Do the elderly have special obligations during a pandemic, that is, something more than the duty we all have for hand washing, social distancing, timely self-quarantining, and most recently, wearing a face mask? Some workers, such as those in health care, grocery stores and pharmacies, and supply chain workers for essential goods, now have obligations beyond ordinary citizens during the Covid-19 crisis. Does being elderly incur duties others do not have?
I believe the answer is, yes, and foremost among these is an obligation for parsimonious use of newly scarce and expensive health care resources. Frank Miller’s recent essay sketches the argument for an age-related rationing policy for the use of ventilators with Covid-19 patients. I support Miller’s position, but my essay is not about policy. Rather my focus is how the elderly should understand their obligations, regardless of policy, concerning not only ventilators but the use of all scarce health care resources in a pandemic.
My position is grounded in a lifespan approach to ethics. The basic idea is that ethics must be rethought at various stages in life and that what might have counted as virtuous or responsible during one phase might be irrelevant or even counterproductive at a later stage. For example, autonomy and productivity, which were cardinal virtues in my youth and middle age, are increasingly unimportant. Things I now value highly are convivial friendships, kindness, and humor, and the essential moral tasks are now integrity and bearing a series of inevitable losses with some degree of dignity. Allowing the moral values I earlier prized to remain prominent into my mid-70s would be a sign of arrested moral development.
Importantly, I can’t take credit for making this moral transition. It simply seems to be what life is offering me at this stage, something that arrived without my bidding. If I can claim any credit it is only for acknowledging where I am in the life cycle, trying to accept it gracefully, and discern its implications.
As I near 75 my overall sense is one of deep gratitude. I have been offered many opportunities and enjoyed much happiness. This is true for health services, as well as career possibilities. I have been favored, first by excellent health benefits from employers, then at taxpayers’ expense a decade ago I entered the privileged class of Medicare recipients. I see this as a happenstance of American health policy, not anything I have merited. At some point I should be prepared to right the balance by exercising restraint, especially when the consequences of not doing so are evident all around me. Part of the moral meaning of aging lies in a sense of reciprocity across generations. As the pandemic rages on, it may well be that my claim on scarce and expensive services will cost others their lives. This is a bargain I am unwilling to make.
My death from Covid-19, were it to occur, would be sad, but not tragic. Yet the death of children and young adults is a tragedy. I have had many turns at bat; they have had very few. Every year I live I have less of a claim on scarce and expensive services relative to others younger than me. It is not that my life is worth less. Judgments about moral worth, regarding both individuals and groups, are notoriously flawed, very likely to be myopic and prejudicial, and it is hubris to attempt such judgments. It simply seems unfair for others to be denied what I have had for so long, and my bond with new and emerging human life can only be affirmed, in a crisis, by a willingness to give back and pay forward. “Sacrifice” would be the wrong term in this context, since it implies that I am entitled. “Generosity” might be a fitting term, but if so, it is a generosity in the service of a larger intergenerational justice.
What might this sense of fairness and stewardship of health care resources mean? Here are some possibilities, though others may present themselves as the pandemic continues. My obligations are:
- To the extent possible, to keep myself well, reducing the burden on the system as a whole;
- To think of myself as already infected, and be especially vigilant about hand-washing, social distancing, and eliminating nonessential occasions for exposure;
- To refrain from using health care services whenever possible, making sure I am not simply responding anxiously to something I can manage alone or something that can be postponed;
- To refrain from being tested, or to allow others to be tested first, even if I have symptoms; others have much more at stake in knowing their status than I do;
- If hospitals become overwhelmed, to refrain from being hospitalized, even when that is recommended, except when I become a major hazard to others in my household; here I would hope for a more robust availability of palliative measures in home care;
- If I am hospitalized and ventilators remain scarce, to forego ventilation in favor of younger patients;
- When a vaccine becomes available, to move near the end of the queue.
A caveat for all these ideas: if they cause more problems than they solve, create more vexing issues, use more resources or create a greater burden than I currently think they would, then the least burdensome alternative should be the one chosen.
Others in my age group may feel differently, and I respect their views. Some elders may have children or others who depend upon them in fundamental ways, so that their very survival implicates others directly and profoundly. Still, I believe my convictions fit within an overall frame for responsible elderhood for many of us. Some may think my position signals resignation, or giving up, or being ready to die. It is none of these. I hope for many healthy and productive years ahead. But having studied the U. S. health care system for decades, I am well acquainted with the inevitable, and usually invisible, need to ration, now made far more severe and visible by this pandemic. Even in the best of times hard decisions are unavoidable, and not everyone who needs care can possibly get it.
A variety of rationing, triage, and allocation schemes are currently being considered by state governments, hospital systems, and federal agencies, as well as the National Academies. One role I and other elders can play in this pandemic is to lessen the stress on the system and the angst of decision-makers in rationing services by bearing witness to the integrity of elderhood.
Larry R. Churchill is Ann Geddes Stahlman Professor of Medical Ethics Emeritus at Vanderbilt University, and a Hastings Center fellow.