{"id":6035,"date":"2020-05-13T07:57:13","date_gmt":"2020-05-13T11:57:13","guid":{"rendered":"http:\/\/www.silvercentury.org\/?p=6035"},"modified":"2020-05-15T07:25:41","modified_gmt":"2020-05-15T11:25:41","slug":"ageism-and-tragedy-in-a-time-of-triage","status":"publish","type":"post","link":"http:\/\/78.142.243.82\/~silvercentury\/2020\/05\/ageism-and-tragedy-in-a-time-of-triage\/","title":{"rendered":"Ageism and Tragedy in a Time of Triage"},"content":{"rendered":"

This essay, which pulls no punches, appeared first in the quarterly magazine <\/span><\/i>Tikkun <\/span>and on its website<\/a> on April 14, 2020. It\u2019s re-posted here with the permission of the author. It has been lightly edited to protect the Silver Century Foundation\u2019s nonprofit status. <\/span><\/i><\/p>\n

Triage means exclusion from treatment. In parts of the United States, triage may become grievously necessary, as pandemic peaks overwhelm resources. Setting proper criteria for such decision-making is crucial for avoiding injustice, guilt and tragedy. Sorrowfully, a medical consensus on whom to exclude has been forming, in \u201cguidelines\u201d from universities and state commissions, that often works explicitly against the old and implicitly against people with disabilities, people of color, poor people and those who live in crowded nursing homes, who are over 75, or 60 or even over 40. Bias in triage decisions is a danger to those whom society has made vulnerable.<\/span><\/p>\n

\u201cThe transition from conventional to \u2026 crisis care comes with a concomitant increase in morbidity and mortality,\u201d warns a document on \u201ccrisis standards of care\u201d transmitted to the Trump Task Force on March 28. This essay responds to recent arguments justifying crisis exclusions that are erroneous and, to my mind, unethical, but, because they are authoritatively presented or widely held, dangerous.<\/span><\/p>\n

\u201cOne thing everyone agrees on is that the most morally defensible way to decide would be to ask the patients,\u201d Dr. [Matthew] Wynia, a bioethicist, is quoted as saying in a survey of opinions reported by Sheri Fink for the <\/span>New York Times<\/span><\/i>. This sounds plausible: in health, some people make living wills requesting that, if unable to speak for themselves (because of, for example, severe cognitive impairment or coma), they be kept alive with \u201cheroic\u201d measures, or not. <\/span><\/p>\n

Consent is indeed necessary from COVID-19 patients who can speak for themselves, who are gasping and scared and might benefit from ICU or intubation if offered. Would such patients sign the same advance directive now? This is supposed to be a moment of choice, involving reassuring explanations from medical personnel about options (even induced coma).  A danger emerges: some candidates for scarce resources might eliminate (\u201csacrifice\u201d) themselves.<\/span><\/p>\n

Consider that internalization of inferiority is real and affects wide swaths of the population. As the feminist and disability rights movements have taught<\/span>, <\/b>many people feel they must be self-abnegating: others\u2019 lives are worth more than theirs. Depressed people may agree to relinquish their chance\u2014but many older people are depressed by the pandemic. We are told often that our lives are more at risk than the lives of others. Family members will be unavailable if we are hospitalized. And, because we are suddenly framed as less valuable by popular opinion and some medical guidelines, older and disabled people may feel expendable.<\/span><\/p>\n

The elderly and disabled categories [have] had pointed, aggressive, societal pressure aimed at them for a long time. Vehemently denied but still widely held is the feeling that the older the patient, the more undeserving of treatment. \u201cSo close to death already.\u201d The attitude spreads, first unconsciously and now explicitly, that younger adults are more valuable than older adults; the healthy, more desirable than the less abled.<\/span><\/p>\n

Ageism permeating the medical profession, a widespread problem, adds to triage confusion. Older people\u2013not deaf and not cognitively impaired\u2014complain in conventional situations that their doctors often ignore them, preferring to talk to their adult children. We are not seen. We may insultingly be considered \u201cburdens\u201d\u2014too costly, too unproductive, too time-consuming.<\/span><\/p>\n

Equal treatment, a constitutional right and an existential necessity, is likely to be ignored in the crisis situation. The University of Pittsburgh guidelines, a model, don\u2019t mince words. The tie breaker should be age. (A tie means all patients with that score have an equal likelihood of survival.) These guidelines give priority to younger patients within these age groups: 12 to 40, 41 to 60, 61 to 75, over 75. (Massachusetts\u2019 new guidelines are similar, as reported on April 13, 2020.) <\/span><\/p>\n

The Pittsburgh document calls this \u201cthe life-cycle principle.\u201d A principle! That sounds not just plausible but lofty. Less so if we call it \u201cculling the old.\u201d The United States has seen a growth of longevity that any nation could be proud of. Now their longevity may be used against people as young as forty.<\/span><\/p>\n

