Is it wrong to prioritise younger patients with covid-19?
BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1509 (Published 22 April 2020) Cite this as: BMJ 2020;369:m1509Read our latest coverage of the coronavirus pandemic
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Dear Editor
The arguments made by Arthur Caplan in favour of prioritizing younger people with covid-19 are a testimony to the challenge posed by non-clinician ethicists failing to engage appropriately with the clinical and scientific basis of the topic in question (1). For example, basing a part of his argument on an apparent policy of restricting dialysis in 2003 to over -65s in some areas of the UK failed to recognize that the newspaper article he quoted was actually a critique, widely held among clinicians of all hues, of the practice (2). In addition, his comments on age-limits on organ transplantation missed out on a vibrant literature criticizing the evidence of ageism in renal transplantation for older people (3).
At a more troubling level, Dr Caplan fails to incorporate basic facts about ageing, including increased inter-individual variability (weakening any group association of increased age for any one individual) and increasing levels of physical and cognitive fitness over recent decades (4). Worse still is the uncritical recourse to the 'fair innings' argument, widely recognized in gerontology to have its origins in ageism and a failure model of ageing, and failing to recognize the many gains of later life both individually and to wider society, neatly illustrated by the creativity of great artists in late old age, as well as of mature politicians and older workers (5).
Finally, Dr Caplan seems agnostic of the extent to which ageism still persists in virtually all fields of care, denying appropriate care to older people for whom it would be appropriate for cancer, cardiac conditions, renal replacement and transplantation, to name but a few. Overt defence of such ageism by physicians, as recently appeared in Italy (6), would be considered abhorrent if applied to other designations with poorer prognoses, whether relating to ethnicity, gender, social class or income. It would appear that older age has become the last bastion of widely tolerated overt prejudicial attitudes and behaviour in medicine: the covid-19 pandemic and the toxic ethical discourse arising from it should be seen an opportunity to finally and openly address and overturn this most tenacious of prejudices which ironically will affect most of us if left unchecked.
References
1) Editorial. The ethics industry. Lancet. 1997;350(9082):897.
2) Laurence J. Hard-pressed kidney units admit turning away patients and offering inadequate treatment. Independent 2003 Jan 14. https://www.independent.co.uk/life-style/health-and-families/health-news...
3) Schaeffner ES, Rose C, Gill JS. Access to kidney transplantation among the elderly in the United States: a glass half full, not half empty. Clin J Am Soc Nephrol. 2010;5(11):2109‐2114.
4) Jagger C, Matthews FE, Wohland P, et al. A comparison of health expectancies over two decades in England: results of the Cognitive Function and Ageing Study I and II. Lancet. 2016;387(10020):779‐786.
5) O'Neill D. The art of the demographic dividend. Lancet. 2011;377(9780):1828‐1829.
6) Vergano M, Bertolini G, Giannini A, Gristina G, LivigniS, Mistraletti G, Petrini F. Clinical Ethics Recommendations for the Allocation of Intensive Care Treatments in exceptional, resource-limited circumstances. Rome, Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva, 26 March 2020. http://www.siaarti.it/SiteAssets/News/COVID19%20-%20documenti%20SIAARTI/...
Competing interests: No competing interests
Dear Editor,
We read with great interest the “head to head” about prioritisation of younger patients with Covid-19 [1], and we would like to make a few remarks, both factual and normative.
We think that age is one among many factors that have to go into any allocation decision. The claim that such a strategy is discriminatory can be challenged by both utilitarian and nonutilitarian objections.
First of all, in Archard’s premise, the statement that using age as a marker of clinical frailty and likelihood of survival is “crude and unreliable” is not supported by scientific evidence. Age per se is not only a reliable predictor of mortality, according to Gompertz law [2]; it is also associated with frailty, regardless of other chronic illness.
There is relevant literature supporting the idea that aging occurs as an emergent phenomenon: people do not die from old age, rather they accumulate age-related illnesses and become increasingly vulnerable to death. Thus vulnerability (frailty) can be quantified through mathematical models and is strongly associated with mortality [3].
