Moral Guidance on Prioritizing Care During a Pandemic

This essay is part of a series concerning the Coronavirus pandemic. Read more from the collection here.

As our society struggles to come to terms with the COVID-19 pandemic, for which our resources to treat the ill may well prove inadequate, difficult and heart-wrenching decisions may have to be made by physicians and nurses. In a democratic republic like ours, “we the people” owe them as much guidance as possible, and we should want that guidance to be framed in ways that protect our society—and each of us individually—from temptations that will come all too readily to mind.

In cases where decisions must be made about who shall be saved when not all can be saved, we also decide what sort of society we want ours to be—we are constituting ourselves as a certain kind of people. When faced with scarcity, some will be tempted simply to pass by those who are older, the physically disabled or cognitively impaired, those who seem to have little to contribute to our common life. Indeed, some of the proposals for treatment allocation that have been made in different states may already reflect a yielding to that temptation.

We believe that such approaches are unacceptable, and recent statements by HHS on discrimination against the elderly or the disabled support this judgment. But there are additional ways in which even otherwise upright decisions could bring with them misinterpretations, seductions, and temptations that it would be wrong to accept.

Here, we identify three temptations in particular, along with principles to counter these, that we believe must be avoided when issuing, following, or contemplating guidelines for allocating resources in this time of scarcity. Various guidelines have been proposed, including, prominently, those by Ezekiel Emanuel and his distinguished co-authors that appeared in the New England Journal of Medicine. Helpful as these are in several respects, we believe it is also important to consider some social pathologies to which our current situation might contribute.

I.  Allowed casualties are not intentional killings.

A first temptation will be to see the deaths allowed in consequence of our decision to treat some and not others as intentional killings. Decisions to save some may be framed (though not, let us hasten to say, by the distinguished authors of the NEJM guidelines) as decisions to kill others. And this slippage is likely to be encouraged by critics as well as friends of our rationing decisions.

But the slippage must be resisted. Already, attacks on the distinction between killing and accepting death as a foreseen side effect of an otherwise morally legitimate act whose object is not death itself, are staples of the pro-euthanasia and physician-assisted-suicide movement. If withdrawing a ventilator from one close to death is permitted, they ask, why not intentionally kill the same person in order to eliminate his suffering? After all, both, it is alleged, are “intentional” taking of life.

The answer is that intentional killing is not the same as allowing a person to die as a proportionate side effect of an otherwise sound moral choice. In intentional killing, someone’s death is deliberately caused either as an end (out of hatred, for example) or as a means to something else (such as the relief of suffering). But when burdensome treatments are refused or withdrawn precisely to avoid the burdens they impose, the intention is to avoid those burdens, and death, even if foreseen, is not intended as a means or as an end, but is accepted only as a side effect.

Similarly, decisions to save some are not choices to kill others, as the NEJM authors acknowledge. This must be held steady in the mind’s eye, lest our allocation choices be used as cover to advance the regime of physician-assisted suicide and euthanasia.

Accordingly we need to exercise tremendous caution in our language: “choosing who will live and who will die” is a dangerous way of expressing what we are about in trying to save whom we can, while mourning the loss of those we are unable to save.

II.  Human lives are all of equal value.

Allocation decisions that will be made in our crisis will, again, have lethal effects in certain cases. When not all can be saved, some will perish. The NEJM guidelines mentioned above make some important recommendations for who should be given priority of treatment. Surely it is right to say, as they do, that critical COVID-19 interventions—testing, PPE, ICU beds, ventilators, therapeutics, and vaccines—should go first to front-line health care workers and others who care for ill patients and who keep critical infrastructure operating, particularly workers who face a high risk of infection and whose training makes them difficult to replace.

But no such prioritization principles should be allowed to undermine a core conviction of our moral tradition, viz., that the lives of all human beings are of inherent, equal, and indeed incalculable value.

