Should age be used to ration scarce resources?  How should age be used, if at all, as an "up front" consideration, or a "tiebreak?" And (2) How should we account for socioeconomic determinants of health in resource allocation decision making?

Stay healthy and safe, and keep doing the good work that you're doing, GeriPal listeners.

-@AlexSmithMD




  


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TRANSCRIPT

Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: Alex, we have two guests with us today.

Alex: Two guests with us today. First we have Tim Farrell who is associate professor in the Division of Geriatrics at the University of Utah School of Medicine. He's also the vice chair of the American Geriatric Society Ethics Committee. Welcome to the GeriPal podcast, Tim.

Tim: Thanks for having me, Alex and Eric.

Alex: We are delighted to have returning to us, Doug White who is vice chair and professor at the University of Pittsburgh School of Medicine, and I think this is something like your third time on our podcast. Welcome back, Doug.

Doug: Hi. Thank you for having me.

Eric: We're going to be talking about, again, resource allocation. We did this with Doug before, I encourage all of our listeners to listen to our first podcasts around resource allocation. Today, we're going to specifically be talking about age related considerations, including should age be part of a resource allocation framework, but before we get into that deep dive, Doug and Tim, do either of you have a song request?

Tim: I've got one. Could we do After Corona Virus Has Gone?

Alex: Okay.

Eric: Which song is that? [laughter]

Alex: This is a parody, right?

Tim: Yeah. It may have been written by a former member of the Eagles.

Alex: Yeah. It says, "I found the song online, thank you for sending me the link." It's by Shredd and Ragan In The Morning, so I have to attribute it to them. This'll be interesting.

Alex: (singing)

Eric: That's wonderful.

Alex: Wait until you get to the end.

Eric: We should just have a podcast with corona virus jokes, too. That should be a future podcast right there.

Alex: I think that's the first parody song ever requested on GeriPal, so that's nice. I love it. I love the first, Tim.

Eric: Thank you, Tim.

Tim: You're welcome. The second part is interesting, as you said.

Eric: Let's start off at the top again. We're going to be talking about resource allocation and specifically how does age fit into these frameworks, because we're hearing from a lot of different places that maybe it does or maybe it should or maybe it shouldn't, but before we go into that, Tim, can I ask you, how did you get interested in this as a subject?

Tim: When this all started happening back in early March or so, I started noticing a lot of political leaders, popular press coming out with statements like "We just could almost segregate, isolate older adults. The rest of us could sort of go on with life as normal," and it got me thinking about this, and looking into this a little bit further and as I started talking with experts, people like Doug, finding out that actually it wasn't just at this larger, popular press level, it was really down into the weeds in terms of resource allocation frameworks if we ever needed to implement them that older adults were disadvantaged and I thought I need to look into this, educate myself about this, and then came to realize that, really, maybe there should be something, a definitive statement put out there about how we handle aging in the context of pandemics and resource allocation.

Alex: As another important set up question here, Doug, we had you on the podcast early on, I think it was our second podcast about corona virus and this'll be our 15th or 16th podcast, and we talked at that time about how we were worried that there was going to be a need to invoke these frameworks here in the United States. Have either of you or any of us heard of an institution in the US that has invoked the framework scarce allocation resource protocol, otherwise simply known as rationing?

Doug: I think there are probably two questions to unpack there. One, is rationing occurring, and then two is, is it occurring in a systematic and an explicit way, and I think the answer to those two questions are different. We know pretty clearly from New York city and from some reports from individual hospitals that at least they've been rationing dialysis, and it's May 8 today and there was just an article in the New York Times on that topic that patients in ICUs who normally would be getting continuous renal replacement are getting half the dose, so they're basically splitting the baby as the way to fix the shortage issue, but we also heard reports of patients in New York state, in New York city in particular, them having to make really hard decisions around what kind of ventilator to give patients, and a lot of patients, young, healthy, old, frail patients also ended up on really substandard ventilators, which is a slightly different issue but it was a rationing decision.

Doug: As the last thing, I got a call two or three days ago from a hospital in Quito in Ecuador where they said "We are already rationing beds and we're not doing it explicitly. We'd like to use the University of Pittsburgh model hospital policy."

Eric: Can I ask you Doug? Because I hear a lot about when these resource allocation frameworks should come in and that we should be doing a lot of mitigation before it happens. What's rationing, what's mitigation? How should we think about that? I think about the CVPH, this critical illness, they're on these dialysis machines, you're seeing them split up, you get this one day, you don't get the other day, is that just good mitigation techniques to prevent a crisis or is that rationing?

