Bioethics Forum Essay
On Being an Elder in a Pandemic
Do the elderly have special obligations during a pandemic, that is, something more than the duty we all have for hand washing, social distancing, timely self-quarantining, and most recently, wearing a face mask? Some workers, such as those in health care, grocery stores and pharmacies, and supply chain workers for essential goods, now have obligations beyond ordinary citizens during the Covid-19 crisis. Does being elderly incur duties others do not have?
I believe the answer is, yes, and foremost among these is an obligation for parsimonious use of newly scarce and expensive health care resources. Frank Miller’s recent essay sketches the argument for an age-related rationing policy for the use of ventilators with Covid-19 patients. I support Miller’s position, but my essay is not about policy. Rather my focus is how the elderly should understand their obligations, regardless of policy, concerning not only ventilators but the use of all scarce health care resources in a pandemic.
My position is grounded in a lifespan approach to ethics. The basic idea is that ethics must be rethought at various stages in life and that what might have counted as virtuous or responsible during one phase might be irrelevant or even counterproductive at a later stage. For example, autonomy and productivity, which were cardinal virtues in my youth and middle age, are increasingly unimportant. Things I now value highly are convivial friendships, kindness, and humor, and the essential moral tasks are now integrity and bearing a series of inevitable losses with some degree of dignity. Allowing the moral values I earlier prized to remain prominent into my mid-70s would be a sign of arrested moral development.
Importantly, I can’t take credit for making this moral transition. It simply seems to be what life is offering me at this stage, something that arrived without my bidding. If I can claim any credit it is only for acknowledging where I am in the life cycle, trying to accept it gracefully, and discern its implications.
As I near 75 my overall sense is one of deep gratitude. I have been offered many opportunities and enjoyed much happiness. This is true for health services, as well as career possibilities. I have been favored, first by excellent health benefits from employers, then at taxpayers’ expense a decade ago I entered the privileged class of Medicare recipients. I see this as a happenstance of American health policy, not anything I have merited. At some point I should be prepared to right the balance by exercising restraint, especially when the consequences of not doing so are evident all around me. Part of the moral meaning of aging lies in a sense of reciprocity across generations. As the pandemic rages on, it may well be that my claim on scarce and expensive services will cost others their lives. This is a bargain I am unwilling to make.
My death from Covid-19, were it to occur, would be sad, but not tragic. Yet the death of children and young adults is a tragedy. I have had many turns at bat; they have had very few. Every year I live I have less of a claim on scarce and expensive services relative to others younger than me. It is not that my life is worth less. Judgments about moral worth, regarding both individuals and groups, are notoriously flawed, very likely to be myopic and prejudicial, and it is hubris to attempt such judgments. It simply seems unfair for others to be denied what I have had for so long, and my bond with new and emerging human life can only be affirmed, in a crisis, by a willingness to give back and pay forward. “Sacrifice” would be the wrong term in this context, since it implies that I am entitled. “Generosity” might be a fitting term, but if so, it is a generosity in the service of a larger intergenerational justice.
What might this sense of fairness and stewardship of health care resources mean? Here are some possibilities, though others may present themselves as the pandemic continues. My obligations are:
- To the extent possible, to keep myself well, reducing the burden on the system as a whole;
- To think of myself as already infected, and be especially vigilant about hand-washing, social distancing, and eliminating nonessential occasions for exposure;
- To refrain from using health care services whenever possible, making sure I am not simply responding anxiously to something I can manage alone or something that can be postponed;
- To refrain from being tested, or to allow others to be tested first, even if I have symptoms; others have much more at stake in knowing their status than I do;
- If hospitals become overwhelmed, to refrain from being hospitalized, even when that is recommended, except when I become a major hazard to others in my household; here I would hope for a more robust availability of palliative measures in home care;
- If I am hospitalized and ventilators remain scarce, to forego ventilation in favor of younger patients;
- When a vaccine becomes available, to move near the end of the queue.
A caveat for all these ideas: if they cause more problems than they solve, create more vexing issues, use more resources or create a greater burden than I currently think they would, then the least burdensome alternative should be the one chosen.
Others in my age group may feel differently, and I respect their views. Some elders may have children or others who depend upon them in fundamental ways, so that their very survival implicates others directly and profoundly. Still, I believe my convictions fit within an overall frame for responsible elderhood for many of us. Some may think my position signals resignation, or giving up, or being ready to die. It is none of these. I hope for many healthy and productive years ahead. But having studied the U. S. health care system for decades, I am well acquainted with the inevitable, and usually invisible, need to ration, now made far more severe and visible by this pandemic. Even in the best of times hard decisions are unavoidable, and not everyone who needs care can possibly get it.
A variety of rationing, triage, and allocation schemes are currently being considered by state governments, hospital systems, and federal agencies, as well as the National Academies. One role I and other elders can play in this pandemic is to lessen the stress on the system and the angst of decision-makers in rationing services by bearing witness to the integrity of elderhood.
Larry R. Churchill is Ann Geddes Stahlman Professor of Medical Ethics Emeritus at Vanderbilt University, and a Hastings Center fellow.
How sad Prof. Churchill. I read your piece more as an expedient reflection on the American life and its Medicare, or lack of it, than an ethical argument for discriminating against the elderly. It is ironic that the elevation of youth as a desirable modern-day physical and mental standard have translated, it seems to me, into a devaluation of the elderly.
