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Aging and disease
Commentary |
Age in the Time of COVID-19. An Ethical Analysis
Sorin Hostiuc1,2,*, Ionut Negoi1,3, Oana Maria-Isailă1,2, Ioana Diaconescu2, Mihaela Hostiuc1,3, Eduard Drima4
1Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
2National Institute of Legal Medicine, Bucharest, Romania
3Floreasca Clinical Emergency Hospital, Bucharest, Romania
4Dunărea de Jos University, Galați, Romania
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Despite using a myriad of methods to combat the spread of COVID-19, the healthcare systems (especially the intensive care units) have been overwhelmed, showing an outpaced capacity of available beds and ventilators. Choosing the right criteria to allocate the scarce ICU seems very challenging, being necessary a rapid, uncomplicated and universally accepted tool for patients’ triage regarding access to lifesaving resources; one such criterion, which generates intense debates, is age. Under certain circumstances, it might seem appropriate to choose to treat a young over an old patient. The main advantage of this approach is the potential for long-term survival, implying an equal right to reach an advanced age. Many authors have given moral reasons to support it, mainly based on utilitarian ethics or on distributive justice. However, there are numerous counterarguments to this approach, which we will summarize in this article. We will show that age should never be used as a unique criterion for withholding/not initiating life-saving procedures, even in pandemics or cases in which healthcare resources are extremely scarce. This approach is based on fundamental Codes of Ethics, such as the WMA Code of Ethics or the Oath of Hippocrates and all physicians treating patients should obey them.

Keywords age      morality      COVID-19      pandemic      medical futility     
Corresponding Authors: Sorin Hostiuc   
About author: These authors contributed equally to this work.
Just Accepted Date: 30 September 2020  
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Sorin Hostiuc
Ionut Negoi
Oana Maria-Isailă
Ioana Diaconescu
Mihaela Hostiuc
Eduard Drima
Cite this article:   
Sorin Hostiuc,Ionut Negoi,Oana Maria-Isailă, et al. Age in the Time of COVID-19. An Ethical Analysis[J]. Aging and disease, 10.14336/AD.2020.0929
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[1] Rothan HA, Byrareddy SN (2020). The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak. J Autoimmun, 109:102433.
[2] Bai Y, Yao L, Wei T, Tian F, Jin D-Y, Chen L, et al. (2020). Presumed Asymptomatic Carrier Transmission of COVID-19. JAMA, 323:1406-1407.
[3] Wang Y, Wang Y, Chen Y, Qin Q (2020). Unique epidemiological and clinical features of the emerging 2019 novel coronavirus pneumonia (COVID-19) implicate special control measures. J Med Virol, 92:568-576.
[4] Rosenbaum L (2020). Facing Covid-19 in Italy—ethics, logistics, and therapeutics on the epidemic’s front line. N Engl J Med, 382:1873-1875.
[5] Vergano M, Bertolini G, Giannini A, Gristina G, Livigni S (2020). Clinical Ethics Recommendations for the Allocation of Intensive Care Treatments in Exceptional, Resource-Limited Circumstances. Recenti Prog Med, 111(4):207-211.
[6] British medical Association (2020). COVID-19 - ethical issues. A guidance note. 2020.
[7] Consejo de Salubridad General (2020). Guía Bioética para Asignación de Recursos Limitados de Medicina Crítica en Situación de Emergencia. Consejo de Salubridad General, 2020.
[8] Farrell TW, Ferrante LE, Brown T, Francis L, Widera E, Rhodes R, et al. (2020). AGS Position Statement: Resource Allocation Strategies and Age-Related Considerations in the COVID-19 Era and Beyond. J Am Geriatr Soc, 68:1136-1142.
[9] Montero-Odasso M, Hogan DB, Lam R, Madden K, MacKnight C, Molnar F, et al. (2020). Age Alone is not Adequate to Determine Health-care Resource Allocation During the COVID-19 Pandemic. Can Geriatr J, 23:152-154.
[10] Zweibel NR, Cassel CK, Karrison T (1993). Public Attitudes About the Use of Chronological Age as a Criterion for Allocating Health Care Resources1. Gerontologist, 33:74-80.
[11] Kilner JF (1988). Selecting patients when resources are limited: a study of US medical directors of kidney dialysis and transplantation facilities. Am J Public Health, 78:144-147.