Doug: Yeah, it's ratcheting, I'd say, right? Rationing is the withholding of a potentially beneficial treatment on the grounds of scarcity, and I think you look at CVPH and you say "This is a continuous therapy. Standard of care is that it's used continuously. We're using it for half of continuously."

Eric: It's part of the name, continuous.

Doug: Yes, but mitigation, Eric, is a different thing. When people talk about mitigation, they're talking about doing whatever you can to increase resources or use them creatively in such a way that you don't have to compromise the standard of care. The paradigmatic example is closing operating rooms to use them as intensive care units and use the ventilators, the operating room ventilators. That's mitigation. That's avoiding having to ration in a formal sense.

Eric: Then something like splitting a ventilator between two people, that's kind of right in there on the line, right? Because it's not really standard of care and there's issues with that too.

Doug: That's right. All we know now about splitting ventilators is that it's substandard. You only do it when you can't give it to everyone. Honestly, in my view, it's more of a psychological technique to avoid making hard decisions.

Alex: So if I could summarize, it seems like there are rationing decisions where rationing is occurring but they're not using a specific allocation framework in making these decisions. For example, around dialysis. When we had a similar experience, I'm talking with some colleagues in New York around this dialysis issue, and one nephrologist said "We're giving it to everybody who asks for it means we're giving everybody crappy dialysis." I guess it's occurring but it's not going about in a thoughtful way, and I think what's underlying that, and Eric, you said at one point, nobody wants to be the first hospital to say that they're invoking the allocation framework. Nobody wants to say like "Hey, we're rationing. We're the first people in the country to do, we are rationing and here's how we're choosing the ration," right? In what sense is like using this framework potentially an academic exercise? Because nobody wants to do that, and as a result, they're just saying "Hey, we're able to give it to everybody. Everybody's getting it. We're still giving dialysis to everybody. We had enough ventilators. Hooray."

Tim: I was going to say I think though at some point, you're going to have to have a system and one of the things that we say very clearly in the position statement is that the reason to do this is to avoid ad hoc approaches and to give those frontline providers, peace of mind is the right word but that they should not be in a position in the midst of managing these patients of sort of wrestling with the ethical issues, and that's where triage officers and triage committees and frameworks such as Doug's really come into play.

Eric: The thing about ad hoc though is it doesn't require the moral courage and leadership of administration to be the first to operationalize one of these frameworks, and I think like Alex is saying, in the US, will anybody actually be that person or will we continue to call things "We're not rationing, we're just giving half the people half the dose of CVPH." Doug, what do you think,

Doug: Absolutely. What's come out of New York state has been, in many ways, appalling. Tia Powell is a fantastic colleague and physician in New York state who headed up the New York State Task Force in 2015 I think to develop allocation policies. They produced essentially a beautiful 300 page approach to allocating scarce resources. It was teed up and ready for the state to adopt and they just refused to adopt any approach knowing that any approach will be criticized and no approach gives some sort of political cover to say "We didn't actually approve that. There's no blood on our hands."

Eric: So all the responsibility falls on that particular physician or nephrologist and nobody in a leadership position, they can just say "Oh, we didn't know."

Doug: Yeah. It's a total failure of leadership.

Alex: Also, I wonder if there are ways of reducing the barriers to invoking the allocation framework so that there are ways that hospitals, I don't know what the answers are, but is there a way we can meet somewhere in the middle where... This fear of being the first hospital to say that we're rationing is real and you can understand the motivations behind the leadership in making those decisions, although we can of course criticize them, but are there ways that we can make it more palatable or acceptable to invoke the framework?

Tim: I'll ask Doug's thoughts about this. One of the things that we specifically target is that our position statement should be relevant not just to hospitals and health systems but to policy makers at the regional and national level, and so in a sense, at the national level, they can provide some political cover if you will, but I also understand the legalities involved and difficulty of having 50 different state legislatures and legal frameworks to go through. If you can put it out a little higher, 30,000 foot level, and have a transparent, accountable process, that might ease some discomfort. I'm not sure what Doug's thoughts are.

Doug: I agree. Listen, these are not decisions for individual hospitals to make. At a minimum, it needs to be a region making the decision to say all of the hospitals in, for example, New York city or in a particular borough are swamped, we have to do this as a group. That really calls on the notion that these are public health decisions and the legitimate authority for those kind of decisions is the state.

