Age in the Coronavirus Age
As soon as the COVID-19 pandemic took off, the intergenerational framing of the issues started spreading. What triggered such a framing is probably the higher hospitalization and mortality rate among 50+. This has led in turn to a series of important questions.
Age in triage
The first one has to do with the use of age as a triage criterion, for allocating access to intensive care unit (ICU) beds in short supply. The issue gained visibility, even though in several European countries, ICU beds never actually reached their full capacity. The COVID-19 crisis led to revising recommendations for access to hospital beds and other scarce health care resources such as respirators. In such recommendations, the use of the age criterion was questioned in some cases (e.g. Belgium), accepted in others (e.g. Italy). Yet, was it challenged or endorsed for the right reasons?
Recommendations were often drafted by actors from the medical sector focusing on the medical efficiency of medical interventions. What was then questioned or recognized was age’s ability to serve as a good predictor of the chances of success of a medical intervention. Some recommendations considered it sufficiently reliable, and others not. However, focusing on age as a predictor of medical efficiency misses other important functions of the age criterion. Crucial in this respect is the fact that the age that a person has reached is a key criterion for anyone concerned about inequalities between short-lived and long-lived persons, or about improving the situation of short-lived people in priority. The length of one’s existence is one of the essential resources that one can dispose of to pursue the projects that give meaning to our lives. Hence, the use of an age criterion in access to life-saving care can be seen as a way of reducing inequalities in longevities, or avoiding to worsen them through health care.
From that perspective, if we have to choose between saving a young and an old patient, it does not matter so much whether the young patient is in a better shape than the old one – and whether age is a good predictor for that. What matters is instead that if we don’t allocate access to an ICU bed to the young patient, she will end up having lived a much shorter life than the other, already old, patient. This is a very different way of understanding the age criterion than the one focusing on age as a reliable proxy for medical efficiency purposes. From that perspective, challenging the reliability of age as a proxy is off target.
In addition, to those rather attracted to a lottery option, being somehow averse to “playing god” and to deciding on any substantive criterion, one can respond that age can itself be read through the lottery prism under certain conditions. By using the age criterion, it is the lottery of our date of birth that is used to determine access to medical resources.
Of course, I am not saying that reducing inequalities in longevities or maximizing the longevity of the least well off should trump all other possible goals of a triage system. Yet, I think that anyone aiming at equal concern towards competing patients in COVID-19-like circumstances should take age seriously in the broadly egalitarian spirit just characterized. And it remains an open question to social scientists why the medical profession has actually not taken this perspective on age more seriously. Perhaps it results from their focus on efficiency more than on equality. And perhaps this focus is itself driven by the mistaken view that efficiency concerns are more internal to - or in line with - medical (as opposed to social) criteria than are equality concerns. This bias is probably also unnoticed by the general public either because of the fact that efficiency and equality concerns often converge on the same age criteria (in cases where the age criterion is endorsed) or because of the increasingly widespread view that age should simply be seen as equally problematic as gender and race (in cases where the age criterion is rejected). Yet, age is special, in a manner that, I submit, renders it normatively different from sex and race, for reasons I explain shortly. We should closely scrutinize the many age-based practices that our societies are involved in. But we should also be cautious about too quickly rejecting each and every age-based policy as “ageist” in some morally problematic sense.
A key building block in any reasoning on the age issue is the lifetime view, a view according to which any age-based differential treatment should always be assessed from the point of view of its impact over people’s entire lives, as opposed to its isolated impact only at a particular time or during a given phase of their existence. The lifetime view is a family of views. And anyone endorsing distributive concerns should take a stance on it, be it to endorse it, reject it, or adjust it. What the view says is that it is generally unjustified to merely look at the impact of an age-based rule at a given moment in time or for a given part of someone’s life, without asking whether this rule also increases inequalities over people’s entire lifetimes, rather than being neutral or even “isogenic” – meaning in the latter case that some age-based rules may actually reduce lifetime inequalities, hence generate more equality. The use of age in deciding on access to ICU beds is arguably a case in point of such an isogenic use.
Note that endorsing the lifetime view does not necessarily commit us to endorsing the view that beyond a certain age, people’s life is supposed to be “complete”, in the sense of fully accomplished in its core respects. The latter view would justify an age threshold beyond which entitlements would significantly drop in strength and/or change in nature. What the lifetime view merely stresses is the need to assess how people are likely to fare over their entire life under various policy scenarios. And plausible versions of the lifetime view claim that for the purposes of such a lifetime assessment, different persons´ longevity may matter a great deal. As a result, a concern for the short-lived as being disadvantaged may command some degree of preference for the young.
