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Views And Reviews Primary Colour

Helen Salisbury: Older lives are not worth less

BMJ 2020; 371 doi: (Published 13 October 2020) Cite this as: BMJ 2020;371:m3915

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  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on Twitter: @HelenRSalisbury

If you’re lucky, age brings wisdom and leisure, but for many it means illness, frustration, and failing bodies. “I’m sorry to be such a nuisance, doctor,” older patients often tell me. I reassure them that they’re not a nuisance and that, if they didn’t trouble me with their ailments, I’d be out of a job.

While a few patients stockpile medication, others worry about “bankrupting the NHS” and try to avoid any treatment that’s not strictly necessary. I try to explain that they’ve already paid for the care and medicines they now need, through a lifetime of taxes.

In this pandemic, I’ve been reminded again of the risk of ageism in healthcare. It’s not always appropriate to give an 80 year old the same treatment as you would a 20 year old, largely because the older patient may not tolerate it. If you have only one ventilator or dialysis machine, most people would allocate it to the patient with more years of life ahead. Luckily, however, we live in a society rich enough to ensure that, if a patient can benefit from a treatment, age doesn’t usually prevent them being offered it. A patient’s pre-existing conditions are an indication of how much extra care is needed, not a reason to limit it.

The Spanish flu pandemic a century ago killed an estimated 50 million people worldwide, a tragedy compounded by the fact that so many victims were in their teens and 20s. It’s undeniably a relief that covid-19 mostly spares this group, but this doesn’t make the excess deaths less important. Any narrative emphasising that most deaths have occurred in people aged over 65, or with underlying conditions, seems to imply that we should be less worried. This deeply offends me on behalf of my older patients—many of whom already fear irrelevance and worry that their opinions or life no longer matter to others—and on behalf of patients with diabetes and high blood pressure.

The concept of easing restrictions on young and fit people while shielding vulnerable ones, running two parallel systems according to your personal characteristics, is nonsensical.1 There’s no easy way to define the people at risk, and even if we could, it’s impractical to keep people hermetically sealed away (think hospitals, care homes, and multigenerational households). This is before we even start considering the risks of long covid in younger patients.

We have no option but to pull out all of the stops to reduce the spread of this disease. Most people, even if they believe that they would shrug off the virus, don’t want to risk passing on the infection to someone who might die from it. Sadly, until we have a proper package of support for people who have to self-isolate, many of those contacted by the (increasingly inadequate)3 track and trace system will reluctantly risk passing this disease on to the most vulnerable people, as they simply can’t afford to stop earning.2


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