Alex: I know we want to move on to the framework, we got to get to age, but I have one more critique about rationing nationally, and that is I read a terrific tweet from David Grabowski who we had on the podcast recently who's a professor of health policy at Harvard, and his tweet was something like, "Half the deaths are in nursing homes," right? The outbreaks are exploding in nursing homes and yet they're not getting half the attention in the press and they're certainly not getting half of the PPE or the testing. In a sense, we're rationing, and some of this is by age, right? Because who's in the nursing home? It's the older adults, and where we're allocating resources nationally, and those decisions are happening without any explicit thinking. It's just the train rolling the way that it's been rolling, right?

Tim: I would just say there that one of the things that I've been thinking about recently, it's not even just the hospitals but further up the supply chain. People that you might not otherwise think about who would be involved in these types of resource allocation frameworks are those who are supplying the resources. So thinking about this more broadly than just the end users but those who are actually producing the equipment and these sort of ad hoc regional collaboratives that have sprung up to distribute resources. The fact that there's this allocation going across state lines, again, to me, suggests that a broader coordinating framework might be more helpful and also just more livable and acceptable to the individual institutions.

Doug: I agree. Also, I would just say I think there are at least two things going on. One, we have the psychological, this rescue imperative. The really intense psychological need to rescue those who appear to be dying in front of us, and Al Johnson, a San Francisco based philosopher, did a lot of cool writing on the rule of rescue a long time ago. I think that's at play. The identifiable life is much more salient to us than the statistical life, but I don't think that's the whole story. I also think that this is just unmasking our bias toward the elderly and unfirm in ways that they're not getting to the forefront of policy maker's minds, and it's a real failing.

Alex: This is perpetuating existing inequalities in our system where nursing homes are beginning second shrift, lower tier resources, and then if you look at the press, it's largely negative hammering nursing homes for being X star rating, whatever, in the press. We should turn to the AGS framework which we will have the link to in the show notes associated with this podcast on our post as well as the companion article which describes the ethical considerations that went into play in developing the framework. Tim and Doug, both of you have developed these frameworks. Tim for AGS leading the working group, and Doug for Pittsburgh, and my sense is they certainly agree far more than they disagree. In fact, I was rereading them this morning, I was like, "Wow, they are so remarkably similar," but Tim, could you walk us through in broad brush strokes what the framework considers?

Tim: I'm happy to do that, and I think the most important thing is that when I was looking at these resource allocation frameworks and noticing that there were actually categorical exclusions that certain people above, say above age 90 just automatically don't pass go, you don't get the resource in question, it would be excluded, we just say that that seems to be unfair, and that's our first recommendation that you should not use age based cutoffs in these frameworks. There's seven different recommendations but just to highlight two additional ones, one would be the impact of social determinants in these calculations, which we've alluded to already, and a third would be, and I know Doug's an expert on this, would be considering the role of survival and how far out you go in terms of calculating a survival benefit and sort of also considering the comorbidities in the equation. The well known frameworks and Doug's framework all include those considerations.

Tim: We go into a little more detail on things like life you save, long term predicted life expectancy, we wax philosophical on some of the shortcomings of some of those approaches, but really, I think if you were to have one takeaway, it's do not use age specific cutoffs. That's probably the take home from the position statement.

Alex: Let's get into the age issue a little bit more. Your frameworks do not use age upfront, I should say. You do consider age and we'll get into that, but first, in a broader sense, which frameworks or states use age upfront?

Tim: I'll just begin, maybe I'll hand the Baton to Doug. I'll just start with my own state of Utah, just looked at the framework. The updated framework has specific age cutoffs. Let's start there and hand it off to Doug.

Doug: That's right. It's not just states and there are several. I think Alabama was one as well. Professional societies put advanced age as an exclusion criteria which is to say if you're above whatever, and they didn't actually specify, but if you have "Advanced age," you shouldn't even get into the queue for a ventilator. That's one, and then we saw recently in Italy, just published, the Italian critical care society's recommendations, they were quite explicit about saying there should be age based cutoffs.

Alex: What are the ethics? We talked about this a little bit, Doug, on our first podcast, what are the ethical underpinnings behind using age as a criteria, and we weigh these things differently and your frameworks weigh it as a consideration that sort of comes in at the end, whereas these other frameworks consider it as something that comes in at the beginning and can be even used as an exclusion rather than thinking everybody part of the eligible pool, just at different priorities.