[12] Callahan D Setting limits: medical goals in an aging society with“ a response to my critics.” Georgetown University Press, 1995.
[13] Moody HR (1994). Four scenarios for an aging society. Hastings Cent Rep, 24:32-35.
[14] Johannesson M, Johansson PO (1996). The economics of ageing: on the attitude of Swedish people to the distribution of health care resources between the young and the old. Health Policy, 37:153-161.
[15] Daugherty Biddison EL, Faden R, Gwon HS, Mareiniss DP, Regenberg AC, Schoch-Spana M, et al. (2019). Too Many Patients…A Framework to Guide Statewide Allocation of Scarce Mechanical Ventilation During Disasters. Chest, 155:848-854.
[16] Bowling A (1996). Health care rationing: the public’s debate. BMJ, 312:670-674.
[17] Nilstun T, Ohlsson R (1995). Should health care be rationed by age? Scand J Soc Med, 23:81-84.
[18] Daniels N (1993). The Prudential Lifespan Account of Justice Between Generations. Justice Across Generations: What Does It Mean. Cambridge University Press, 257-283.
[19] Lambie R (2013). Allocation and Ageism in Aoteaora. An exploration of the ethical justification for age-based healthcare rationing. University of Otago, New Zeeland.
[20] Wareham CS (2015). Youngest First? Why it is Wrong to Discriminate Against the Elderly in Healthcare. SAJBL, 8:37-39.
[21] Cesari M, Proietti M (2020). COVID-19 in Italy: Ageism and Decision-Making in a Pandemic. J Am Med Dir Assoc, 21(5): 576-577
[22] Butler RN (1980). Ageism: A Foreword. J Soc Issues, 36:8-11.
[23] Savulescu J, Persson I, Wilkinson D (2020). Utilitarianism and the pandemic. Bioethics, 34:620-632.
[24] Stone JR (2012). Elderly and older racial/ethnic minority healthcare inequalities -- care, solidarity, and action. Camb Q Healthc Ethics, 21:342-352.
[25] DeBolt K (2010). What Will Happen to Granny-Ageism in America: Allocation of Healthcare to the Elderly & Reform through Alternative Avenues. Cal WL Rev, 47:127.
[26] Robb C, Chen H, Haley WE (2002). Ageism in Mental Health and Health Care: A Critical Review. Journal of Clinical Geropsychology, 8:1-12.
[27] Nelson TD (2005). Ageism: Prejudice Against Our Feared Future Self. J Soc Issues, 61:207-221.
[28] Onder G, Rezza G, Brusaferro S (2020). Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy. JAMA, 323:1775-1776.
[29] Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. (2020). Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet, 395:1054-1062.
[30] Gautier SV (2017). Textbook on transplantology - «a very timely book ». Russian Journal of Transplantology and Artificial Organs, 19:5.
[31] The World Medical Association (2006). WMA International Code of Medical Ethics.
[32] De Bruin DA, Parilla E, Liaschenko J, Marshall MF, Leider JP, Brunnquell DJ, et al. (2009). Implementing ethical frameworks for rationing scarce health resources in minnesota during severe influenza pandemic. Minnesota Center for Healthcare Ethics, 2009.
[33] Collet T-H, Sykiotis GP, Aubert CE, Baumgartner C, Blum MR, Feller M, et al. (2018). Subclinical hypothyroidism: should we still treat elderly patients? Clinical implications of a new trial in primary care. Rev Med Suisse, 14:470-474.
[34] Bagenstos SR (2020). May Hospitals Withhold Ventilators from COVID-19 Patients with Pre-Existing Disabilities? Notes on the Law and Ethics of Disability-Based Medical Rationing. Notes on the Law and Ethics of Disability-Based. doi: 10.2139/ssrn.3559926.
[35] Beauchamp TL (2001), Childress JF Principles of biomedical ethics. Oxford University Press, USA, 2001.
[36] Hostiuc S Informed consent (Consimtamantul informat), 1st ed. Casa Cartii de Ştiinţă: Cluj-Napoca; 2014.
[37] Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, et al. (2020). Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med, in press.
[38] Rusinova K, Simek J (2014). Should we relax the definition of death or the dead donor rule? Intensive Care Med, 40:917-918.
[39] Iltis AS, Cherry MJ (2010). Death Revisited: Rethinking Death and the Dead Donor Rule. J Med Philos, 35:223-241.
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