Age shall not limit them…
In life you sometimes have weeks at the end of which you look back and feel as if you are witnessing someone else’s story – this week has felt a bit like that for me.
It has been a very busy week responding to the Coronavirus outbreak from a social care perspective. Part of it has led me to being involved in national conversations with colleagues in the acute and palliative care communities across Scotland. I have to admit that I have found some of the conversations very hard – painting as they did a picture of the raw reality of impossibly hard clinical decisions which may have to be made in the coming weeks and months. Alongside this I have read papers which have described the criteria which may potentially have to be utilised in a context of limited resources.
As many of you know over the years I have written and spoken about human rights, about ageism and age discrimination, and have sought to challenge the casual assumptions which serve to dismiss and limit the contribution, value and role of older citizens in modern society. In ordinary times it is perhaps easy to gain an audience for such conversations as few would intellectually defend a position which values another solely by their chronological age. But we are not living in ordinary times, so I want to in this piece reflect on what are the risks of discrimination and impact upon the human rights of older people in the face of this pandemic.
Hard decisions
One thing is a self-evident risk and some have suggested almost inevitable and that is that no matter how many respirators we manage to get access to, no matter how many ITU beds and critical care beds we manage to put into commission, there will not be sufficient resources including pharmacological ones to enable every single person who reacts severely to Covid-19 to get the optimal clinical response which they might expect in ordinary times.
Phrases to describe this resource restriction such as ‘capacity challenge,’ ‘the management of patients’ and ‘clinical prioritisation’ have now come out from clinical contexts into ordinary parlance. What is meant in effect is ‘rationing’ and the establishment of criteria to determine who gets what treatment and support. Before I go on much further I want to assert that I know of no clinician, carer or nurse who will not seek to do their absolute best for those they are caring for. I know of no politician or strategist who is not today doing their best to ensure we maximise the resources we can get hold of. Our staff in social care and the NHS are dedicated to the alleviation of pain and distress and will always seek to put the person at the heart of their practice and care. I know that the decisions they may have to make and take will be emotionally and psychologically traumatic for these professionals.
Having said that we need now, I believe, as a wider society, to be both more aware of and to give assent to the criteria for such decision making, both to support the staff making those decisions and to protect the lives of some of our most vulnerable citizens and their families.
Covid-19 and older people
Anyone can catch Covid-19 as we have witnessed in the last few days in the United Kingdom with sad news of fatalities across the age spectrum.
But what is also clear is that the virus does not treat everyone equally. We know from the mortality figures from across the world that older individuals, people with a supressed immune system and multiple co-morbidities are particularly likely to be chronically affected and to perhaps die.
The impact on older people is hardly surprising. As you get older your immune system is weaker, lungs are less responsive and there is a greater likelihood of you having multiple conditions such as dementia, heart disease, cancers and other conditions which make recovery from any illness slower and harder.
It is because of this that on Wednesday the World Health Organisation Director General Tedros Adhanom Ghebreyesus said:
“We need to work together to protect older people from the virus …They are valued and valuable members of our families and communities… Older people carry the collective wisdom of our societies. Ensure their needs are being met for food, fuel, prescription medication, and human interaction.”
But age is not a predicator of weakness. There are plenty individuals in older life who are physically more responsive than those half their age. It is not age per se that means someone is likely to respond poorly to Covid-19 but underlying conditions, co-morbidities and frailty.
Yet in some parts of the world one of the concerning issues has been the extent to which age has been automatically assumed to be a dispositive or exclusive indicator of mortality risk from Covid-19. These models ignore the other realities which include that one’s gender and pre-existing conditions are key factors that correlate to the probability of dying from Covid-19. Yet we are not saying that treatment should only be given to women.
This mistaken assumption around age is both clinically wrong, ethically dangerous and potentially lethal.
How do you prioritise?
We are clearly not the first country to potentially be facing such decisions around resource prioritisation. Italy and Spain are ahead of us in the pandemic and there we have witnessed a whole range of responses to the necessity of prioritising resources.
Faced with the risk of constrained resources in a pandemic emergency we have to establish at the outset and before such realities arise very clear criteria on which clinicians are enabled to make judgements, often in pressurised circumstances and frequently with only partial clinical histories about patients and individuals. We have to prioritise. This process of ‘triage’ is well known. It enables those with the greatest clinical need to have those met as a priority. Anyone who has been to an Accident and Emergency Department will know this all too well.
What matters is the basis on which you establish the triage or resource allocation or rationing system. From an ethical and human rights perspective those criteria have to be as neutral and universally accepted as possible. They cannot be based on discriminatory characteristics or presumptions. In the current pandemic I would argue that it must surely be clinical factors alone which are used to determine who has the greatest need and who is likely to have the best clinical outcome. Age undeniably influences this process, but it can never be the sole criteria or even an overarching criteria. It may be the easiest one to utilise because we can determine age very quickly compared to the other influencers such as the clinical benefit of treatment, the frailty of the person and the extent to which they have co-morbidities.
To base any treatment principle on an ethical model which considers chronological age as the ‘key’ significant indicator is quite simply to engage in the most obscene discrimination and to effectively devalue any human life beyond a certain age.
Human rights
The horrors and the barbarity of the Nazi regime resulted in the desolation of Europe in the 1940s and in the deaths of millions. Out of that agonised ground grew the international set of rights which are the barometer by which we have come to determine what it truly means to be human. These human rights are a bulwark not just against extremism, but they are the standard bearer for action and a guide for response especially in times of challenge and emergency. Any ethical or clinical framework has to be able to stand up to the rigour of a human rights analysis. I am not at all convinced that any framework which advances age as its significant criterion can be defended in human rights terms either legally or morally. How can such be defensible against the articulation of the right to life or of the prohibition not to engage in inhumane or degrading treatment? How can such be evidence of a State and Government fulfilling its duty to do all things in a manner which is compatible with the UN Declaration of Human Rights?
We can do better…
Flexibility and compromise, responsiveness and speed will unsurprisingly be the watchwords of the next days and weeks, but dignity, humanity, equality and human rights must also be the language behind our ethical choices. A sharply utilitarian view of the world ignores the advances in our understanding of geriatric medicine and downplays the capacity and contribution of millions of our fellow citizens.
As I have commented before the way in which we respond to coronavirus will determine the society we will be for years to come. Will we be one which values all regardless of age? Will we make really hard decisions based on individual clinical prognosis or will we take the delusory easier but exceptionally dangerous road of determining that age is the main or significant determinant when we have to choose not to treat?
Older people vulnerable to Covid-19 in Scotland and across the United Kingdom today are grandparents and parents. They are workers, caregivers and volunteers. They are not disposable. They are the best of us, and we have a duty to be the best for them.
Dr Donald Macaskill
CEO, Scottish Care
