Corona, Crisis, and Health Care

It is too easy to let mere utilitarian concerns determine how people get medical treatment in a time of crisis:

We live in a finite world with finite resources, so often there may need to be some rationing or prioritising of where these scarce resources go. This is certainly the case with health care. There are only so many public dollars available. There are only so many hospital beds. There are only so many doctors and nurses. There are only so many ventilators. There are only so many doses of various medicines.

In a recent article on how a government can use a crisis to take away individual freedoms and take ever more power onto itself, I looked at COVID-19 and some of the radical and draconian measures being taken by some federal and state governments. I mentioned how Italy for example is cutting health care for the elderly. Those who are over the age of 60 are being denied various types of medical help.

So what are we to make of this. Is it right? Is it ethical? Is it fair? Medical ethicists have long wrestled with such matters. And in times of war and in extreme crisis we especially need to allocate scarce medical resources and make difficult decisions as to who gets what.

For example, triage may sometimes be called for. This is, as one online site says, “(in medical use) the assignment of degrees of urgency to wounds or illnesses to decide the order of treatment of a large number of patients or casualties.” People are divided into various groups and will receive treatment accordingly.

But this is always something we must undertake very carefully. It is far too easy to end up with mere utilitarian considerations. We can too easily treat entire classes of people (the elderly, the disabled, and others) as second-class citizens. This is always an area that we must take great care in.

Of course entire libraries exist devoted to books and articles on this. It can be a very complex issue indeed, and where one stands on these matters largely depends on what one’s starting point is. A hardcore utilitarian like Peter Singer will have a lot less concern about allowing certain groups of people to be bumped off than, say, one who adheres to the Judeo-Christian worldview.

Let me here appeal to several philosophers, ethicists, and public policy experts from that camp. I could pull any number of books from my shelves to assist me here, but let me instead refer to several recent articles. One piece from America begins this way:

As state health officials plan for health care rationing during the coronavirus pandemic, lawyers, ethicists and theologians are warning that denying care on the basis of age or disability violates federal law. “There’s always the temptation when things get rough, and when you’re looking at rationing situations and looking at triage, to fall into the error of devaluing human lives,” Dr. Robert George, a professor of jurisprudence and director of the James Madison Program at Princeton University, told CNA on Monday.

While health care rationing may be a “reality” during a crisis, George said, it can never be done on the basis of categories such as age or disability. “What we think it’s critical to avoid is falling into the trap of making judgments about whose life is and whose life isn’t a life worth living, or falling into the trap of thinking that some peoples’ lives are inherently superior to others,” George said.

George and two other scholars—Fordham theology professor Charles Camosy and Harvard sociology professor Jacqueline Rivers—requested a legal memorandum on federal civil rights protections against age and disability discrimination.

They did so citing reports that health care entities are already planning for “crisis” scenarios in the new coronavirus (COVID-19) pandemic, which has already resulted in more than 46,000 confirmed cases in the U.S., according to Johns Hopkins University.

Since Charles Camosy is mentioned in the article, let me run with him a bit further. He has authored a number of books on these issues, including his most recent one: Resisting Throwaway Culture: How a Consistent Life Ethic Can Unite a Fractured People (New City Press, 2019).

Image of Resisting Throwaway Culture: How a Consistent Life Ethic Can Unite a Fractured People
Resisting Throwaway Culture: How a Consistent Life Ethic Can Unite a Fractured People by Charles C. Camosy (Author) Amazon logo

He recently wrote a newspaper opinion piece titled “Coronavirus crisis: The wrong way to decide which patients get hospital care” that is worth alerting you to. He speaks about how “individual health providers will have to wrestle with that dreadful thing: rationing” and then says this:

For a professional ethicist like me, this is sobering but hardly surprising. We are finite creatures in a world of finite resources. The idea that we are always and everywhere masters of our own fate — and can collectively solve every problem without painful trade-offs — is an illusion. Our coronavirus moment is a dramatic reminder of this.

But that doesn’t mean we shouldn’t try to do our best — and thank God for truly heroic health-care workers on the front lines. Especially given that most know their situation is about to get much worse.

The Italians have already faced the bedeviling moral dilemmas of rationing, and in a guidance to providers, the Italian government has recommended that resources be rationed by age.

According to a translation of the government guidance, age-based rationing is “a way to provide extremely scarce resources to those who have the highest likelihood of survival and could enjoy the largest number of life-years saved.”

Bioethicists like me disagree over which values should guide rationing, but we generally agree about focusing on those who can benefit from the treatment. If the age of a patient makes it unlikely she would benefit, the hard truth is that limited resources will likely go to someone else.