Doug: Yeah, exactly. The way that you use it and the reasons behind it ethically matter, and legal matter, makes all the difference. So categorically excluding someone based on being 86, it's not clear the rationale. Maybe it's about prognosis, maybe not. Maybe it's about you've lived a full life, maybe it's about you're not socially worthy. All those claims, it's just uncertain unless it's really unpacked, but what we can all agree on is that it violates US Anti-discrimination law. Once you get beyond that, then there are a lot of other reasons that you might invoke age. If age was a perfect predictor of outcomes, if we have really good data that said if you're above 90, that the survival rate is zero, that might be ethically relevant but you would be using age as a proxy for prognosis rather than age in and of itself.

Doug: Then I would say the third argument is what we call the life cycle based argument, which is it's almost counterintuitive in that it says that in some ways, the elderly are the best off in the sense that they have had the most opportunities to get what we all hope for which is the ability to live through life stages, to live a full life, and that in contrast, the young are the worst off. So this would be an approach to prioritizing the worst off in society, and I get that that is not a clean analogy because there are lots of ways that the elderly in the moment might rightly be viewed to be the discriminated against or in some ways, certainly not the best off, but that's the logic of the fair endings or life cycle argument.

Eric: Fair ending, so somebody who, older adult, they've played seven innings, they've made it that far versus somebody who's younger, only played four innings, they still potentially have five more innings left, they certainly should get it over that other person.

Tim: Alex, as I think we all know, sometimes the eighth and ninth innings can be the most exciting part of the ball game.

Doug: In Little League, every kid gets to play. They get some minutes.

Alex: You get a participation trophy at the end. How far away from the guidelines can we get into baseball?

Doug: I'm actually being serious. I think the Little League analogy is apt here which is to say everyone gets some shot. Worst off is the little kid at the very end of the bench, and he or she gets played.

Eric: Isn't there something to that? I remember there was some qualitative studies looking at what do people actually think is fair, and I think based on that from Maryland, I think information is that most people thought using age as exclusion was bad, but that there was something to fair innings. There was something to this idea that most, at least in these focus groups, that they felt like maybe that that was a good thing for later on in the process, like a tie breaker.

Doug: Exactly. The Hopkins Maryland group led by Lee Daugherty Biddison and Ruth Faden did an amazing job. They did what's called deliberative democracy which they engaged more than 300 community members in Maryland and took them through multiple half day long engagements where they really put these issues to them, gave them reading in advance, gave them expert consultation in the moment, engaged them in small group discussion and then surveyed their opinions at the end, and what they found is that most people didn't think age should be a primary criterion, but roughly 70% said that on balance, when there are circumstances in which not everyone can get a resource, there should be some times when the younger person gets some priority.

Tim: I would just add that, taking a slightly different context, if we're talking about new therapies for COVID or immunizations, it may be the older adults differently or highly than other groups. We can invert this potentially and use similar arguments, but I think that's certainly clear from the community engagement work.

Doug: It's a really good point, what Tim just raised. This notion that there might be certain circumstances in which you use age or really any other criterion, some medical decision, but it might be just the reverse in others. For example, it may be that the older adults will get priority for medications and vaccines because they're the most likely to benefit from them. I think that illustrates that we need to take a fairly nuanced approach to how we think about allocation such that you can't make one framework and then it applies to everything.

Eric: I got another question we are seeing, when you look at mortality rates for COVID, we see like it just starts going up at the age of 50 and it goes up and up with every other decade, so obviously those who are much older, 80s or 90s, their risk of dying from this, so much higher than those who are in their 30s or 40s. So should age play a role from a prognosis standpoint and is there... I'm going to stop there and ask that question.

Tim: I'll just say one of the things that we talk about in the position statement is the difficulty in prognostication. I think the three of you are the experts in prognostication, but certainly long term prognostication gets difficult short term slash near term. I know we can talk about the nuances there. Probably a little bit more comfortable at least for clinicians, and so I think that's one branch point if you're talking about short versus long term. I think that's critical.

Doug: Eric, the way you framed the question was around COVID. It may be that COVID is a particular disease where age is particularly good in terms of correlating with prognosis, but just to sort of take a step back and think about making system level or policy level decisions, you two more than anyone know that age in and of itself as a predictor of all comers and illness is a pretty poor prognosticator, so I think it's much more important to look at it through that lens rather than through the narrow lens of COVID because it will only be 50% of patients in an ICU that have COVID.