In the case of Covid-19, in particular, from a clinical perspective, preliminary outcome data [4,5] show a strong correlation between age and Covid-19 lethality.
Archard's first argument ("where is the line") can be challenged by two objections. The first one is that in the example used (of an 18 year old versus a 19 year old), the age criterion is of course very weak; but this does not at all imply that the criterion may be equally weak when preferring an 18 year old to a 92 year old.
Also, Archard, as other scholars, views this as a line-drawing exercise, trying to identify some point when a life should be seen as complete. This could be seen as a kind of Dorian Gray view of the world, where one maintains a "full" claim up to a cut off and then precipitously falls off a cliff. This is not defensible, either in theory or as a practical matter. A person of 74 years 11 months cannot precipitously lose claim on his 75th birthday. As a practical matter that doesn't work in any case, since we may not have enough ventilators or other scarce resource to meet the needs of everyone below the cut off or may have enough resources to spare to take care of some above the cutoff. Even if for practical reasons we need to temporarily draw a line, that line should continually be adjusted as demands and resources require.
Regarding the fair innings argument [6], a similar problem arises. He and others take the fair innings argument to entail a cutoff between those who have (to continue the sports analogy) completed the game (say 9 innings in baseball) and those who have not. Instead, the concept should be better defined as a continuum through life, as suggesting that whoever has had fewer opportunities for living deserves a priority in a forced choice over those who have had more opportunities. So at all points along the continuum of life the younger deserves opportunity over the older when there is a forced choice between them. This is also one of the factors that should feed into organ allocation decisions as well as allocation of ventilators.
While using age as a criterion, there are two quite different perspectives. We may not agree on which is more appropriate. One uses age as a crude place-holder for utility on the belief that, in general, older people are more difficult to treat and get less benefit from medical intervention. This is partly because they predictably have fewer years left and therefore get fewer life-years from a given successful treatment. Utilitarians focus on this first perspective. Justice theorists either offer a simple view that all people regardless of age or life-expectancy have equal moral claim or they rely on fair innings arguments that focus on the number of calendar years one has had. Holders of this view focus on chronological age rather than physiological age. In much of the age-based allocation discussion, the two perspectives, utilitarian and non utilitarian, may lead to similar allocation positions and thus can form a coalition when it comes to allocation policy.
Lastly, while Archard stigmatizes value judgements in his third argument, he inadvertently makes a value judgement in describing people who deserve to carry on eating in Lucretius's dining metaphor. When he states that the need for care "might arise from choices, the consequences of which an individual should rightly be held responsible for", we believe his claim be unethical and discriminatory. "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" is a statement that does seem a value judgement and therefore should be avoided.
In summary, we believe there are strong reasons, both clinical and ethical, supporting the claim that prioritising younger patients with Covid-19 is not discriminatory.
Marco Vergano
Consultant, Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Turin, Italy;
Chair, Ethics Section, Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI), Rome, Italy
Robert M Veatch
Professor Emeritus of Medical Ethics, Senior Research Scholar, Kennedy Institute of Ethics, Georgetown University, Washington DC, USA
References:
[1] Archard, D., Caplan, A. Is it wrong to prioritise younger patients with covid-19? BMJ 2020; 369 :m1509. doi:10.1136/bmj.m1509
[2] Gompertz, B. (1825). "On the Nature of the Function Expressive of the Law of Human Mortality, and on a New Mode of Determining the Value of Life Contingencies". Philosophical Transactions of the Royal Society. 115: 513–585. doi:10.1098/rstl.1825.0026
[3] Mitnitski, A.B., Rutenberg, A.D., Farrell, S. et al. Aging, frailty and complex networks. Biogerontology 18, 433–446 (2017). doi:10.1007/s10522-017-9684-x
[4] ICNARC COVID-19 report 2020-04-04. https://www.icnarc.org/DataServices/Attachments/Download/c5a62b13-6486-e... (last accessed 2020-28-04)
[5] Richardson S, Hirsch JS, Narasimhan M, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. Published online April 22, 2020. doi:10.1001/jama.2020.6775
[6] Williams, A. Intergenerational equity: an exploration of the 'fair innings' argument.” Health Econ. 6, 117-32 (1997).