Besides the use of age in triage, a second issue concerning justice and age has quickly become salient in the COVID crisis: the disaster experienced in care homes. There is no doubt that the COVID-19 crisis will trigger reflection about care homes: whether they should exist at all, which minimum safety requirements they should meet, how they should be funded, what their purpose should be, etc. Without denying the uncertainties we were facing, let us assume, realistically I think, that we could have done much better in care home in countries like Belgium, France or Spain. Interestingly enough, it is a challenge to anyone taking the age criterion seriously and endorsing the lifetime view to explain what is wrong with the very high mortality rates experienced in care homes. Since they reduce inequalities between short-lived and long-lived persons, some people may hastily conclude that defenders of the lifetime view should rather see such high mortality rates as… welcome.
There are at least two ways of avoiding such a conclusion. The first one stresses that the lifetime view does not need to disregard efficiency concerns. If our principle of justice is sensitive to whether lives could have been easily saved, a defender of the lifetime view does not need to accept what happened in care homes. Of course, if letting older people die in care homes were absolutely necessary to save younger lives, the story would be different. But I submit that this is not a realistic description of what happened.
Alternatively, rather than stressing that our principle of justice needs not be exclusively concerned about reducing inequalities, we may also consider that it is the scope of the lifetime concern that should be properly understood. Aiming at maximally improving the situation of the short-lived or more generally of the least advantaged over her lifetime may be constrained by other values. These can include a rejection of social segregation or a sense of minimum decency that should apply at any moment in time, regardless of people’s respective ages. And it is plausible that the way in which we have let old people die in care homes failed to comply with such requirement. In short, those concerned about age-based policy should look both at the lifetime perspective and at what may point at failures of such a lifetime perspective, taken in its pure form, to capture our moral intuitions on the matter.
Sacrificing the young
As we entered lockdown a third age-related issue emerged. Somehow, as our elderly members were dying at shocking rates, often being treated with so little recognition that they sometimes didn’t even deserve being included in the mortality statistics, the idea of “sacrificing the young” started being invoked by authors especially concerned with (the stringency of) lockdown. There is no question that, had we properly anticipated what has happened, a lockdown so restrictive as the one that has been imposed in e.g. Spain or Italy could have been avoided. It is also clear that the lockdown itself has led and will continue to lead to major impacts on people’s lives, regardless of whether the absence of lockdown would have done better. The question is whether we should adopt here an intergenerational framing again, such that lockdown advocates should be blamed for having disregarded the interests of the young.
Here, I would stress three considerations. First, in line with the lifetime intuition above, it is important to assess the impact of lockdown on the young not only as an age group, but more importantly as a birth cohort, all along their current and future lives. It is likely that the COVID-19 crisis will have durable scarring effects on all of us, throughout our lives. It might have stronger ones on those who belong to more recent birth cohorts as a result of e.g. the fact that economic sectors that have been especially affected are also those in which youth employment is more important.
Second, I doubt that this special impact in itself generates separate obligations towards the young, e.g. of a reciprocity type. What it does is add to all the other dimensions of what we are already expected to be transferring to the next generation. It could very well be that the world we are passing on is less favorable than the one we inherited, as a result of climate inaction, the way in which we unleash financial markets, etc. The effect of the COVID-19 crisis and of our (non-)reaction to it on the various generations at stake should simply be treated as part of this whole inheritance package.
The third and last point is about the “sacrifice” rhetoric. I don’t think it was fair to apply it specifically to the young, at a time in which we were letting our elderly parents die in care homes or in ICUs at rates that a proper preparation could have avoided. There is no contradiction in simultaneously claiming that we sacrificed the elderly through our messy reaction and that the lockdown will have a possibly lasting and more marked effect on some generations, an effect that any theory of justice between generations that incorporates at least some distributive concern should take seriously. Doing that does not require that we shift the focus of the word “sacrifice” from those who irreversibly lost their life – often without even being able to exchange a few last words with their close relatives -, to those who may still recover from it, especially if surviving overlapping generations really care about acting fairly towards one another. And of course, as we start knowing more about both the virus and the effects of lockdown, the differential impact on different cohorts should be an important element to consider in deciding how our control strategy should evolve.
Axel Gosseries is a FNRS Research Professor and a Professeur extraordinaire at the Chaire Hoover, Louvain-La-Neuve. He has published extensively on intergenerational justice and his books and articles have appeared in various languages. After agreeing to write for Demography, Ethics and Public Policy, Axel proposed to write a post on the intergenerational dimensions of the ongoing Covid pandemic rather than a profile on his most recent academic project. We thank Axel for this timely contribution to DEPP.
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