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  • BIOETHICS FORUM ESSAY

Why I Support Age-Related Rationing of Ventilators for Covid-19 Patients

Published on: April 9, 2020
Published in: Covid-19, Hastings Bioethics Forum, Health and Health Care

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.

 

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  1. Nicolette Erasmus on

    I am curious about your age Prof Miller? Read Dr Chris Wareham’s extremely well-argued article on the ethics of age discrimination in the African Journal Online. It answers your comments on whether age discrimination is reasonable and fair, and your assertion that the young have much more to lose. He is a young man. Both my parents are over 80 and are full of life. Many much younger people with pre-existing conditions would have a much poorer prognosis on hospitalisation than they do. I hope you will reconsider.
    You can find Dr Wareham’s article here: https://www.ajol.info/index.php/sajbl/article/viewFile/120177/109661

    • Bonnie Steinbock on

      I’m 73, and I see the justice in Frank Miller’s view, both on grounds of saving lives and on grounds of fairness. Still, I am concerned about those who are younger than 80 but have a worse prognosis due to other health conditions. The advantage of age as a criterion is that it’s easy to apply, which may not be true of risks due to health, but is ease of application sufficient on either consequentialist or justice grounds?

      • Nicolette Erasmus on

        Indeed, ease of application is precisely the problem: it is open to abuse. It is one thing to be judged by one’s peers. It is quite another to treat life as dispensable based on age alone when patients are at their most vulnerable, and care-givers are invariably younger. If statistics and probabilities were all that mattered one could dispense with ethics and replace it with AI – computers without hearts and minds. Ethics are meant to elevate professional thinking and moderate abuse of power. Age discrimination, because it exploits, is an evil.

        • DK, RN, PhD on

          Well said, Nicolette. The use, or non-use of resources, based solely on age, is a slippery slope we do not want to venture down. After age, what next? I don’t even want to begin to think about it. Age discrimination is not only dangerous, it devalues and discounts the wisdom and experience of our population.

        • Deborah G. Mayo on

          I agree with Nicolette’s point. Moreover, once doctors accept that they may refuse a vent to X, or take it from X to give to Y, they seem more inclined to give up on treating X altogether. They’re a lost cause. Fortunately, doctors are starting to see that mechanical ventilators often do more harm than good, and they focus instead on non-invasive forms of oxygen & actually treating the disease. https://errorstatistics.com/2020/04/12/paradigm-shift-in-pandemic-vent-protocols/

      • Alan Jay Weisbard on

        I am 69, and I have instructed my son, who holds my power of attorney for health care, that I do not want to be placed on a ventilator if I should become seriously ill with Covid-19. I largely agree that chronological age should play a role in allocation decisions under scarcity, but it should not be the only criterion. As data continues to come in, we know more about the impact of comorbidities on prospects for survival. I think vents should be made available first to those with the best chance of survival and leaving the hospital to recover.

    • Kaye Jones-Mahoney on

      This is a powerful argument against rationing any healthcare based on age alone. The argument is measured and stands as much now in the days of COVID as when it was written in 2015. As an ex ICU nurse age was a factor in decision making about ventilation and treatment options but never the only factor and this is something we need to focus on now. We have an every increasing elderly population due to the improvements of medicine and we cannot now make an arbitrary decision that 1) 70 is classed as elderly (I know some sexagenarians who are a lot healthier than those in younger generations) or that 2) being in that group negates the need for ventilation.
      Thank you so much for sharing.

  2. William M Novick M.S., M.D. on

    Dr. Miller,

    I am a pediatric cardiac surgeon and arm-chair Bioethicist (1-5) whose practice is entirely in low- and middle-income countries as the Professor of Surgery and International Child Health at the University of Tennessee Health Science Center since 2001. I am also the founder of 2 501c3 NGO’s that provide clinical and educational services for pediatric cardiac care in many resource-limited countries. Our teams deal specifically with resource allocation on a daily basis in many of these countries and we have to make these difficult decisions on who gets the last ventilator, who gets the last bit of a particular medication or the blood transfusion in order to survive. Our philosophy mirrors yours with the exception that we look at it from the point of view of which child is likely to survive based on the severity of their cardiac defect and condition that they present in when they arrive in the hospital. We are looking to save the most children who will have the most productive lives after they recover, these are difficult heart-rending decisions that cannot be made easily. Although it is difficult to believe that the US, the medical mecca of the world, is now facing shortages in medical supplies and ventilators to the point where we may need to make these difficult decisions, the day has arrived and the good of the many outweigh the good of the few or the one (6).
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    5. Novick WM. The Recalcitrant Non-informed Patient. Ann Thorac Surg 2019 108:1608-09.
    6. Spock FO (Leonard Nimoy)
    Star Trek II: The Wrath of Khan. Paramount Pictures. 1982. Quoted in Enk B. The 15 Most Surprising Deaths in the Movies. Yahoo! Entertainment. May 7, 2014.
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    Date accessed: January 10, 2019

    • Linda Granowetter MD on

      I am a pediatric hematologist -oncologist: 68 years old and with well controlled asthma.
      I have told my health care proxies (my sisters and brothers-in-laws) that should I require a ventilator for Covid-19, a trial of intubation would be reasonable if there are sufficient ventilators available. But should I have a cardiac arrest I do not want to be resuscitated. If my getting ventilator care would prevent a younger, previously healthy person with a better chance of survival of a chance getting a ventilator, I want to forego or come off ventilation. I have lived a good life, I enjoy my life and I do not want to die, but I think that the lives of younger , healthier people should be given priority. I appreciate Nicolette Erasmus comments, but reverence for the elderly does not mean that an elder’s life should be preserved above the life of people who have full lives ahead of them. Allowing someone to die when the time comes is reverence. If “the time comes” in the guise of covid-19, so be it. Although age may be an imprecise parker for health, overall those that are older do not usually fare well on ventilators in this epidemic.