Competing interests: No competing interests
Dear Editor
Better to ask whether it is right to keep on prioritising current older patients with COVID-19 over all other patients in this and the next generation as we are now doing. We should stop and we should value them equally.
The ethicist Daniels (1988) in "Am I my parents’ keeper" argues from a Rawlsian perspective that resources should be allocated throughout the stages of life to provide a fair lifetime share. It is rational to distribute one’s own allocation to maximise your chances of reaching old age. It would be irrational to choose an option that reduced your chances of reaching old age, but maximised your life expectancy once you had. Having reached old age in part due to scarce resources being allocated to help you do so, it is then not appropriate to ask for further scarce resources to prolong your own life with the result that someone younger has a lower chance of achieving your own life expectancy.
The ethicist Callahan (1990) in "Setting Limits" argues for a communitarian perspective that society should provide an acceptable minimum of care, but not “unlimited health efforts to conquer illness and death”. The aim should be to allow all to live out a full lifespan in which “life’s possibilities have on the whole been achieved” and “death is a relatively acceptable event”. On reaching old age relief of suffering takes priority over extending life.
It is possible to choose your conclusion by choosing your ethicist. But the World Health Organisation has previously surveyed populations across the world about prioritising scarce health resources. Murray (preface of WHO 2001) indicates that most accept that the life of a young adult in child bearing years is greater than that of the elderly. Presumably this is because they are the future. They will produce the next generation, they are a large part of the economy that provides for everyone, and they care for the elderly directly or indirectly.
We are in lockdown and have shut down our economy in order to be able to ensure largely older patients with COVID-19 with significant co-morbidities can be put onto ventilators. It is all these steps together that are the intervention. But death can never be prevented and lives are never saved, only the number of years to death and their quality of life can be changed.
This intervention is not for the 80% intubated and ventilated COVID-19 patients who die anyway. Their outcome is not changed. Of those that survive this, estimates seem to be that 70% will have significant brain and/or lung damage due to being ventilated. Not all of these patients may be entirely thankful, even if the rest of us demand that they are. It is also not for the patients who receive CPAP and oxygen but who would have survived anyway without it. It is only for those patients for who the outcome is changed, who would have died but now don't. This is perhaps an average of 100 patients a day since the pandemic hit the UK.
Early estimates of the economic costs, now seen as very optimistic, were £2.5B a day, or £25M per death delayed. These patients would probably have died in an average of about a year if there had been no pandemic, and assuming their multiple co-morbidities mean their quality of life was about half that of full health, that's £50M per QALY. The pound sign is only to allow comparison with what we give up when we choose to do this. The average for all NHS interventions is £13K per QALY (NICE’s £25K per QALY is for new interventions).
This means that we are valuing a year of healthy life by preventing early death from COVID-19 through ventilation at nearly 4,000 times more important than a year of healthy life for all other patients in the country with any other illnesses.
Increasing the NHS budget by £650,000 a day for the duration of the pandemic would have provided the same health gain. Compare that with £2.5B a day. These patients we are not treating will die and have grieving relatives because we choose to ventilate elderly patients with multiple co-morbidities who have COVID-19. You can play with the figures, but you'd have to change them to unrealistic levels to change the conclusion. There is extreme bias towards elderly COVID-19 patients, and it is wrong.
And it is worse. The recent Marmot report shows the adverse effect that ten years of “Austerity" have had on health and early death, largely in the young. Read it and weep; it is mild compared to what is coming. Worse again, the Bank of England now says that future generations will still be paying for the economic shut down. So, the children not yet born who are the grandchildren and great grandchildren of those we are doing this for, will be less healthy and die younger than they would have done had we not.