It is a constant temptation of humanity to elevate the lives of some over the lives of others, and this will surely be augmented by the practice of prioritization. But it should be clear that, while there are valid reasons (in certain circumstances) to give priority to, for example, health care workers, this hardly means that their lives are more valuable, or more important, than the lives of their patients. We must be vigilant to ensure that the coronavirus crisis not lead to any cheapening of the value and dignity of each individual human being’s life.

This must especially be kept in mind in thinking about health care allocation for the elderly and disabled once this pandemic has passed. The elderly are not owed less because of their age; nor are the disabled to be given a lesser share of the healthcare resources to which all are entitled. We need to emerge from the pandemic with these principles intact.

III.  Expressive significance matters.

And this leads to our third point. Consider the language used by the authors of the NEJM piece: “Maximization of benefits can be understood as saving the most individual lives or as saving the most life-years by giving priority to patients likely to survive longest after treatment.” Further on, the authors are more judicious, reserving a life-years approach, or other considerations, only for “comparing patients whose likelihood of survival is similar,” which to some of us seems reasonable, though others of us disagree.

However, we all share a concern that a life-years approach, even if used only as a secondary consideration, could come to be understood in ways that would cut against the claims of the elderly, the disabled, and those who seem to have little to contribute.

Simply put, we fear the practical effects of emphasizing life-years, especially in a culture like ours. In practice such a policy could appear to systematically privilege the lives of the young over the old. Day after day, week after week, all across the country, and with the whole nation watching, the pattern would recur: a ventilator would be denied to an older patient and given to a younger one; denied to the 50-year-old in favor of the 30-year-old or the 15-year-old; taken from the middle-aged or retired, from parents and grandparents.

What lesson would people draw from this, and what attitudes might it entrench? That depends in part on what our culture has already primed us to think. And ours is a culture in which youth is worshiped and the natural effects of age are despised. Sometimes we fall into a pattern of thinking of the elderly as a “burden”—on themselves and on us. We already have political movements, and in some places laws and policies, that would permit or encourage assisted suicide or euthanasia for those with lives judged to be no longer “worth living” or “burdensome” to society, including the frail elderly.

In this milieu, a policy of almost always prioritizing the young over the old could reflect and entrench a bigotry that is already widespread. It could lead to a further devaluation of the lives of the elderly, which could work severe and often lethal harms far beyond the triage scenarios imposed by public health emergencies. That is a possibility that gives us strong prudential reasons to oppose any principles that would advise doctors to maximize the number of life-years saved rather than to look to the number of lives saved—old or young.

IV. Conclusion.

Moving forward, we must not blur the distinction between “saving the most individual lives” and “saving the most life-years.” A patient who—even if successfully treated—is likely to live only a few more years is, here and now, equal in dignity to one who may live for decades if successfully treated. So we agree with Dr. Daniel Sulmasy when he writes that we should focus on the benefits of treatment during this pandemic by prioritizing those with the most profound needs and those who are most likely to survive the treatment. Rather than claim to maximize benefits by attempting to calculate the number of “life-years” we can maximize, we should focus, as Dr. Sulmasy puts it, on the “patient’s objective clinical state, as best it can be assessed, for example by using a clinical scoring system to determine who has the best chance at survival.” Doing so will almost surely still leave us uneasy and discontented, because we cannot do all the good we would like to accomplish. But we will not risk contributing to a cultural tendency to undermine our understanding of the equal worth of the elderly and disabled.

This is a reasonable way forward in our decision-making that affects all those—young and old, able-bodied and disabled—whom we are committed to regarding as our equals. None of this is to deny, however, that in a time of pandemic, such as this, there might be occasions when some patients should themselves consider—not out of legal or even strict moral duty, but rather as a supererogatory act of generosity—giving up access to something to which they are entitled so that someone else might have it. None of us should place greater value on one life than we place on another, but any of us may rightly decide for ourselves that we will live in such a way that we are prepared forgo care in order that someone else may live.

