Thursday, April 30, 2020

COVID-19, rationing and the question of age

Discussions about the role that age should or should not play when allocating medical resources during the COVID-19 crisis have been deeply revealing. Probably no bioethicist would come out in favor of basing such decisions simply on (older) age, though there is no problem finding such opinions on Twitter. But many bioethicists heavily rely on likelihood of recovery and number of years of life expected post-treatment in their favored allocation schemes, which in the context of COVID-19 will frequently come down to the same thing. In addition, constructs like the 'life cycle' or the 'fair innings' view are often sprinkled into the decision-making recommendations, i.e. the idea that all other things being equal, resources like mechanical ventilation should be given to those who have not yet been able to enjoy all stages in life's course. It is probably safe to say that, in most influential bioethics allocation schemes, age is not your friend.

These ways of thinking about age and rationing have been defended by prominent bioethicists for years, pre-COVID. Some of their limitations have been pointed out over the years, and in the wake of COVID-19, they are being pointed out again. As Harald Schmidt writes in the New York Times, despite the appearance of impartiality and equity, the criteria of likelihood of recovery and number of years of life expected post-treatment in fact biases access to medical care against those in society whose infected bodies were already compromised by racial, class and other factors. In addition, the idea of making decisions that favor youth over the aged on the basis of 'fair innings' is problematic for similar reasons. Just because a person is old does not mean that they had a good time of it: this confuses quality and quantity. Those who have suffered from systemic discrimination throughout their lives have had 'unfair innings'. And now, on top of all that, they are accorded less priority for medical resources during a pandemic, because they had the audacity to stick around. The common thread here is that commonly promoted allocation criteria fail to acknowledge how their implementation could compound existing social injustice.

But there is also something else. These allocation criteria are commonly promoted as if they are obvious and universally accepted. But there are good reasons to question this, as Nancy Jecker points out in a recent article in The Hastings Center Report (#behindapaywallgoddammit). Moral standing associated with age differs in different cultural contexts. In some countries, youth are favored over those who are old for a number of reasons, including the idea that youth are or are potentially 'more productive' than those who are old. Such countries tend towards a 'hourglass' conception of the life course, i.e. that your moral status gradually diminishes over time, which is supposed to explain why the death of a child is more tragic than the death of an older person. But in other contexts have alternative conceptions of the life course and aging where, if anything, some societies tend to discriminate against the young, and understand the moral importance of a person as something that grows over time and in that person's relationships with others. From this perspective, an older person is not someone lacking in utility whose allotment of time is running out, but someone who has gradually accumulated worth ('become more human') in the community.

There is no way of determining which conception of aging and moral standing is 'correct'. The point here is rather that criteria commonly proposed for the allocation of scarce medical resources in prestigious journals by prominent bioethicists during the COVID-19 crisis carry with them a number of underlying cultural assumptions. Making life-altering decisions on their basis may appear perfectly appropriate in some contexts, but expecting one size to fit all is unreasonable. And this matters in a global pandemic.

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