Certainly, there’s nothing new about ageism in our society. Bias against older individuals, and treating seniors as second class citizens, is something many of us have experienced as we’ve entered our later years. Perhaps what’s new, however, is the public airing of attitudes that were previously kept private, due to the coronavirus. For example, with the negative nickname of “the Boomer Remover,” cavalier pundits are questioning whether the prevalence of senior deaths from COVID-19 is really something that society should worry about. If “it’s only the elderly” who are succumbing to the disease (which in fact conveys a false sense of security for younger folks), should we really wreck our economy or close our businesses? (Take a look at the ageist comments of the Texas Lt. Governor who suggests older people should sacrifice themselves for the benefit of a better economy for younger people). 

Geriatrician Louise Aronson, author of the widely-praised recent book Elderhood, has tried to capture the ethical dilemmas of this “senior moment” in our society. Writing in The New York Times, Dr. Aronson wonders, “No one wants young people to die. So why are we okay with old people dying?” In fact, Dr. Aronson makes clear that with healthier aging and longer lives, today’s older adults are not all “on their way out.” In another interview, Dr. Aronson makes the point that half of Americans live past age 80 and that a healthy 85-year-old woman has a good chance of living another decade of life. So, if most of us are not “on our way out,” does that mean we will get access to appropriate coronavirus treatment should we fall ill? Dr. Aronson worries that, given equipment and ICU shortages, “we may eventually have to offer (just) palliative care to people who might have survived with intensive care.”

And that’s the $64,000 question: Will older victims of COVID-19 be denied access to intensive care and ventilators if shortages dictate that choices need to be made about rationing care? These existential questions about who will live and who will die are playing out in real-time in hospitals around the country- and the concern is that older adults may get the short end of the stick. All sorts of guidelines and protocols are now being dusted off and discussed, with most decision-makers agreeing that the guiding principle should be to do the most good for the most people and to make sure criteria are fair, equitable and transparent. While all hospitals are required to have some sort of ethics or triage committee in place to make these decisions in as dispassionate and unbiased a manner as possible, there is always the concern that some people may, in essence, be told “they don’t matter enough,” and that age and social utility bias will creep into the decision-making process. Therefore, if you or a loved one find yourself in such a situation, make sure to ask about the decision-making criteria used in that hospital. And, make sure that you and your loved ones are clear with providers about any health care directives or advance care planning wishes that the seriously ill patient may have made before being afflicted with COVID-19. (And now is a good time to review your own advance care planning with your loved ones).

And speaking of decision-making criteria, you may want to take a look at 2 just-published pieces from the New England Journal of Medicine that directly address these issues. In the first, The Toughest Triage — Allocating Ventilators in a Pandemic, expert authors underscore the life and death nature of decisions to ration ventilator access and suggest that hospital triage committees, uninvolved in patient care, be brought in to rationing discussions and that involved caregivers have no role in decisions or actions to remove a ventilator. In an accompanying article, Fair Allocation of Scarce Medical Resources in the Time of Covid-19, the authors lay out 4 values they say must underscore this sort of decision process: Maximizing the benefits from the scarce resources, treating people equally, giving priority to the worst off and rewarding instrumental value (giving priority to those who can save others, such as physicians and nurses). While these values sound fair and equitable, the challenge remains for us all to ensure that older patients- no matter their age- are given a fair shake when resources become scarce.