Crisis-care protocols should ignore patients' age, say ethicists

Adults 65 and over are the age demographic most likely to die or become severely ill from COVID-19—which prompts the ethical question: Should advanced age be a factor in deciding who receives lifesaving medical resources during dire shortages?

A new analysis examines ethical arguments for applying age-based criteria when clinicians must set priorities for lifesaving resources, such as ventilators, as occurred with early COVID-19 patient surges.

The paper, newly published in the journal Bioethics, concludes that age and age-related criteria should not be used to avoid mutual sacrifice during public health emergencies.

"I don't think life years remaining is ethically defensible. Some children at cancer hospitals are very sick and their life expectancies are short, but I would never say that their lives are worth less. Each person has intrinsic value regardless of age and ability," said author Nancy Jecker, a professor of bioethics at the University of Washington School of Medicine and a Fulbright U.S. Scholar for South Africa.

In multiple analyses spanning the last two years, Jecker has examined ethical dimensions of the COVID-19 pandemic. In this paper, she explores the bases for clinical decisions about allocating lifesaving care.

When there are too few medical resources to treat all the patients who require care, standard triage protocols are invoked to prioritize those who can survive with an intervention but who otherwise will die. In 2020, amid the worst COVID-19 surges, standard triage criteria were inadequate because too many people qualified, Jecker wrote, and further criteria were needed. In response, state hospital associations and professional groups quickly produced guidance, leading to debates over age-based and other criteria.

People 65 and older are significantly more vulnerable to death and serious illness from COVID-19. As well, chronic diseases and comorbidities mean older adults are more likely, at a population level, to die and suffer grave illness.

With this backdrop, Jecker's paper considered whether, if multiple patients have the same disease prognosis, individuals should have less access to a scarce medical resource based on older chronological age, later life stage, shorter life expectancy, or less chance of near-term survival.

Jecker also investigated criteria that are "age-blind" but which disproportionately impact older adults, such as saving the most lives, life-years, and life-years adjusted for health-related quality.

"At a population level, age is a predictor for COVID-19 mortality, but so are chronic health conditions," Jecker said. "Men have been more likely to die of COVID, and minorities and pregnant women have been more likely to have bad outcomes with COVID. But what do we do with that information? It doesn't follow that, just because your population-level group has relatively worse outcomes, we should deprioritize your care when resources are scarce."

Jecker rejected the argument that older people have had "fair innings," a widely used rationale for favoring younger over older people.

"Whether an individual has had a fair innings depends not just on the numbers of years they have, but what those years have been like. If someone has been disadvantaged throughout their life, deprioritizing their care only perpetuates a pattern of injustice experienced throughout life," she said.

Jecker proposed that a "pandemic triage" protocol consider more patient-specific values. A Clinical Frailty Scale, for instance, is a better predictor of near-term survival than a person's chronological age and can be a feature of individuals at any age, she said.

"I think near-term survival matters. To the extent that comorbidities make it less likely that someone will survive near-term, that could be ethically included in a scoring system."

In discerning patients' likelihood of survival under dire conditions, triage team members will likely reach a point "where ethically defensible criteria run out," Jecker said, "and at that point, I favor a lottery as the fairest way to prioritize people."