But then there is the “number of life years” the patient could “enjoy,” as the Italians put it. This consideration comes from providers’ growing tendency to think either implicitly or explicitly about how many “quality-adjusted life years” their interventions might produce. It is a poisonously utilitarian and inherently discriminatory mentality. It is ageist — discriminatory against the elderly — and ableist — discriminatory against the disabled — to its core.

He continues:

It should not be up to physicians to decide whose subjective quality of life deserves to be prolonged. Physicians almost always rate the quality of life of their patients significantly lower than patients do themselves — and miss the fact that their patients often prefer length of life to quality of life (whatever that means). In short, they are terrible deciders about who should live and who should die.

Happily, New York state put together a protocol back in 2008 titled “Allocation of Ventilators in a Public Health Disaster” (largely reaffirmed in 2015) designed for a moment like ours. Wisely, our state insists that age and health problems or disabilities unrelated to what is causing the epidemic shouldn’t serve as the basis for rationing. Prognosis for recovery is what matters.

A New York hospital could choose to give its last ventilator to the 72-year-old marathon runner rather than to the 57-year-old pack-a-day smoker. Again, based only on prognosis for recovery. The objectivity of the standard removes much of the physician’s subjective ideology from the picture.

Finally, let me share a few thoughts from a Jewish theologian:

Notice how the all-too-familiar rhetoric of dehumanization works: “The elderly” are bunched together as a faceless mass, all of them considered culprits and thus effectively deserving of the suffering the pandemic will inflict upon them. Lost entirely is the fact that the elderly are individual human beings, each with a distinctive face and voice, each with hopes and dreams, memories and regrets, friendships and marriages, loves lost and loves sustained.

But they deserve to die—and as for us, we can just go about our business. It is bad enough if we remain indifferent to the plight of our elders; it is far worse to dress up our failings as moral indignation.

As a rabbi and theologian watching this ethical train wreck, I find myself thinking about the biblical mandate to “honor your father and mother.” The Hebrew word usually translated as “honor,” kabed, comes from a root meaning “weight.” At the deepest level, then, the biblical command is thus to treat the elderly as weighty. Conversely, the Bible prohibits “cursing” one’s parents. The Hebrew word usually translated as “curse,” tekalel, derives from a root meaning “light.” At bottom, then, the biblical proscription is on treating the elderly lightly, as if they are inconsequential.

Why do I say “the elderly”? In its biblical context, the obligation to honor parents is a command given to grown children (as are the Ten Commandments more broadly—you don’t tell children not to commit adultery nor to covet their neighbors’ fields). When you are an adult, the Bible instructs, you must not abandon the elderly. Giving voice to a pervasive human fear, the Psalmist prays, “Do not cast me off in old age; when my strength fails, do not forsake me!”

What does it say about our society that people think of the elderly so dismissively—and moreover, that they feel no shame about expressing such thoughts publicly? I find myself wondering whether this colossal moral failure is exacerbated by the most troubled parts of our cultural and economic life. When people are measured and valued by their economic productivity, it is easy to treat people whose most economically productive days have passed as, well, worthless.

From a religious perspective, if there is one thing we ought to teach our children, it is that our worth as human beings does not depend on or derive from what we do or accomplish or produce; we are, each of us, infinitely valuable just because we are created in the image of God. We mattered before we were old enough to be economically productive, and we will go on mattering even after we cease to be economically productive.

As stated, these are often difficult and complex matters. But we must especially resist the siren call of mere pragmatic and utilitarian concerns in a time of great crisis. If we treat entire groups of people in such a cavalier fashion, we will be causing as much harm as the virus itself.

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13 Replies to “Corona, Crisis, and Health Care”

  1. Thanks Bill for this great article, especially the quote from the Jewish theologian (Shai Held): “we are, each of us, infinitely valuable just because we are created in the image of God. We mattered before we were old enough to be economically productive, and we will go on mattering even after we cease to be economically productive.”
    And borne out by Jesus’ words in Matthew 25:36, “I was sick and you looked after me”.

  2. Looked at from an elderly and personal aspect there may be some sacrifices to be made. I would gladly sacrifice my life for someone younger, with longer to live and more to give, first of course, family.
    My first sacrifice is just to make sure I am as safe as possible, so as not to be a burden on others, staying home is a good start.
    Second, having a stock of basic essentials by sacrificing a little extra money each week at the supermarket so as to have a reserve in storage, things we normally use so that we can rotate. This we have always done.
    Next sacrifice is to offer family, friends, neighbors my help when we do the shopping, or from our own stocks.
    Ultimately, if I do contract the disease then I will do all I can, myself, to weather the storm, maybe I will come out of the tunnel at the other end, maybe not, I will accept what my family can offer in the way of love and caring, but not risking their health. Hospitals and doctors are not for me when there are others who need these resources.