Do the math. If age is the tie breaker, let\u2019s say there are 10 ventilators, and 100 people who are tied in terms of equal benefit. One is 83 years old, 4 are 70, 22 are 60, 35 are 50; the rest are under 40. All 10 of those under 40 would get the ventilators; none of the others. That is culling the old. Some triage guidelines suggest patients be warned their ventilator could be taken away from them. Isn\u2019t a lottery more fair? A lottery system (for a brief time of crisis) may horrify some people, but in the long run \u201cthe ice floe\u201d principle is far more perilous for a society.<\/span><\/p>\n

With hostile ageism rampant, as we see, mere chronology counts more than an individual\u2019s medical condition. An article in the <\/span>New England Journal of Medicine<\/span><\/i> gives \u201cpriority to those who are worst off in the sense of being at risk of dying young and not having a full life.\u201d The retired, veteran<\/span>,<\/span> New York philosopher Andrew Wengraf, argues against the \u201cfull-life\u201d argument:<\/span><\/p>\n

Age may be a vivid, sociological category, but to age is just to go on living. It is true that when Bertrand Russell died age 97, he was said to have had a fulfilled life, a life not free of disappointments but certainly fulfilled\u2026. And inasmuch as life is finite, we are nearer death when we are old. But Russell was not obliged to die because of having enjoyed a long, rich life. The burden of proof is on anyone who thinks Russell has a duty to die prematurely. That person needs to explain how Russell could acquire that discriminatory outcome as an obligation. Without that, it cannot simply be imposed upon him in a triage queue.<\/span><\/p><\/blockquote>\n

New York state\u2019s guidelines are not ageist. Governor Andrew Cuomo said categorically, \u201cMy mother is not expendable.\u201d Justice in Aging, a San Francisco, legal NGO [nongovernmental organization] that protects low-income, older people, has co-written a letter to California health officials asking that treatment discussions \u201cinclude an explicit prohibition on triage and triage guidance that consider an individual\u2019s estimated remaining number of years of life and other factors that cannot realistically be operationalized without taking age into account.\u201d The Johns Hopkins criteria for treatment, which rightly depended on public input, ask no more than one year of potential life, thus respecting people in their nineties. I have a dear aunt who is 99, healthy, practicing social isolation, not ready to die. At 79, I assert that my life is worth no more than that of my aunt, nor less than that of a 30-year-old.<\/span><\/p>\n

Ethicists rightly omit most exclusion criteria (color, gender, low income). Future <\/span>perceived value <\/span><\/i>ought to be another no-no. Behind the mask, fortunately, a doctor cannot tell if that person with double pneumonia is Einstein or a homeless person of the same age. But age is as visible as gender and race. If we were to exclude people because of age, we would lose many of our current leaders. The UK would lose Queen Elizabeth. And some disabilities are clearly visible.<\/span><\/p>\n

In a hospital crisis, ethical decision-making, going case by case, must fight <\/span>every<\/span><\/i> societal bias of long standing: <\/span>refusing<\/span><\/i> to weigh the life of a white person as worth more than that of a person of color, the life of a man more than a woman, a cis person over a trans person, an apparently able person over a person with an obvious disability, or a younger person over an older person. And what of an old, black woman, or someone else whose visible intersectional category may activate prejudice? Ethical triage even in crisis care should focus on the individual\u2019s medical condition, not the sociological category. Training for doctors and nurses must include not only clinical guidance but situational awareness about potential bias.<\/span><\/p>\n

Having to decide on triage occurs at many stages, from EMTs to the bedside. Excluding people or withdrawing treatment from some may feel tragic to doctors, as well as for the patients who die and for their families. Where bias rules, however, triage becomes criminal. The government document to the Trump Task Force wants all health care workers to have \u201cadequate guidance and legal protections \u2026 from unwarranted liability\u201d (p.4).<\/span><\/p>\n

But even the best-designed bias training cannot prevent the appearance at these multiple decision points of many people suffering from long-term health inequalities based on gender, race, national origin or immigrant status, and low income. For them, discrimination starts in utero with inadequate prenatal care. Early deficiencies may grow worse (toxic environments, substandard housing) throughout life, as sociologist Dale Dannefer has shown through his concept of cumulative disadvantage. Middle ageism\u2014causing people to lose jobs early in life, preventing them from finding work again\u2014leads to family dysfunction, foreclosure, diseases of stress. Inequality goes on so relentlessly that such people are inevitably at more risk if COVID-19 hits them. Injustice is clearly built into any crisis standard of care that prioritizes the likelihood of highest long-term survival, in a society that has lacked Medicare for All for the past 60 years.<\/span><\/p>\n

The most just answer seems to be that all those with similar conditions, and equal chances of one-year survival, participate in a lottery. A petition to this effect, addressed to the US Surgeon General, called \u201cJust Rationing,\u201d can be signed at Change.org\/JustRationing.\u2026<\/span><\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

Triage means exclusion from treatment. In parts of the United States, triage may become grievously necessary, as pandemic peaks overwhelm resources. <\/span><\/p>\n

Read more Ageism and Tragedy in a Time of Triage<\/span> ›<\/span><\/a><\/div>\n

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