  3. David Cameron on

    As a fellow 71 year old , I fully support Professor Miller’s recommendation for age related rationing of ventilators if demand outstrips supply. In addition as a palliative care physician, I also endorse his call for providing adequate palliative care for all critically ill patients. While there has been much talk of the shortages of testing materials, ventilators and PPE, I have yet to hear any concerns about the shortage of skilled health professionals who can provide adequate palliative care. Perhaps one of the legacies of COVID19 will be the greater recognition of need for skilled palliative for all critically ill patients both in hospital and in the community.

  4. Mark Sheldon on

    As a 75 year old bioethicist I support Miller’s recommendation, but I would like to add an additional consideration. Every day doctors and nurses are dealing heroically and selflessly with the current crisis, and a certain percentage of these individuals are dying or are bringing home the infection to their families. Some of these individuals are living separately from their families, or they have sent their children to live with relatives out of concern for their children.

    Every time a person is put on a ventilator there is very significant risk to the doctors and nurses placing the tube or attending to the tube, and there is and even greater risk for healthcare workers. Given the not very promising statistics that Miller quotes regarding the success of such interventions for the elderly, I do not want to be the one that puts this extraordinary burden on these health care workers. And I think we need to see them as an extremely value resource that deserves very careful allocation. Ultimately this is less about rationing where a choice is being made that suggests that the elderly or of less value, but more about triage where, given the medical resources that are available, we need to move forward in saving as many lives as possible.

  5. Keith Adams on

    I am in my 86 th year and in really good shape and fully active. For some reason I have always been taken for being as much as 20 years younger than I am … Probably good genes. Except for the case where a patient is a major contributor in ongoing society or huge financial contributor to the hospital.
    The hospital staff should be allowed to make the decision as to which patient is to be let go and that decision not be second guessed after the fact … it is a tough decision to make and to live with. Let it be.
    All effort and facilities should be employed to the patient most likely to survive and able to enrich society, I hate to think what state our world would be today had Sir Winston Churchill and or Pesident Roosevelt been cast aside when they were old and severely ill based on age alone … Just saying …. Snowy

  6. Elizabeth Motta on

    It is admirable that Dr. Miller has offered to forgo treatment as his personal goal during this pandemic. However I suggest that before we collectively choose age as an absolute discriminating factor we should first clarify our societal goals, have a deep understanding of the need for such a commitment, and understand personal prognosis based on individual uniqueness. And we must be transparent about the options and choices.
    Is our goal the fair/equitable distribution of scarce resources, or the maximization of the best clinical outcomes, or the survival of health care workers, or the preservation of young lives, or the honoring of those who have served? It is probable that health care professionals blend these goals (and more) while evaluating whether to offer or withhold treatment.
    We should also have a very clear view of what scarcity entails. Is the scarce resource ventilators, ICU beds, respiratory therapists, money…? Levels of scarcity will vary within and between communities, and will change over the duration of the crisis. One concept of scarcity will not fit all.
    And finally, there are many valid health, disease, and frailty considerations. Although advancing age may be statistically reliable in stratifying risk of death, it does not describe the uniqueness of an individual and define the ability to survive.

  7. S. Baker on

    Dr. Miller,

    I think your analysis of the ethical issues involved in ventilation for the elderly was very thorough, even though an application of the principles you discuss might affect me personally at age 74 with well-controlled but chronic pulmonary disease. You did not discuss the long-term prognosis for those who have been on a ventilator and sedated for the one or more weeks required to save the life of a seriously ill COVID 19 patient and the future health effects of long-term ICU treatment for the elderly in particular. If my understanding from recent media reports is correct, patients whose lives are saved by ventilator treatment may have long-term health and quality of life changes, and I would assume these might be most pronounced in the elderly. If my understanding and assumptions are correct, more information on these “ventilator toleration” issues might influence advance directives and informed consent in a way that would spare medical professionals the agony of making triage decisions. I think a further exploration of these issues in a Hastings Center essay would be very helpful to current debate.

  8. Fernando-Miguel Gamboa-Antiñolo on

    Entering to debate the topic in a top level forum is an honor for me. For a few months now I have been following the discussions in this publication about decision making in the Covid epidemic.
    I am an internist in a small hospital in Seville, Spain. I work attending multipathological patients, with great physical or cognitive limitations, and oncological and non-oncological palliative patients.
    The drama of the pandemic puts the problem of decision-making in clinical practice ahead. An always complex problem.
    I understand that age alone cannot be an element for making decisions. It is true that with older age there is less physiological reserve and less expectations of complete recovery. But I think comorbidity, frailty and clinical complexity better define the limits of proper treatment than age alone. I understand that decision-making must take into account the opinions of patients on their expectations and choices, but excluding the elderly based on their age as the sole criteria I think is a mistake.

  9. Temeika Beasley Spruiells on

    I’m concerned about this rationale because this frame of thought could be applied using statistics for other factors. As an African American, I understand the numbers are grim for those who contract Covid. However, the reasons for much of their experience is their lifestyle: long hours which lead to poor food choices because they live in food deserts, and unhealthy forms of entertainment. Of course this is a generalization, but this occurs more than naught in the poorer African American communities. What if the doctors begin to ration based on the outcomes of African Americans? Here is the deal, I do not have any of those stereotypical behaviors. I may be better off, but because of generalizations I could miss an opportunity for care.

    Notably, here are some elders—the minorities in that group who can survive. To ration healthcare, takes away their opportunity to live. My partner is sixty-five (we have a twenty-year difference) and much more fit than any of my colleagues. They are on meds and she is not. She would miss out but has a better chance at survival. We really have to think about where this road could lead.

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