Bioethics Forum Essay
Why I Support Age-Related Rationing of Ventilators for Covid-19 Patients
The Covid-19 pandemic raging around the world is raising health-related ethical issues from the micro level of individuals and families to the macro level of governments and societies. The pressing issue of availability of mechanical ventilators spans the territory. Reflecting on that issue demonstrates that bioethics is personal and political. As a 71-year-old bioethicist, I recently drew up an advance directive specifically for the possibility that I might have to go to the hospital with Covid-19, and I am writing this essay to explain why I consider rationing mechanical ventilation based on age to be one morally relevant criterion.
As the surge of patients presses on hospitals, the resources of intensive care beds and mechanical ventilators are likely to be insufficient to treat all who may need them to have a chance at survival. Who should get access to these scarce resources when all can’t be served? Who will die to make way for others who might have a chance to live?
Within the context of medical ethics, with its focus on the clinician-patient dyad, no ethical issue is more fraught than the allocation of scarce medical technology. Indeed, it was on the radar of philosophers and theologians at the very beginning of bioethics as a field of study, more than 50 years ago, in particular in the context of the novel intervention of dialysis for end-stage renal disease.
In normal times, outside of a health crisis, intensive care beds and technology are properly allocated first-come-first served. This is unsatisfactory when the existing supply is outstripped by demand, as is occurring, or likely to soon occur, in the Covid-19 pandemic. In such a context, rationing of some sort becomes morally imperative. What criteria should govern access to ventilators?
A short essay does not afford space for a systematic argument in favor of age as one, but not the only, criterion for rationing the use of ventilators in the context of the Covid-19 pandemic, especially for doing justice to various objections that would be raised. Nevertheless, the key ethical considerations can be outlined. Some patients suffering from Covid-19 develop a progressive pneumonia, which may rapidly lead to severe respiratory insufficiency; for these patients, mechanical ventilation, often for two weeks or more, may become necessary to give them a chance of survival.
While outcomes data are meager at this point, they suggest a grim prospect for elderly patients needing mechanical ventilation. A single medical center in Wuhan, China described intensive care outcomes for 52 patients. Of that total, 37 patients received mechanical ventilation, and 30 of them, 80%, died during the 28-day follow-up. Of 10 patients aged 70 and older, only 1 survived. A much larger data set reporting outcomes for 1591 patients in ICUs in Lombardy, Italy between February 20 and March 18, 2020, demonstrated considerably higher rates of mortality depending on age: 29% for those 61-70; 40% for those 71-80; and 55% for those 81 and older. However, many patients in those age groups remained in the ICU at the time the study was completed. For the 22 patients aged 81 and over, 12 had died (55%); 2 had been discharged (9%); and 8 (36%) remained in the ICU. If half of those remaining in the ICU in that age group subsequently died, the overall mortality rate would be 73%; if all of them died, it would be 91%.
In addition to older patients having a relatively poor prognosis, the number of years of life that they have had the opportunity to experience supports an age criterion for rationing ventilators. Other things being equal, the young have much more to lose from death than the elderly. I would suggest that an initial age criterion for rationing ventilators when the demand outstrips the supply is a cut-off of 80.Eighty years of age is just above the average life expectancy in the U.S., which is 79 years old. It seems fair to say that people who have reached that milestone have enjoyed an opportunity to live a complete life. On average, not many years of life with relatively good health and functioning are left to those aged 80.
If demand for ventilators keeps growing and further outstrips supply, I believe it could be justifiable as a matter of policy to forgo mechanical ventilation for all patients 70 years of age and older who have a medical condition that puts them at elevated risk of death, such as chronic renal disease, cardiovascular disease, diabetes, and chronic lung disease. Finally, in a yet more dire shortage I believe the age limit could be set at 70, regardless of a patient’s overall medical condition. This stringent rationing policy would include me. I view myself as having lived a complete life. Losing a relatively small chance of survival and recovery to a tolerable quality of life seems to me a reasonable sacrifice in favor of younger patients, and consistent with promoting the common good in the extraordinary societal situation posed by the current pandemic.
To be sure, the surge of Covid-19 patients in need of mechanical ventilation in the U.S. might not overwhelm available resources, such that implementing an age criterion for rationing becomes justifiable; however, the situation in other countries might be relevantly different.
Some people will object to my proposal on the grounds that I am endorsing age discrimination. But what matters is whether using age as a rationing criterion is reasonable and fair.
A policy of rationing that adopts age as a criterion can be morally tolerable only if elderly patients who must forgo mechanical ventilation receive adequate palliative care. In the pressure to save lives during pandemic, palliative care might become neglected; however, failure to provide it abandons patients to unnecessary suffering and bad deaths. The right of all patients to receive medical-indicated, life-sustaining treatment, and the duty of clinicians to provide it, may need to be limited during a pandemic. In contrast, palliative care is a moral imperative for all critically ill patients.
Franklin G. Miller, PhD, is a professor of medical ethics in medicine at Weill Cornell Medical College and a Hastings Center fellow.