Eric: That 60 year old in your ICU actually may have a worse prognosis than that 80 year old, depending on kind of what they came in with. We got another question. Go ahead, Tim.

Tim: I was going to say we talk about also incorporating new information in deliberations of triage committees, and I think as we learn more about COVID, we'll have better information. Actually, I went online today and looked at the SOFA score, and there was a little yes or no button for "Does your patient have COVID or not" and I thought, "This is interesting." The SOFA folks are starting to actually take this into account, so I think we'll have more refined prognostic models with COVID over time.

Eric: I'm going back to a New England Journal, Zeke Emanuel, love him or hate him, "Just use life expectancy. We should just be using that. We're trying to save most lives, most life years. Should we be using life years, life expectancy when we're thinking about this?" Age is an important marker for that.

Tim: I think Emanuel strikes more of a utilitarian tone and I think what we are saying in the position statement is that that's really more of an aggregate measure and really glosses over some of the individual factors in terms of prognostication, and so we come down on the side of more of that individual assessment, which is why we come out and say that we don't think that life you saved should be part of a resource allocation framework.

Doug: Here's the example that I find really compelling. It's a thought experiment, but say there are two people, twins, whatever separated at birth. One lives a socially advantaged life. The other does not and ends up in sort of the worst social circumstances. Lives in poverty, in a food desert with poor access to healthcare. Those two with identical genetics, say that they're 50, the socially advantaged one is 50 and healthy and has 40 years of life left, the 50 year old twin who had lived in poverty may have seven years left, and so if you really looked at life expectancy only, you'd prioritize the 50 year old who was socially advantaged over the one who was disadvantaged, and I think many of us look at that and say "That's not okay."

Eric: There's other calls out there so maybe advocating for that we should give extra or minus points, or I guess it depends on your framework that you're using, to give those socially disadvantaged people more favorable numbers in a framework. If they grew up or they're living in a zip code that is more socially disadvantaged or if they have other markers of that, what do you guys think about that?

Doug: I think it's a really important idea and I would offer two things. One, we've tried to do that in crude ways, in the University of Pittsburgh model of policy, in the sense that we treat as equal people who have five years left to live and people who have 50. That's a way to try to level the playing field of social inequalities. The other is that you might've seen that there are some systems that give some priority to healthcare workers which turns out to be a fairly white group of people. We expanded that to say it should be all essential workers, and that starts to cut across a much broader racial and socioeconomic demographic. Grocery store workers, delivery truck drivers, maintenance crews, and so I think that's another way.

Doug: Then the third thing I would say is that we're working with a group of economists at MIT that have put together an allocation strategy that uses something called categorical reserves where you can actually preferentially prioritize individuals based on social disadvantage in a way that may actually affirmatively redress some of these things. That raises certainly big political questions about how should affirmative action rather than neutralization of problems come into play, but it's at least worth I think exploring the feasibility of it.

Tim: I was going to say that the area deprivation index certainly is powerful. I would also say it's not even just adding in these factors but how you weigh those factors, and I think that's going to be critical to explore. I don't have the answers but I think, like Doug said, I think it's worth exploring.

Eric: I guess the other question is there's people coming together thinking about this, putting together these frameworks, and then there's like the boots on the ground when you try to actually sandbox it, try to play it out in your ICU even if you're not in crisis, how are you actually going to practically do it? The essential worker part, how do you actually know if somebody is essential worker? Elon Musk is now making ventilators, now he's an essential worker. I worry that well educated people are going to be very good at figuring out how they're all of a sudden an essential worker versus those who are not, may not be savvy enough in the medical system to declare themselves an essential worker. The other worry I have with like healthcare providers is that the only way you really know is if they work in your hospital, so now we're biasing just people who work with us to get these ventilators.

Doug: A couple thoughts. I agree, this is a harder to specify thing. However, each state has, and there's a federal list of essential employees or essential professions, so you can appeal to a state authorized list of jobs. We actually do a reasonable job of figuring out what our patients do in terms of their social and occupational history, so it's not infeasible to do that. That's the first thing I would say. Maybe I'll leave it there.

Tim: I was going to add to that, my concern with this would be that we sort of forget about the invisible workforce of caregivers, and I think they are essential and already are overlooked. Thinking about that large workforce, actually, we're probably helping the social isolate and reduce the transmission of COVID really should also be prioritized, but it all comes down to what you think the definition of essential means. That's where it really is important.

