Is it wrong to prioritise younger patients with COVID-19?

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With health services overburdened around the world, clinicians are facing an ethical dilemma in having to decide who should receive treatment. But is it wrong to prioritise younger patients with COVID-19? Two experts debate the issue in The BMJ. Dave Archard, Emeritus Professor at Queen’s University Belfast, says this is no excuse for wandering blindly into discrimination, but Arthur Caplan, Professor of Bioethics at New York University’s Grossman School of Medicine, argues age is a valid criterion when supported by data.

There are three reasons why age should not be used to decide who should and who should not receive potentially life saving treatment, argues Emeritus Professor Archard, Emeritus Professor at Queen's University in Belfast. 

The first is that a simple “younger than” criterion is clearly unsatisfactory. 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 writes.

Secondly, there is the fair innings argument. This holds that everyone should have an opportunity to lead a life of a certain duration. Resources should then be distributed (and care given selectively) to ensure that those who have yet to live that length of life are prioritised over those who have already managed to do so.

But while this has an intuitive appeal, there is no agreement on what counts as a fair innings. “Someone who has had her fair innings may yet have much to give the world that another who has not may be unable to offer,” he says.

Finally, 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, he writes.

Such discrimination publicly expresses the view that older people are of lesser worth or importance than young people. “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.

But Professor Caplan argues that age is a valid criterion when supported by data.

He points out that age has played a role for many decades in limiting access to care when rationing life saving treatments, such as access to renal dialysis and organ transplants. That said, even in conditions of extreme scarcity “it would be discriminatory to simply invoke age to exclude those in need from services,” he writes.

The key ethical question, he says, is whether age by itself is ever a morally relevant factor in deciding who gets care when rationing is unavoidable.

Like Archard, he points to the notion of fair innings, but says this commitment to equality of opportunity has nothing to do with the relative contributions of old people versus young people. 

However, 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, he adds.

“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 a life, makes age an important factor in making the terrible choice of who will receive scarce resources in a pandemic,” he concludes. “Ageism has no place in rationing, but age may.”

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