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How Many "At Bats" Should We Get?

When it comes to allocating limited medical resources, must we older adults give up COVID-19 treatment so that younger players can take the field?


As with all other crises, the COVID-19 pandemic in America has sparked discussions that employ our two favorite metaphors: war and sports. We wage a fierce battle against the virus, fighting for our lives while researchers and pharmaceutical companies are racing to find a vaccine and jumping over hurdles to get their discoveries and products over the finish line.

Given such tendencies, it shouldn’t be surprising that, at a time when major league sports are struggling to start, restart, or continue their seasons, discussions about the possible need for health care rationing naturally include athletic references –– more specifically, to those of America’s National Pastime, baseball.

In a recent post for The New Old Age blog, titled “Should Youth Come First in Coronavirus Care?”, New York Times columnist Paula Span cites the opinion of retired bioethicist Dr. Larry Churchill: “…[H]e subscribes to a ‘life span approach’ to ethics, sometimes called the ‘fair innings’ approach: He has had his turns at bat. Younger people have had less time to experience life’s opportunities and pleasures.”

In comparing the death of a 40-year-old to his own, 75-year-old Churchill considers the former "tragic" because of that person's "unfulfilled potential" as opposed to his own demise, which would be merely "sad."

In all fairness, writes Span, Churchill doesn't claim that everyone else should subscribe to his view, which he feels is appropriate only for himself. Each of us older adults should make up our own minds about whether or not to forego hospitalization, ventilation, or other means of care in order that a younger person could benefit from it.

But let's look deeper into the validity of making such a comparison at all.

In the newer American National Pastime called "surviving the pandemic," our testing, tracking, and treatment resources are scarce and disproportionately distributed. Because of this situation --- and unlike in a baseball game --- any of us may be limited to the number of "at bats" we get for treatment.

And so health care providers as well as the rest of us are being forced to consider two painful questions: 1) Who gets to decide which patients are admitted to the ICU, offered available drugs, and, if need be, put on a ventilator? and 2) On what should those decisions be based?

By citing the criterion of "potential," Churchill reflects an ageist position that assumes that the passing of years naturally reduces a person's chances to be productive, engaged, or contributory, however he defines them. For him, potential is based solely on one's place on the lifespan timeline. But who can draw such a blanket conclusion?

Given ageism's intersectionality with systemic racism, sexism, ableism, and classism in our culture, that 40-year-old's potential could be significantly stifled or even quashed just by living life as a female, an immigrant, poor, or a minority; or living with a disability, in a rural area without Internet accessibility, or in a neighborhood with inadequately funded public schools. Let's remember that institutionalized discrimination is often the main cause of someone's "unfulfilled potential."

Acknowledging this intersectionality is vital when dealing with the effects of COVID-19 on older adults. Toward this end, the American Geriatrics Society has released a position statement that says, in part:

A just healthcare system should treat similarly situated people equally, as much as possible. There is something particularly unjust about membership in a class, such as an age group, determining whether a person receives health care....When assessing comorbidities, the disparate impact of social determinants of health including culture, ethnicity, socioeconomic status, and other factors should be considered.

As Span points out: “The statement also opposes criteria like ‘life-years saved’ and long-term life expectancy, which similarly disadvantage the older population. Instead, it recommends treating patients based on the likelihood of being discharged from the hospital and surviving for six months.”

We should recognize ageism as the global social pandemic it is and inoculate ourselves and others through the vaccine of education about what aging really is –– and isn't –– so that we can develop antibodies against internalized ageism in ourselves and prejudice/bigotry in others.

That’s the full-season strategy.

In the meantime, while COVID-19 rages across the globe, governments and health care systems need to abandon longstanding tribal rules that pit two “teams” –– Youngsters and Oldsters –– against each other. The real deadly game is between the members of all leagues (based on age, socioeconomic status, race, gender, geographic location, and physical ability) vs. the virus itself. Everyone, regardless of individual situation or condition, deserves unlimited at-bats.

Consequently, the people in charge of allocating resources, directing research, and caring for the sick should stop focusing on a rationing strategy that determines who will live and who will die based on broad parameters. Instead, they must fully commit all of their efforts and resources to maximizing the speedy, accurate diagnosis and effective, individualized treatment of anyone who gets the virus.

To win against COVID-19, they shouldn't eject anyone from the field. Instead, they need to immediately create, distribute, and follow a robust, organized, universal playbook outlining four directives:

Get in the game.

Step up to the plate.

Swing for the fences.

And knock it out of the park.


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