In traditional African communities, the elderly are revered and respected, cared and provided for. In return, they provide wisdom, tradition, family patriarchy and matriarchy that binds extended families, ancestral homes and traditional communities. “Elders” play a significant role in social and communal cohesion. Gogo’s, or grandmothers, are loved, cherished and respected by the young, often raising the very young when their parents leave rural areas to find work in the cities. These are generalisations, but the notion that Youth is a virtue in itself is a particularly Western, if not uniquely American Hollywood, standard. In countries with well-established Medicare systems, the elderly contribute financially their entire working lives, from low-claim youth into retirement, precisely so that they can be cared for in old age at greater expense to the system, when they need it most. The disparities in your views (and many of your peers) in North America, and mine out of Africa, are stark. They appear to be culturally specific. Heaven help us all if disposing of the elderly in favour of Youth, the ideal and the unformed, were to take hold and become the new normal.
Thank you Nicolette. The idea of a disposable elderly population could very well be the beginning of a society where there are expanding ideas of who is disposable next – would it be the disabled, the infirm, and so on. Yes, heaven help us if be begin down that road.
Here we get into the not-so-hidden underside of “lifespan ethics,” and that is lifespan is correlated strongly with social determinants of health, including access to healthcare, and not facing the stress of systemic discrimination. The government has sent a shot across the bow of healthcare saying that age cannot legally be a factor in deciding who gets access to medical care. So we get the apparent logic of comparing lifespans. Of course, we live in a society where a homeless person has a lifespan somewhere close to 15-years less than a prosperous white person. A black person who is also poor, I believe the span is 7-years (these numbers are both from memory and may not be completely accurate). So, a 70-year old, well-off white person will almost always win the “lifespan” lottery over a 70-year old poor brown, black, or Native person. In some ways, just using age is more ethical then using a projected lifespan. That is the other issue, how accurate are our measures of projected lifespan? Given the vulnerability of the old, the younger members of our society have serious ethical duties to protect the old. There is only so much a vulnerable individual can do to protect themselves, and many of the older members of our society, at least the ones who can’t hole up in their second or third home, are very vulnerable.
Thank you for your emphasis on gratitude, stewardship and restraint, and for your list of obligations. How would you avoid skating to the edge of a claim that “now that I am 75 I can actually afford to be selfless though I couldn’t before”? Don’t some of these points apply as much to younger people as to us elders? And could elders be less constrained and more trusted than our juniors to teach and model them for the whole community?
I just read your piece with great interest. I live in Florida, the state where Gov. DeSantis has been extremely slow to shut down the state, even as spring breakers overran our beaches. Florida’s infection and death rate rises daily. I have been social distancing and observing other recommendations in an effort to stay safe. About 8-10 days ago I called each of my children who all live in other states. One is my medical surrogate. I told them that should I become ill with the Covid19 virus and be taken to the hospital, that I do not wish to be ventilated. At the age of 89 it is unlikely that I would survive. I believe that the ventilator should be used for a patient with a much greater likelihood of survival and recovery. I would request medications for comfort.
Why are resources scarce? Who controls the production and distribution of needed resources? Who makes policy creating scarcity in healthcare? Who adopts a “scarcity” based “lifespan” rhetoric without justifying the terms of rhetoric? Who claims authority to advise death for some, discriminating against the undesirable? Who lacks enough historical sense to select life for some and death for others without first blaming the owners of scarce resources? Who pretends that ethics is not politics? And who so blatantly serves an unjust status quo?
Dr. Begher, pulmonologist at S. Maurizio hospital in Bolzano ( Italy ), wrote
“They leave. Wise, silent, as perhaps their life, made of work and sacrifices, was humble and silent. A generation leaves, the one that has seen the war, smelled and deprived it, between fleeing to an air-raid shelter and the eager search for something to feed itself. Hands hardened by calluses go away, faces marked by deep wrinkles, memories of days spent under the scorching sun or the bitter cold. Hands that have moved rubble, mixed cement, folded iron, in a tank top and a newspaper hat. Those of the first refrigerators leave, of black and white television. Wrapped in a sheet, like Christ in the shroud, they leave us those of the economic boom that with sweat have rebuilt this nation of ours, giving us that well-being that we have taken advantage of with impunity. The experience, understanding, patience, resilience, respect, now forgotten qualities go away. They leave without a caress, without anyone shaking his hand, without even one last kiss. Grandparents leave, historical memory of our country, heritage of all humanity. The whole of Italy must say THANK YOU and accompany you on this last journey with 60 million caresses .
In Italy we have had two regions with different and significant outcomes of the pandemic.
In Lombardy 10901 people out of 61326 sick out of a total of 10 million inhabitants, in Veneto 882 people out of 14,432 sick out of 4 million inhabitants.
But in Veneto there are 64.8% of patients in home isolation instead of 28.4% in Lombardy. Several public health response strategies at Covid 19 have led thousands of people to hospitals in Lombardy while in Veneto the primary care network with frontline family doctors have managed to keep Covid positive patients at home by limiting the number of infected people.
The real problem was the retirement homes where thousands of elderly people died from the failure to prevent and delay the diagnosis and therapy measures, with health personnel who had not had personal protective equipment by the NHS.
This also explains 16060 health workers with coronavirus infection with 116 doctors who died on the job including 46 general practitioners.
General practitioners went bare-handed to visit Covid 19 patients both at home and in retirement homes: their average age greater than 60 years immolated a generation of doctors who lived the profession as a mission and died as heroes.
Personal situations vary. I am 73, alone, isolating. No family within a thousand miles. Trying to remain safe in both the short and long term. Because I have a widowed daughter with an autistic son. She cannot work as his school is closed, as is the treatment center where he normally gets various therapies. I am their only source of income. So it’s not just about me and I will not be getting to the end of the line for a vaccine…should we be lucky enough to get one.
I am a 75 year old woman. I am smart, funny, curious, a lifelong learner, shaped by a lifetime of experiences – good and bad, and more than willing to bring my expertise and wisdom to the table. I have some health issues. I deal with them. They make me stronger.
I have a passion for life in all it’s forms. I AM NOT DISPOSABLE!!!