  3. Good article Bill. Thank you. Being in the ‘vulnerable age group’ I have little confidence that if push came to shove, the elderly would be treated ‘honourably’ if this pandemic really takes hold. I say this because as a society, we have not only legalised but in many instances celebrated, laws allowing the killing of the most vulnerable in our society; ie., the elderly and infirm and the babies in mothers wombs. That said, it would be a terrible call for any health worker to have to decide who gets life-saving treatment and who doesn’t, if the demand becomes overwhelming. When JESUS walked the earth, GOD anointed HIM with the HOLY GHOST and with power and HE went about doing good and healing all who were oppressed by the devil. (Acts 10:38). When JESUS the SON of GOD comes back will HE find faith on the earth? I hope so but it seems a lot is being said in fear (sadly by believers as well), giving oxygen to the virus but it seems with few exceptions, Margaret Court being one, the Church is by and large, being silent in the public arena, with no words or acts of faith to bring JESUS and hope into the mix. Whatever happens; whatever the world in it’s earthly wisdom decides to do with the old or the young, believers must keep their eyes on JESUS and encourage one another daily as the Bible tells us. Thank you for the encouragement you bring to us and the reminders to hold fast and to put our faith and trust in GOD. Bless you Bill. Cheryl Ciccotosto

  4. Dear Bill,

    Thank you for another thought provoking article. I am elderly [83] but reasonably healthy for my age. I think like Harry but I pray that I would have the courage to persevere in such unselfishness. I also agree with Chery l doubt very much if Australia was faced with a situation as bad as Italy’s that we would act any differently because we haven’t done very well in upholding the sanctity of human life. Abortion has contributed to the ageing of the population When I think of all the unborn babies robbed of their lives needlessly I think how angry the Author of Life – God Himself must be.As Tolstoy said ”Life is all, Life is God and to love life is to love God”

    As humans I think we reap what we sow in this life and as countries we do too. Although it is not the only reason for the ageing populations in the West artificial contraception has led to smaller families. Compliant governments gave way to militant feminists in the sixties and seventies which economically drove every woman into the workforce creating a situation over the decades where it needed two wages to maintain a household.They could have introduced a fairer taxation system because not all women wanted to put their children in day care centres. They could also have supported the traditional family more but governments have actually been anti family. Now the pandemic has delayed school closures and played havoc with day care centres because they do not know what to do with the children. This is putting lives at risk. My hope is that we will learn from this and that there will be enough wise and good people to lead us through it.

  5. Thank you, Bill and all contributors, who posted comments about the current pandemic. It is beyond sad that Italy — a culture that loves life — would resort to rationing health care to people over 60. Rather than being a purely philosophical dilemma, ,the current crisis has been exacerbated by a reduction in American industry over the past 50 years. Corporations were allowed to send factories overseas where managers could exploit people in foreign countries by paying them very little, and all the while the CEOs were raking in millions and billions of dollars for themselves. At the same time, certain industries made the United States dependent on importing foreign products instead of keeping American factories open and producing goods. Now the U.S. is faced with a shortage of hospital beds, respirators, masks, and gowns for patients and medical personnel, among a variety of other necessities to deal with a widespread infection.

    The most appalling thing is the announcement by Lt. Gov. Patrick of Texas (who would make a very good Nazi, by the way) that he is willing to sacrifice himself so that his grandchildren will not have to live in “economic hardship.” Well, money is not everything. There are plenty of mentally sharp, responsible, and productive senior citizens who still have much to contribute to society. At the same time, there are far too many hedonistic, mindless young people like the virus-spreaders who just recently had packed the beaches of Florida for spring break. If they continue with this mindless, immoral, and Godless lifestyle, they will continue to be a detriment to society. My husband and I are not about to “sacrifice” ourselves for these individuals who are contributing very little — if anything — to the welfare of the world. We have several individuals among our friends and family whom we love dearly and for whom we are responsible, and we are doing everything we can to protect and support them and ourselves.

  6. Recently became aware of an online posting by a South Indian nurse working in Italy. She, as a Catholic, was deeply concerned about the life-and-death choices she is being asked to make with respirator equipment on the basis of likely prognoses for two patients in adjacent beds – involving taking the potentially life-saving equipment from one patient and transferring it to the neighbouring patient. Sin takes on a very trenchant, vivid reality in such circumstances.

  7. Bill,
    Irrespective of the current virus crisis I have unfortunately witnessed even within the Church the devaluing of the elderly. I recall when some older members struggled with the extreme volume of the music, they were essentially told thats too bad because we need to appeal to young people and to just bring ear plugs or fellowship elsewhere.
    The faith, witness teaching, example and testimony of the senior saints was a real encouragement to me in my early adulthood, and still impacts me today. The loss of this demographic can only be to the detriment of the whole body.

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