In the next few weeks, as the pandemic perhaps reaches its zenith, we will have the opportunity to decide once again what sort of society we intend to be. We should eschew all invidious discrimination and recommit ourselves to treating all who are ill as bearers of profound, inherent, and equal worth and dignity.

Ryan T. Anderson, PhD
William E. Simon Senior Research Fellow in American Principles and Public Policy,
The Heritage Foundation.
St. John Paul II Teaching Fellow in Social Thought,
University of Dallas.

Charles Camosy, PhD
Associate Professor of Theological and Social Ethics,
Fordham University.
Former member of the Ethics Committee, New York Presbyterian Children’s Hospital.
Former member of the Ethics Committee, Children’s Hospital of Wisconsin.

Margaret Chisolm, MD
Professor of Psychiatry and Behavioral Sciences, and of Medicine,
School of Medicine,
Johns Hopkins University.

Farr Curlin, MD
Josiah C Trent Professor of Medical Humanities,
Duke University & School of Medicine.

Robert P. George, JD, DPhil, DCL, DLitt
McCormick Professor of Jurisprudence,
Princeton University.
Former Chairman of the U.S. Commission on International Religious Freedom.
Former member of the President’s Council on Bioethics.
Former member of the U.S. Commission on Civil Rights.

Mary Ann Glendon, JD, MCL
Learned Hand Professor of Law,
Harvard University.
Chair of the U.S. Department of State Commission on Unalienable Rights.
Former Vice Chair of the U.S. Commission on International Religious Freedom.
Former member of the President’s Council on Bioethics.

John Keown, DPhil, PhD, DCL
Professor,
Kennedy Institute of Ethics,
Georgetown University.

Aaron Kheriaty, MD 
Associate Professor,
Department of Psychiatry & Human Behavior,
Director, Medical Ethics Program,
School of Medicine,
University of California Irvine.

Katrina Lantos Swett, JD, PhD
President,
Tom Lantos Foundation for Human Rights.
Member of the U.S. Department of State Commission on Unalienable Rights.
Former Chair of the U.S. Commission on International Religious Freedom.

Patrick Lee, PhD
John N. and Jamie McAleer Professor of Bioethics and
Director of the Center for Bioethics,
Franciscan University of Steubenville.

Daniel Mark, PhD
Assistant Professor of Political Science,
Villanova University.
Former Chairman of the U.S. Commission on International Religious Freedom.

Paul McHugh, MD
University Distinguished Service Professor of Psychiatry,
School of Medicine,
Johns Hopkins University.
Former member of the President’s Council on Bioethics.

Melissa Moschella, PhD
Assistant Professor of Philosophy,
Catholic University of America.
Adjunct Professor of Medical Ethics,
Columbia University Vagelos College of Physicians and Surgeons.

Jacqueline C. Rivers, PhD
Lecturer in Sociology and African-American Studies,
Harvard University.
Executive Director,
Seymour Institute for Black Church and Policy Studies.
Member of the U.S. Department of State Commission on Unalienable Rights.

William Saunders, JD
Fellow and Director of the Program in Human Rights,
Institute for Human Ecology and the School of Arts & Sciences,
The Catholic University of America.

Christopher Tollefsen, PhD
College of Arts and Sciences Distinguished Professor of Philosophy,
University of South Carolina.
Member of the U.S. Department of State Commission on Unalienable Rights.

Candace Vogler, PhD
David B. and Clara E. Stern Professor of Philosophy,
University of Chicago.

Tyler VanderWeele, PhD
John L. Loeb and Frances Lehman Loeb Professor of Epidemiology,
T.H. Chan School of Public Health,
Harvard University.

Cornel West, PhD
Professor of the Practice of Public Philosophy,
Harvard University.
Class of 1943 University Professor Emeritus,
Princeton University.

Shaykh Hamza Yusuf
President,
Zaytuna College.
Member of the U.S. Department of State Commission on Unalienable Rights.
 

(Affiliations are for identification.)