Recovering Old Age

As the outbreak of coronavirus spread this past spring, the world of biomedical ethics exploded with journal articles, consensus statements, and blog posts arguing over the proper criteria for rationing ventilators and other scarce medical resources. The flashpoint came from some of the earliest pandemic guidelines, which appeared to promote discrimination against the elderly — the most likely to die from the disease.

In a widely cited statement, published online in the New England Journal of Medicine in late March, bioethicist Ezekiel Emanuel of the University of Pennsylvania and colleagues argued for a strategy for allocating medical resources that would maximize benefits by both “saving more lives and more years of life.” In practice, rationing on the basis of life-years strongly favors young people, who have more years left to live than the elderly and people with disabilities. Given “limited time and information” in an emergency situation, the authors suggested, saving the greatest number of patients who have “a reasonable life expectancy” is more important than improving length of life for those who do not. The overall effect of this strategy would be “giving priority” to those “at risk of dying young and not having a full life.”

In response to proposals like this, and to even more directly discriminatory rationing strategies that recommended age-based cutoffs for certain treatments, the U.S. Department of Health and Human Services published a bulletin declaring that rationing based on age or disability would be illegal for any HHS-funded health programs, including Medicare and Medicaid. Similarly, rightly fearing that a focus on maximizing life-years would reinforce cultural bias that values the lives of the young over the old, many conservative bioethicists spoke out against age-based criteria. For instance, according to a joint statement issued by the Witherspoon Institute, all lives should be treated equally, for all are of “inherent, equal, and indeed incalculable value.” A policy preferential to the young would be unethical, and would send the message that society views the lives of its seniors as less valuable, less worth living, and would lead to further devaluation and inequity.