Canada is bracing for a wave of Covid-19 cases to flood our hospitals. The images and stories out of China, Italy, and now the United States, provide an unrelentingly grim account of dying patients and exhausted clinicians. Many have predicted we will, like them, experience a shortage of ICU beds and ventilators and be forced to make difficult decisions about who will get life-saving treatment. Each province in Canada has its own plan for managing this crisis, many of which had already been tested in large scale exercises, informed by lessons learned from proceeding pandemics such as SARS and H1N1. However, during the current crisis, the lessons being learned about who should receive potentially life-saving ventilators may be unduly shaped by the desperation seen in those regions hardest hit by the pandemic and not by our widely held values about protecting vulnerable citizens; values articulated in our pandemic plans.

The dilemma of who lives and who dies in a time of mass casualties when resources are stretched thin is one for which the modern process of triage was invented. During the Napoleonic Wars, a French surgeon divided the wounded into three categories based on their likelihood of survival, with non-clinical considerations like nationality or rank deemed irrelevant. That utilitarian principle of maximizing benefit – i.e., saving the most lives – remains the foundation  of triage care today, despite the ever-increasing sophistication of the categories and prognostic tools. Many pandemic triage plans now include the additional benefit-maximizing criterion of prioritizing patients who will survive longest after treatment.[i] This can mean choosing the patient most likely to recover from treatment without it shortening their life expectancy, or choosing a younger patient because of the greater number of years they will left to live.  Advocates for this latter age-based criterion have become even more vocal since the pandemic began with the Italian experience held out as a lived example to support their view.[ii]

In mid March, under great pressure from skyrocketing case numbers and physicians traumatized by the awful burden of making bedside life and death decisions, Italy’s association of intensive care physicians introduced guidelines that set maximizing life expectancy as a criterion for getting intensive care treatment and conceded that “an age limit may ultimately need to be set” to meet it[iii] – irrespective of an individual’s underlying health status. It has recently been reported that some hospitals in Italy have now implemented this restriction, with the limit set at 60 years of age.[iv] It is unlikely the Italians had included that criterion in their pre-crisis pandemic plan because it amounts to simple discrimination. Desperate times can lead to desperate measures. We should not follow suit.

The Ontario Pandemic Influenza Plan of 2013 (OPIP)[v] confirms this intuition by explaining that vulnerable populations experience more negative health outcomes during a pandemic than other groups and are more vulnerable to their effects. This is especially true for the elderly who are more likely to be exposed to infection by virtue of being in group living arrangements, more likely to suffer serious illness if exposed, and least likely to benefit already from triage criteria that excludes those with pre-existing health conditions.

During the H1N1 outbreak of 2009, a group of clinicians and bioethicists, drawing from multiple sources including town hall feedback from Canadians, identified key ethical, legal, and practical considerations that should be used to evaluate any triage criteria, like an age limit, intended to help clinicians make the excruciating decision of who would get one ventilator when clinical triage criteria identified two equally deserving candidates.[vi] One of those considerations is: does the criterion in question reflect widely held values and moral intuitions or violate them as little as possible? The adoption of an age criterion that explicitly privileges the young over the elderly, over and above an age cutoff that may already exist in a triage plan (e.g., patients over 85 are excluded in the clinical triage Sequential Organ Failure Assessment scale),[vii] is an abandonment of our moral obligation to protect the interests of our most vulnerable in society, especially in a time of crisis. A guiding ethical principle in Canadian pandemic plans is reciprocity:  the obligation to support and protect those who assume a disproportionate share of burdens in a crisis.[viii] The elderly will have born a greater burden of death and illness from this particular pandemic than likely all other groups combined. There is no ethically sound reason to compound that sacrifice with denial of treatment because of their age when resources become even more scarce. So, we recommended that first come, first served or random selection be used to decide who of the two equal candidates gets the ventilator. Nothing witnessed in this current crisis directs us to other fairer criteria.

As Rabbi Held wrote in a recent Atlantic article about our cruelty to the elderly during this pandemic: “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.”[ix] That value of a single human life, not one subdivided into life years and then totalled in comparison to another, is what gives us hope during a crisis and guides our compassion. The elderly among us, like all survivors, will help us rebuild after the crisis has passed and provide the experienced counsel that comes with years earned. Let us not regret the decisions we make now when that time comes.

[i] https://journal-chestnet-org.libaccess.lib.mcmaster.ca/article/S0012-3692(15)51990-9/fulltext

[ii] https://www.nejm.org/doi/full/10.1056/NEJMsb2005114?query=featured_home

[iii] www.saarti.it

[iv] https://www.jpost.com/International/Israeli-doctor-in-Italy-We-no-longer-help-those-over-60-621856

[v] http://www.health.gov.on.ca/en/pro/programs/emb/pan_flu/pan_flu_plan.aspx

[vi] https://www.longwoods.com/content/23833//identifying-prioritization-criteria-to-supplement-critical-care-triage-protocols-for-the-allocation

[vii] https://jamanetwork-com.libaccess.lib.mcmaster.ca/journals/jama/fullarticle/194262

[viii] https://repository.library.georgetown.edu/handle/10822/978222

[ix] https://www.theatlantic.com/ideas/archive/2020/03/respect-old/607864/