As the COVID-19 pandemic continues to spread, healthcare workers around the world have found themselves in the morally distressing position of having to ration critical care resources (such as ventilators and intensive care unit beds) when their supply is exceeded by the needs of increasing numbers of infected patients. Hospitals across the country have now formed committees of critical care and emergency medicine specialists, ethicists, lawyers, patients, and community members to develop protocols for triaging patients and allocating resources according to principles of distributive justice, including maximizing public health and minimizing discrimination.
In particular, triage protocols aim to save the most lives possible during a public health emergency. While some advocates have rightly condemned the practice of excluding access to critical care support on the basis of age alone, it is also unethical to mandate absolute age-blindness when it comes to resource allocation.
First, to start with the hopefully obvious, the blanket denial of resources to patients over a certain age regardless of other factors is unethical, as it implies that those lives somehow have less value. This should categorically disqualify any system that denies critical care strictly on the basis of age.
That being said, failing to consider age at all would undermine the public health imperative to maximize lives saved. Advanced age is associated with decreased physiologic reserve, or the ability to withstand multiple "hits" to the homeostatic mechanisms that regulate the human body. As such, age is an important predictor of short-term mortality, in addition to being correlated with multiple comorbidities such as cardiac disease and pulmonary disease that also may confer increased mortality.
For example, in an COVID-19-positive patients admitted to intensive care units (ICUs) in the Lombardy region, patients over 60 were only about half as likely (12% vs 23%) to be discharged from the ICU and almost three times as likely (35% vs 13%) to die in the ICU compared with patients 60 and younger.
Even with the understanding that all lives have equal and infinite value, it is in the best interest of public health to maximize lives (and arguably life-years) saved. There is indeed ethical precedent for this utilitarian approach seeking the greatest good for the greatest number of people. For example, in allocating solid organ transplants, we decline to list patients with life-limiting illnesses who are less likely to derive significant and sustained benefit, understanding that this is a scarce resource, the benefit of which we must maximize.
We should reject arguments that it is wrong to consider a utilitarian approach in a crisis involving a profound shortage of resources because it prioritizes efficiency over individual human lives. This is a false dichotomy, as the metric by which its "efficiency" is determined is, of course, the number of human lives saved, all of which are infinitely valuable.
It is also disingenuous to advance the idea that a first-come-first-served system would be free of bias or prejudice. It is well established that access to care is not uniform across populations, and it is not hard to imagine that the already privileged would be able to leverage their privilege to get to hospitals sooner. Such a system might also have the unintended consequence of punishing people who practice greater social distancing and become infected later in the pandemic closer to the peak when competition for scarce care resources is greater. In a first-come-first-served system, there is too great a chance that the white, wealthy, and well-connected will find ways to game the system and further exacerbate existing disparities.
Finally, to take a page from moral and political philosophy, if we were all to don what described as a "veil of ignorance" and design the fairest triage system possible without knowing our own specific characteristics (including age) and lot in life, it is not unreasonable to believe that we would design a system that favors the concept of "fair innings," that every person deserves an equal opportunity to experience every stage of life. By this measure, one could argue that a triage system should indeed prioritize younger individuals who have not yet had the chance to experience the births of their children, the pinnacles of their careers, and the pleasures of retired life.
There are legitimate concerns regarding the possibility of age discrimination, and one would hope that the age-associated risk factors for needing disproportionately prolonged resource-intensive care or for being less likely to survive regardless of care would be adequately captured in other aspects of triage scoring systems without directly taking age into account. However, as a fair compromise, we should at least use age as a tie-breaker in triage decisions. It is practical insofar as it is a continuous variable, and more importantly, it is ethical in that it gives at least a nod to the concepts of fair-innings and maximizing life-years saved while making a clear effort to avoid any age penalty except in case of a tie.
We expect conflicting considerations whenever scarce resources are at stake, and there will be no perfectly fair system with which everyone will agree. But this in no way lessens our duty to strive toward a system that allocates resources as fairly, as efficiently, and as transparently as possible.
Sarah C. Hull, MD, is a cardiologist at Yale School of Medicine and associate director of its Program for Biomedical Ethics. Benjamin Tolchin, MD, is a neurologist at Yale School of Medicine and the Yale Comprehensive Epilepsy Center.