We also know there will be another pandemic, and that could even be next year. Once in 100 years doesn't mean it happens every 100 years. Recent pandemics have just not been quite lethal enough, and many extremely lethal diseases have not been quite infectious enough to be pandemics.
If we cannot close down our economy as part of our intervention in the next pandemic, which we know will come, why are we doing it now? Only this single generation of elderly will be able to receive this intervention, future ones will not. Is that fair? We have also had national pandemic response plans in place for 15 years based on influenza. Pandemic influenza kills young adults the most. We never planned on doing this for them.
Those of us in older generations have already implemented changes in society that have reduced the opportunities for the young in education, wages, job security, debt, welfare, housing, pensions, and the environment. Now we are also doing it for their life expectancy and health. If I were young (instead of someone who is retired with a significant co-morbidity for COVID-19) I think I might be beginning to get angry.
Dr James Andrew Rixom
Retired Consultant in Public Health Medicine.
Daniels N. (1988) Am I my parents’ keeper. New York: Oxford University Press
Callahan D. (1990) Setting Limits. New York: Simon and Schuster
WHO 2001 International Classification of Functioning, Disability & Health
Competing interests: No competing interests
Dear Editor,
We read with interest the Head-to-Head “Is it wrong to prioritise younger patients with covid-19?”
https://www.bmj.com/content/bmj/369/bmj.m1509.full.pdf
There are at least three issues which support Dave Archer’s (DA) position but which neither author touched on.
First, over many years, an older person may have developed a skillset or contacts which in the short or longer term may have a greater positive impact on society than, as yet, someone much younger.
For example, while a retired healthcare worker might be deemed too old to be ventilated if age is used as a criteria for selection, that hasn’t stopped healthcare workers from being asked nor from accepting the request from the Government and NHS Executive to re-license so that they can use their skills to help save others.
Furthermore, many older people continue to be economically active. Older people currently comprise 11% of the UK workforce and are predicted to make up an increasing proportion of the workforce over the coming years. A recent article noted that “workers aged 65 and older will be responsible for more than half of all UK employment growth over the next 10 years and almost two-thirds of employment growth by 2060” (1). Additionally, we must remember older people are providers and continue to contribute to the economy in other ways: as unpaid carers (carers of partners, carers of grand-children) and the “bank of mom and dad”, saving governments billions annually.
Second, an older person will have paid taxes over 40 – 60 years on the understanding that the NHS would be available – free for all at the point of need – whenever they might need it. Should society tell such a person that they cannot access the required healthcare because someone who hasn’t yet contributed (or made a much smaller contribution) has been selected to receive that health care in preference to them? This ‘social contract’ has apparently been broken by decisions made with input from ethicists, health administrators and politicians - yet without any input from the individual concerned. Where is the morality in that position?
Third, while both authors discuss the “fair innings” argument, as DA points out there is no agreement on what counts as a fair innings. Both authors discuss this in theory but don’t attempt to put any qualitative or quantitative assessment on what level of ‘innings would be denied to older individuals”. We have however seen a systematic attempt by the government from the start of the COVID-19 crisis to ‘label’ deaths as mainly in older people with other significant co-morbidities. Yet a report by the Intensive Care National Audit and Research Centre (ICNARC) stated that out of 225 patients admitted to critical care units only 10% of ICU cases in the UK with COVID-19 had serious comorbidities (2).
In the last few days, Hanlon and colleagues further quantify this issue. They report that the years lost to life (YLL) for males 60-69, 70-79 & 80+ were 26.8, 18.4 and 11.0 years respectively and, for females, 25.5, 17.7 & 10.4 years respectively where the multi-morbidity count was 0 (3). These figures decrease with increasing multi-morbidity scoring but all retain significant durations even down to a score of 6. For example, even at age of 70-79 with 3 co-morbidities 12 years of life are lost and at 80+ the figure is 6 years of life lost.
