The ethical position is that old people have equal claims to life with anyone else. Arthur L. Caplan, head of the Division of Medical Ethics at NYU’s School of Medicine, writes, “It seems to me that we want to guide our decisions about access to healthcare not by biases about being too old or treatments being too expensive, but first and foremost, we want to ask whether there is benefit. Does it work? Is it going to help the individual?” The ethical responsibility is clear: If a 90-year-old can benefit and wants to have a necessary treatment, give it to her. Risks to older people arise in societies when health care systems are overwhelmed. Given the government delays, this is likely to happen in the United States now: “What will happen when there are 100, or a 1000 people who need the hospital and only a few ICU places are left?” Matthew K. Wynia and John L. Hick, who helped write the Guidelines for Establishing Crisis Standards of Care, give the standard answer, “The ethical justification for withholding or removing potentially lifesaving care from one person or group without their consent and giving it to another is that the latter person or group has a significantly better chance at long-term survival.”
General guidelines become questionable, however, if younger people in power are already implicitly biased, thinking that people much older than they are close to death, or that they have had “full lives,” or that they no longer care to survive. Do you believe this? Doctors may not recognize the ageist prejudice involved in any of these prejudgments. Or they may admit these beliefs, assuming — because ageism is so common — that everyone agrees. An otherwise healthy 75-old gets pneumonia, as does a 37-year-old with end-stage lung cancer. “Which very sick patient gets intensive care?” If the 37-year-old would die even on a respirator … you save the “old man” who could have 25 good years.
In Italy and Switzerland, where the epidemic has stressed the medical system, doctors asking this question are sometimes answering, it seems, on the basis of age alone. In Switzerland, the head of an infectious disease unit, Pietro Vernazza, projects that they will have to weigh “a patient of a certain age in desperate conditions” against “a younger sick person.” But verbally, this is already wrongly decided, by labelling the older person’s condition “desperate” while the younger person is only “sick.” The mayor of Bergamo said that in some cases in Lombardy the gap between resources and the enormous influx of patients “forced the doctors to decide not to intubate some very old patients,” essentially leaving them to die. “Were there more intensive care units,” he added, “it would have been possible to save more lives.”
In a crisis like this, ethical decision-making going case by case must fight every societal bias of long standing: refusing to weigh the life of a white person as worth more than that of a person of color, the life of a man more than a woman, a cis person over a trans person, or a younger person over an older person. And what of an old black woman, or someone else whose intersectional category may activate prejudice? Ethical triage focuses on the individual’s condition, not the sociological category. Training for doctors must include not only clinical guidance, but situational awareness about potential bias.
This ethical trial of rapid decision-making (who will be allowed to survive?) is often foisted on front-line medical personnel who do not have such training. After the Covid-19 epidemic is over, do we want to be forced to conclude that elders died more frequently than younger people (as some early mortality statistics show they do) because, in many cases, age-bias denied them treatment?
Denying anyone medical care is heartbreaking, but denying someone out of bias is exponentially worse. Once aware of the high stakes of medical ageism, some responsible people, particularly as they grow older, may find themselves left with a lifetime of shame and growing remorse.
The advice from the European Society of Intensive Care Medicine’s Task Force on avoiding the tragedies of triage is obvious: “Hospitals should increase their ICU beds to the maximal extent by expanding ICU capacity and expanding ICUs into other areas. Hospitals should have appropriate beds and monitors for these expansion areas.” The real crime at the governmental levels, and at the level of hospital administration, is to not open enough hospital beds and intensive care units, fast enough. Preparation is the task of yesterday, and certainly today. We must do everything we can to avoid hastening the deaths of the old.
As a society, we will be grieving all deaths. Triage is tragic in itself, whether on the battlefield or in civilian hospitals. But only bias makes it criminal. In this saddened state, we should be able to go forward without the added burden of fearing that our country, and our medical personnel, were guilty of a crime against humanity.
Margaret Morganroth Gullette’s latest book, Ending Ageism, or How Not to Shoot Old People (2017), won a prize from the American Psychological Association for contributions to women and aging, and an Award for Independent Scholars from the Modern Language Association. Gullette has great admiration for the medical personnel in this pandemic who are risking their lives to save others. She is a Resident Scholar at the Women’s Studies Research Center, Brandeis University.