With pubic healthcare systems becoming increasingly strained due to the impact of COVID-19, healthcare professionals are having to question whether to factor age in as a priority when deciding who to treat.
Now, an article recently published in The BMJ outlines two sides of the debate over whether younger people with COVID-19 should be prioritized for receiving treatment.
Dave Archard, Emeritus Professor at Queen's University in Belfast, argues that prioritizing younger individuals would be entering into discrimination, while Arthur Caplan, Professor of Bioethics, at NYU Grossman School of Medicine in New York talks about why he thinks age should be considered, once data support reasons for doing so.
Archard begins by pointing out that prioritizing who should receive potentially life-saving treatment becomes unavoidable once the demand for treatment exceeds the availability of supplies and that various recommendations made in the past have been based on ethical principles.
"It is easy then to see why age might be proposed as a simple, clear, and definitive basis on which to decide matters: when there are no other relevant differences between two patients in equal need of care, choose the younger," he writes.
However, he points out the "crudeness and unreliability" of basing decisions on age, which may only be a marker of differences in factors such as chances of survival or clinical frailty rather than a marker of anything else. This then suggests an element of unjust discrimination because it allows treatment decisions to be determined by "unwarranted animus or prejudice" towards old people.
Three main reasons for not prioritizing age
Archard says there are three main reasons why age should not be a prioritizing factor.
Firstly, he asks where the line would be drawn in terms of what constitutes "younger than." For example, prioritizing an 18-year-old for treatment over a 19-year-old would be no less morally reprehensible than using a coin toss to decide who receives treatment, he says.
"If young people as a demographic group are to be preferred to old people, then there are problems of distinguishing in a non-arbitrary way between two patients who differ only in being just above and just below the agreed threshold of age."
Secondly, he refers to the "fair innings" argument, which posits that people who have not yet lived for a certain amount of time should be prioritized over those who already have.
However, there is no consensus over what constitutes fair innings, says Archard:
"Someone who has had her fair innings may yet have much to give the world than another who has not may be unable to offer."
Archard argues that even if what counts as fair innings can be agreed upon, why exactly should this be seen as a fair basis for determining who receives treatment, especially since luck and circumstances play a significant role and regardless of age, the need for treatment may be the result of bad luck.
"It is hard not to think that it matters what kind of life has been led and might still be led," he says.
Thirdly, Archard thinks that discrimination in the provision of care based on age sends a message to the public that older people are of less value than younger people.
"It stigmatizes them as second class citizens… 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," he concludes.
Caplan, on the other hand, says that age becomes a valid criterion when it is supported by data and points out that age has been a defining factor for decades, once access to emergency treatments such as organ transplants or dialysis requires rationing.
He refers to previous reports of some countries having an age of over 65 as a criterion for denying intensive care when services are scarce. He also refers to how in Europe and the US, "it is almost unheard of for anyone over 80 to receive a solid organ transplant from a dead donor."
However, Caplan does think that denying such services to an entire group based merely on age would be discriminatory and wrong, but he also thinks the vital question is whether age should be considered once rationing has become inevitable.
Referring to the "fair innings" point, he says that this commitment to equality in opportunity has nothing to do with the relative contributions of old people versus young people. However, when the aim becomes to save lives in the face of limited resources, then he thinks the reduced likelihood of survival with older age may begin to deserve consideration.
"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," concludes Caplan. "Ageism has no place in rationing, but age may."
Archard Dave, Caplan Arthur. Is it wrong to prioritise younger patients with covid-19? BMJ 2020; 369 :m1509, https://www.bmj.com/content/369/bmj.m1509