It is therefore important to expose the narrative which appears to have been perpetuated that the vast majority of the deaths have been in older patients with comorbidities apparently implying, falsely, that these patients would have been expected to die soon anyway.
All of the above further support DA’s argument that the provision of care on the grounds of age is to send a message about the value of older people and publicly expresses the view that older people are of lesser worth or importance than young people. We also agree with his concluding sentence that “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”.
John FR Robertson, Professor of Surgery & Consultant Surgeon, University of Nottingham. MB ChB, BSc, MD, FRCS
Marcia Stewart, Lay member, Social Care professional & emeritus academic BA(Hons), DipSW, CQSW
Denise Kendrick, Professor of Primary Care Research and General Practitioner, University of Nottingham. BM, MSc, DM, MFPH, FRCGP
Herb F Sewell, Emeritus Professor of Immunology & Consultant immunologist, University of Nottingham. MB ChB, BDS, MSc, PhD, Hon DDS, Hon DSc, FRCP, FRCPath, FMed Sci
References
1. https://www.theguardian.com/society/2019/dec/31/over-65s-to-account-for-...
2. ICNARC report on COVID-19 in critical care, 20th March 2020
3. https://wellcomeopenresearch.org/articles/5-75/v1
Competing interests: No competing interests
Dear Editor
When health and care systems become stressed and fearful, they are likely to default to silent anticipatory triage where thinking can get crowded out. We consider there have been signs of this nationally over recent weeks. Treatment decisions based on age, not a good predictor on its own merit of whether a person will benefit from escalation of treatment, are one example of this ("Is it wrong to prioritise younger patients with Covid-19?", 25 April). We are also concerned that silent decision-making has resulted in those who might have benefitted from supportive treatment (regardless of whether ventilation was appropriate) staying away from hospital.
Although there has been prior research (1,2,3) and some recent UK public debate (4) about triage, there has been little discussion of decision-making support under new conditions of stretched, but not overwhelmed, resource. Here, decision-making must take into account (as it has always had to) the actual resources available. The case for transparent decision-making is not just to prepare for the possibilities of harsh surges of need relative to capacity but also to prepare for the possibility that the worst does not come to pass, thereby avoiding the unforeseen hazard of over-triage.
We are likely to be on a chronic relapsing and remitting course with Covid-19. The virus is widespread in the world and likely to remain so. There is the potential for fatigue in healthcare capability and in the containment and mitigation strategies used to control surges.
This changing state, which we may be in for significantly more than a year, means that hospitals need to develop dynamic and resilient systems of decision support which are: a) locally responsive yet regionally and nationally consistent, b) informed by best clinical evidence, c) engage with democratic deliberation and debate to ensure accountability for reasonableness (5) and d) remain within the basic rule of law that has taken the UK centuries to build.
As a multi-disciplinary group of professionals in a London Teaching Hospital, we have developed a decision-making framework, accompanied by access to 24/7 clinical ethics and other decision-support expertise, for doctors facing grey-area-type problems on the frontline. Without these systems in place we believe that frontline staff and NHS Trusts are potentially left exposed both psychologically and legally by complex situations arising during the Covid pandemic.
References
1. New York State Task force on Life and the Law, New York State Department of Health. Ventilator Allocation Guidelines (Nov 2015). Available at: https://www.health.ny.gov/regulations/task_force/reports_publications/do...
2. Lee Daugherty Biddison, E., Faden, R., Gwon, H.S. et al. Too many patients… A framework to guide statewide allocation of scarce mechanical ventilation during disasters. Contemporary Reviews in Critical Care Medicine. Chest. 2019. 155;848- 854
3. White DB, Katz MH, Luce JM, et. al. Who should receive life support during a public health emergency? Using ethical principles to improve allocation decisions. Ann Intern Med.2009;150:132-8.
