The tragic reality of COVID-19 has forced hospitals to produce triage protocols that will determine which patients get prioritized for treatment. While protocol will differ depending on the institution, it is generally accepted that one of the fundamental values that hospitals will aim to uphold is the maximization of benefits. This means that all else equal, we should use our scarce resources to save as many lives as possible and to prioritize those who will benefit most. Putting this into effect will require that doctors make clinical judgments as to who will more likely survive treatment.
But what if there are two patients—one 70 years old and the other 40 years old—with equal survivability? Who should we save? Incorporating age as a factor is not an unlikely scenario. In the midst of the outbreak’s peak, some hospitals in Italy implemented a cutoff age of 80 but then had to lower it to 75.
To be clear, I am not asking if we should implement a cutoff age; rather, I am asking if age should be used to break a tie between two patients who are clinically comparable.
Some bioethicists think age should matter, that between two patients with equal prognoses we ought to save the younger one. And the reason is because the younger patient has had less time to go through the stages of life. This position holds that there is great value to go through the cycle of life—e.g., to be a child, a young adult, and a senior.
While I am sympathetic to this life cycle view, I think it is mistaken, because it misplaces the emphasis on the stages of life rather than on the goods that people can experience while they go through those stages. Knowledge and wisdom are both good, and it is certainly the case that we accumulate them over time, but it seems strange to say that being old in itself is what is valuable. So we ought to prioritize younger patients not because death deprives them of going through the stages of life but because it deprives them of more future well-being. This is a minor distinction that practically results in the same protocol.
I should clarify that I am not saying that younger people should be prioritized because they have more to contribute to society. It is not about social or economic worth, which is a concern that Dr. Pagel, a British researcher, raised in a recent New York Times article. Nor is it about intrinsic worth. The prioritization of younger people is not based on the fact that they are more intrinsically valuable. It is consistent to say that everyone is equally intrinsically valuable by virtue of being human, and that death will deprive more future well-being from some.
Focusing on the deprivation of future well-being will immediately bring up concerns. What if the older patient has children and the younger one does not? Should we then save the older one because she has more to lose? Surely, all else equal, not being able to spend more time with one’s children is a great loss. Or what if the older patient has a life partner while the younger one is single?
In response, age is a proxy for how much future well-being a person can experience, because younger people generally live longer. However, it may very well be the case that a particular young person, due to poor life circumstances, would not be deprived of as much future well-being than an older person would, were she to die. In such a case, death would be worse for the older person. But again, in general, we think that younger people can experience more future well-being. So while the older patient may have a loving partner and children, it may also be the case that the younger patient has not had as much time to experience those goods.
Admittedly, we cannot know for sure if one particular person would be deprived of more future well-being than another particular person, since we cannot predict the future. Yet we do not let this ignorance prevent us from believing that death is indeed bad for some people. Why? Because we have reasonable expectations. I have a reasonable expectation that my life will go relatively well for the foreseeable future, and because of that, it would be bad for me to die right now. Likewise, we can reasonably expect that younger people living in a country like the United States will experience greater net well-being than older people living in a similar situation. This is, again, a general statement, so there will always be exceptions.
Let us take a look at another concern. In a recent CNN article, Ira Bedzow and Lila Kagedan argue that triage decisions should only consider clinically relevant factors that affect the chances of “overall survival from Covid-19” and that life-years—that is, the number of years a person has left to live—is a non-clinical factor. While I agree that life-years is not a clinical factor, triage decisions must be influenced by such factors.
What we are talking about is how to prioritize patients who are clinically comparable. Whatever approach we take will inherently consider non-clinical factors. For instance, to prioritize patients who are clinically comparable according to a “first come, first served” approach, which is mentioned as an alternative, takes into consideration a non-clinical factor. The fact that one patient arrives at the hospital earlier than another is not clinically relevant. So the question is not really if triage decisions should consider non-clinical factors, but rather which non-clinical factors they should consider. I believe there is good reason to use age as a tiebreaker, because death is generally worse for the younger.