The Arguments For and Against Prioritizing Younger Patients with COVID-19

Would it be wrong to prioritize younger patients with COVID-19 for treatment? There are merits to both sides of the argument, according to a Head to Head debate-style essay published in The BMJ.

Dave Archard, an emeritus professor at Queen’s University in Belfast, and Arthur Caplan, PhD, William F. and Virginia Connolly Mitty professor of bioethics at NYU Grossman School of Medicine in New York, debated the policy of considering age as a factor in prioritizing care for patients with COVID-19. They wrote that health care services are overburdened, and workers are having to make choices about who receives treatment.

Archard believes this overtaxed healthcare system should not be a cause for discriminating among patients.

Caplan suggested that age can be a valid criterion when supported by data.

Using age as a determining factor to decide which COVID-19 patient gets treatment becomes exposed as “wrongly discriminatory, because it licenses differential treatment based on ‘unwarranted animus or prejudice’ against old people,” Archard wrote. He outlined 3 key reasons that age should not be used to determine who should or should not receive what could be life-saving treatment.

First, he claimed that being younger than someone else is not a satisfactory criterion on its own. Being 18 years old versus 19 years old would not be any different than a coin toss or a first come, first served policy, he wrote.

Secondly, Archard employed the “fair innings” argument, which holds that everyone should have an opportunity to lead a life of a certain duration. This leads to those who have already led a life of a certain duration to be passed over for life-saving treatments over those who have not yet done so. While a compelling angle, Archard wrote that there is no consensus on what can count as a fair innings.

“It is hard not to think that it matters what kind of life has been led and might still be led,” he said. “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.”

Third, Archard wrote that if age was to be a criterion for life-saving healthcare, then it would imply a devaluation of older people.

“Such discrimination publicly expresses the view that older people are of lesser worth or importance than young people,” he said, adding that it contributes to the view that older people are second class citizens.

Older people are already disadvantaged with respect to social care, employment, and in other ways, Archard said, and it would be wrong to contribute to that injustice. He went further, adding that it would be implied that a possible culling of elderly people was the goal.

However, Caplan said such behavior is not wrong, and that age—when supported by the data—can be a valid criterion for health care eligibility. Those who are disadvantaged, such as the elderly, disabled, poor, or of an ethnic minority, have faced much discrimination in and out of health care systems.

Age would not be among the reasons they are denied opportunity for care, he said.

Caplan said that in some countries, such as Italy, age over 65 years was cited as an exclusionary criterion for accessing intensive care services when they were limited. In parts of the UK, age over 65 years is a barrier to undergoing renal dialysis, he added. Furthermore, he said, throughout Europe, Canada, Israel and the US, it is rare for anyone over the age of 80 to receive a solid organ transplant from a deceased donor.

“That said, even in conditions of extreme scarcity it would be discriminatory to simply invoke age to exclude those in need from services,” he wrote. “Blanket exclusion based simply on age of an entire group with no additional rationale or justification is wrong.”

Caplan continued that policies surrounding pandemic planning begin with a warning against blanket discrimination based on age, disability, race, gender, gender orientation, or religion. Age alone does sometimes permit access, Caplan noted, using an example of a “women and children first” policy when seeking lifeboats on a sinking ship. In that case, children were prioritized due to their age.

“Giving priority to the very young seems to evoke broad consensus,” Caplan wrote.

But why, Caplan asked, is age morally relevant? First, he cited fair innings; those under 18 are typically seen as gaining priority and those over 80 are viewed with lower priority as they have had a chance to “experience life, pursue their goals, and flourish as human beings.”

Using age as a qualifier for health care treatments can also maximize the number of lives saved, Caplan said. There is a diminishing chance of survival as age increases, he said, when considering ventilator use and renal dialysis.

“The relevance of old age as a predictive factor of efficacy—combined with the powerful principle of healthcare affording equality of opportunity to enjoy a life—makes age an important factor in making the terrible choice of who will receive scarce resources in a pandemic,” he concluded. “Ageism has no place in rationing, but age may.”