4. British Medical Association (BMA). 2020. Covid-19 – ethical issues. A guidance note. Available at: https://www.bma.org.uk/media/2226/bma-covid-19-ethicsguidance.pdf
5. Daniels N. Accountability for reasonableness. BMJ. 2000;321:1300-1301.
Competing interests: No competing interests
Dear Editor
David Archard argues against prioritising younger patients with covid-19, highlighting its crudeness and ‘unwarranted animus or prejudice’. I was concerned, then, to read his subsequent argument that ‘it is hard not to think that it matters what kind of life has been led and might still be led’, suggesting that those who have more to ‘give the world’, may be more deserving of care. The exact meaning of this is unclear, but this, and the idea that people should be held responsible for choices which may have led to increased care needs, could feasibly discriminate against the most vulnerable in society. This may include those from lower socioeconomic backgrounds; with poorer access to education; that have been the victims or trauma or abuse; the homeless; and those with mental illness. That these people may have less to 'give to the world' is likely a reflection of how little the world has given to them.
To make decisions based on age alone is inadequate, but it is an objective measure and does not enter the dangerous realm of moral judgement. In reference Archard's metaphor, it is not the role of healthcare professionals to consider who ‘deserve(s) to carry on eating’ based on their life decisions and capacity to 'give'. Whoever we are, and whatever we have or have not done, there is always room to realise new ambitions or talents. Or not. Either way, this does not make a life less valuable, and we should have compassion for the complex reasons some may have less to give than others.
Competing interests: No competing interests
Dear Editor
Having worked in intensive care since 1980 one or two things are quite clear in my mind! Firstly life is very sweet, no-one knows what (if anything) is coming next and few people really want to die. Neverthless dying on a ventilator receiving the full paraphenalia of "intensive care" is a horrible way to go! No-one looks their best drugged and intubated on an ICU ventilator and one should never understimate the pain and suffering - best described as a form of "torture" - associated with a prolonged epsiode of intensive care. Indeed it can only be justified in my opinion if there is a good chance of making a recovery with a reasonable quality of life. That is the tricky bit - we don't have a crystal ball and despite all the "big data", it remains difficult if not impossible to prognosticate with any degree of certainty in individual patients. However as Art Kaplan points out, elderly patients in general do not do well if they require a prolonged (>24 hours) period of invasive ventilation. As long ago as 1984 Mark Smithies, Jack Tinker and I pointed out the poor outcomes in intubated octagenarians admitted to the Middlesex Hospital ICU with a "medical" (non-surgical) emergency and nothing much has changed since!
Of course we should prioritise younger patients with COVID-19 for many reasons but most importantly because they are more likely to survive intact with minimal disability and a good quality of life! The elderly have to accept that they cannot go on for ever and they should not be greedy! Just as I would give up my seat on a bus for an elderly person in 1960s (when I was young) we, the elderly, must now give up our ICU ventilator for a younger person today! In doing so we can not only feel good about our altruism but also avoid a horrible "end of life" experience!
As a 66 year old physician in the "front line" (if indeed we have one in Australia) I have an advanced directive stating that under no circumstances do I want to end my life in an ICU or indeed in a hospital. My children are aware of my wishes and I would advise anyone over the age of 65 to think carefully about how they would like to die!
Competing interests: No competing interests
Re: Is it wrong to prioritise younger patients with covid-19?
Dear Editor
Debates about age and resource take into account the potential loss of life as measures in years or QALYs. This is never adjusted to account for the change in perception of the length of time with age. When we are children the passage of time from one birthday to the next is huge - say, one fifth of a life when going from age four to five. From eighty to eighty-one is just over one per cent of a life.
This is the phenomenon described in Weber`s law and seen in many physiological systems such a drug dose response curves and strength of stimulus and nerve electrical activity. There is a logarithmic relationship between change in stimulus (say passage of time) and the perceived change. An older person may gain a year of life but it may be perceived as being just a few weeks yet the resource consumed in that year is not changed. There are graphs of age and actual perceived percentage of life lived that are sobering. Perhaps now is the time to have such adjustments incorporated into our calculations of QALYs and life expectancy?
Competing interests: Author of a book on ageing, frailty and death