Doug: I would just say I think that we should push on this though, because it is a way to some degree affirmatively redress social inequalities. When you look at the list of essential workers, the vast majority are not white collar jobs.

Alex: Meatpacking workers. It makes you wonder in some ways, like what are the motivations behind this? Who gets put on there? Of course some of it will be political when we're talking about a state list or a federal list, and some of them will be for reasons that may not make as much sense. Meatpacking workers, very diverse group by the way, but my concern is that Trump added them to the list of essential workers because he didn't want meatpacking shortages, he wanted to protect businesses who wanted to keep those workers coming in, and potentially because he doesn't value the lives of those people who work in the meatpacking industry as much as he might value other lives. That is a controversial statement but I'm going to make it anyway.

Doug: All the more reason to redress that right.

Alex: Last question for me is about the evolution, and I remember on your last podcast, Doug, you talked about how you changed your thinking around instrumental value, and I know that this, we were just talking about socioeconomic factors and we have another podcast that we did with Kirsten Bibbins-Domingo's arguing they should be incorporated in a greater extent in our bedside decision making, and Harald Schmidt we should thank who published this. He's a doctor at University of Pennsylvania, published an article about this in the New York Times, and I can see that right at the top, it says "Update. After this essay was published, the model guidance," linked to Doug's Pittsburgh guidelines, "For rationing ventilators was revised." I'm interested in both of your thoughts and how your thinking has evolved over time and throughout the course of the pandemic and what sort of push back you've gotten from different groups and how you've responded to that.

Doug: Well, I mean, for me, this has been an evolution over the last decade. If you really go back and look at the first framework that we put together, which was much more conceptual, we talked about life expectancy writ large and we put that on equal footing with life cycle, and if you look at the framework now, you see that neither of those are there in the same way. I would say that this work of specifying and engaging the public and refining based on feedback is critically important. I wish that I could get it right the first time but that's just not really, at least for me, that's not feasible. What I think is important is that we go through this reflective process where we have an initial idea, we bounce test it with the public, we engage policymakers and scholars, legal scholars too to say "Now how does this fit with civil rights law?"

Doug: We get the perspectives of other people, like Harald Schmidt, and we refine things. I would say that, a small point, that we had revised the framework before Schmidt's article and we revised it further because of the things that he misunderstood about the framework. We had already done away with using anything like long term life expectancy and really focusing on near term prognosis, so we felt we had to make that even more clear. Be that as it may, the work is in going through this process of what philosophers call "Wide reflective equilibrium" and trying to figure out, when we have these competing goals of equality and actual medical effectiveness, how do we balance them when in some ways they're simply incommensurable, and that's a hard process.

Tim: One of the most important edits I think I made to one of the final drafts of the position statement was adding to the title the words "COVID-19 era and beyond," because I think if we look too narrowly at the current time, we're just going to miss these opportunities for reflection, and we argue, we make some post pandemic recommendations including regular review of these frameworks and resource strategy, so we can't be standing still and maybe we'll be coming out with a revised statement in another six months or a year. I think we all need to be, as Doug said, have this reflective equilibrium and take new information to account to get better with these frameworks.

Eric: Doug, Tim, I want to thank you both for joining us today. Both of you have done amazing jobs in putting this together. Really love Tim. I think the idea of, and I think for the AGS statement, just not using age as an exclusion is an important thing to highlight, because we're seeing it out there, we saw it in Italy, we're seeing in other countries, and I think the other important thing too is that it certainly feels like, at least here in the Bay Area, we're past that surge for now that we're not going to be using these frameworks. However, come fall, or five years down the line, if something else comes up, it's important to have. Doug, as always, it's amazing to have you on this podcast.

Doug: Thanks. You guys are awesome, it's fun to be on.

Tim: Thanks for having us.

Eric: Speaking of fun, Alex, you want to do a little bit more that parody song?

Alex: Just remember, you requested this, Tim.

Alex: (singing)

Tim: Well done.

Alex: I think that reaches a new low for low brow for our podcast. [laughter]

Tim: Actually, I initially suggested just the Don Henley version. [laughter]

Eric: Tim, thank you very much for joining us.

Tim: Thank you for having me. It's a lot of fun.

Eric: Doug, big thank you too.

Doug: Thanks guys.

Alex: Thank you to Archstone Foundation and thank you to our listeners, and if you're listening to this, please like our podcast in whatever platform you're listening on.

Eric: With that, stay safe, everybody.



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