Denying older coronavirus patients treatment in favor of the young could be seen as slaughter, says expert
With public healthcare systems becoming increasingly strained due to the impact of the COVID-19 pandemic, healthcare professionals are having to decide who should receive treatment. A question has also been raised on whether one should factor in age as a priority when deciding who to treat during the coronavirus pandemic.
A leading scientist now says that denying older COVID-19 patients treatment in favor of the young could be seen as culling or slaughtering the elderly.
Dave Archard, emeritus professor, Queen's University, Belfast, UK, was participating in a debate organized by the British Medical Journal (BMJ) on whether it is wrong to prioritize younger patients with COVID-19, which had two experts arguing for and against.
Archard says that age is no excuse for wandering blindly into discrimination. However, Arthur Caplan, William F and Virginia Connolly Mitty professor of bioethics at the NYU Grossman School of Medicine, New York, US, argue that age is a valid criterion when supported by data.
"To discriminate between patients in the provision of care on the grounds of age is to send a message about the value of old people. Such discrimination publicly expresses the view that older people are of lesser worth or importance than young people."
"It stigmatizes them as second class citizens. We already discriminate against old people in so many ways, and they are socially disadvantaged in numerous respects (social care and employment, for instance)," says Archard.
"It would be an egregious moral error to compound such injustice. And it would be hard not to think — even if it was not intended — that a cull of elderly people was what was being aimed at," argues Archard.
He says that prioritization, that is, deciding who should and should not receive potentially life-saving treatment, is inevitable once the demand for such treatment exceeds the supply of resources.
However, he points out the "crudeness and unreliability" of basing decisions on age, which may only serve as a marker of differences in factors such as chances of survival or clinical frailty rather than a marker of anything else.
Archard reasons that if it is not a marker of something else, then it is hard to see why age should be used as the "determinative criterion". It becomes "exposed as wrongly discriminatory because it licenses differential treatment based on unwarranted animus or prejudice" against old people, he warns.
The expert says that a simple "younger than" criterion is unsatisfactory and that using age to make such an important decision is no better than flipping a coin.
"It cannot be that an 18-year-old is preferred to a 19-year-old on the grounds of one year's difference in age. This would be not much better morally than tossing a coin or a crude 'first come, first served' principle using the time of arrival at a hospital to determine whether care is given," he argues.
According to Caplan, it is not wrong to prioritize younger patients with COVID-19. He says that many reports have indicated that in some countries, including Italy, age over 65 years was invoked as an exclusionary criterion for accessing scarce intensive care services.
However, this is hardly the only instance of age being used to distribute scarce resources, says Caplan. He elaborates that age has played a role for many decades in limiting access to care when rationing life-saving treatments.
"Access to renal dialysis has been restricted to those under 65 in some parts of the UK, while in Europe, Canada, Israel, and the US, it is almost unheard of for anyone over 80 to receive a solid organ transplant from a dead donor," says Caplan.
He adds, "That said, even in conditions of extreme scarcity it would be discriminatory to simply invoke age to exclude those in need from services. Blanket exclusion based simply on the age of an entire group with no additional rationale or justification is wrong."
But there are many instances of rationing where age alone is used to permit access, including "women and children first" in access to lifeboats during shipping disasters and in many policies regarding rationing of resources in a pandemic where children are given first access simply because of their age, says Caplan.
"Giving priority to the very young seems to evoke broad consensus," says Caplan. So what makes age in itself morally relevant?
According to Caplan, one reason for using age is if the "overarching principle for rationing" is to maximize the number of lives saved.
"Most rationing policies do posit this as a fundamental principle. If the goal is to save the most lives with scarce resources then age may matter if there is a diminishing chance of survival with increased age. And for ventilators and renal dialysis that is precisely what the data show," he says.
Caplan says another reason is the notion of fair innings — that each existing person must enjoy an opportunity to live a life.
Caplan argues that while there is no hard and fast rule for what is an "unfulfilled" life age for a person, most policies distributing life-saving resources look to those under 18 as gaining priority while those in their 80s and beyond — who have had a chance to experience life, pursue their goals, and flourish as human beings — receive lower priority.
"To the extent to which data support the risk of failure or the odds of success, age can justifiably be used to ration care if maximization of lives saved is the overarching goal. Indeed, the relevance of old age as a predictive factor of efficacy — combined with the powerful principle of healthcare affording equality of opportunity to enjoy life — makes age an important factor in making the terrible choice of who will receive scarce resources in a pandemic. Ageism has no place in rationing, but age may," says Caplan.
Archard, however, says that there is no agreement on what counts as fair innings. "Even if we can agree, it is not clear why we should speak of fairness" in the context of COVID-19, he says.