Should age matter in COVID-19 triage? A deliberative study

Abstract

The COVID-19 pandemic put a large burden on many healthcare systems, causing fears about resource scarcity and triage. Several COVID-19 guidelines included age as an explicit factor and practices of both triage and ‘anticipatory triage’ likely limited access to hospital care for elderly patients, especially those in care homes. To ensure the legitimacy of triage guidelines, which affect the public, it is important to engage the public’s moral intuitions. Our study aimed to explore general public views in the UK on the role of age, and related factors like frailty and quality of life, in triage during the COVID-19 pandemic. We held online deliberative workshops with members of the general public (n=22). Participants were guided through a deliberative process to maximise eliciting informed and considered preferences. Participants generally accepted the need for triage but strongly rejected ‘fair innings’ and ‘life projects’ principles as justifications for age-based allocation. They were also wary of the ‘maximise life-years’ principle, preferring to maximise the number of lives rather than life years saved. Although they did not arrive at a unified recommendation of one principle, a concern for three core principles and values eventually emerged: equality, efficiency and vulnerability. While these remain difficult to fully respect at once, they captured a considered, multifaceted consensus: utilitarian considerations of efficiency should be tempered with a concern for equality and vulnerability. This ‘triad’ of ethical principles may be a useful structure to guide ethical deliberation as societies negotiate the conflicting ethical demands of triage.

Public attitudes toward pandemic triage: Evidence from conjoint survey experiments in Switzerland

“… Emanuel et al, 2020 ; Farrell et al, 2020 ). Our finding that members of the Swiss public would not base triage decisions on the patient's age, in combination with similar results from other countries ( Kuylen et al, 2021 ), lends support to voices that suggest caution in using age as a criterion ( Farrell et al, 2020 ). Our findings also suggest that there might be a discrepancy between Swiss public sentiment and the existing Swiss guidelines ( Scheidegger et al, 2020 ), according to which age is considered under some conditions.…”

“…However, several related studies from other countries have produced similar results. In the UK, Kuylen et al (2021) found, as mentioned above, that the public is reluctant to use age as a criterion for pandemic triage. In addition, Larsen and Schaeffer (2020) found similar to us a pronounced tendency to discriminate against foreigners in the allocation of medical care in Denmark.…”

“…In discussions about the design of triage guidelines, medical, ethical, and legal considerations are obviously central. However, many have pointed out that it is also important to learn about the general public's attitudes toward pandemic triage or the rationing of medical care more generally ( Biddison et al, 2019 ; Fallucchi et al, 2021 ; Kuylen et al, 2021 ; Neuberger and Ubel, 2000 ). For one, the existing medical ethics literature has identified not one but several different ethically permissible approaches to conducting triages ( Biddison et al, 2019 , p. 849), which have in part directly contradictory implications.…”

Quality of life in elderly ICU survivors before the COVID-19 pandemic: a systematic review and meta-analysis of cohort studies

“…In particular, services will need to weigh up various ethical positions to decide how important age is to these admission policies. 11 It is therefore important that older persons’ subjective outcomes are better understood.…”

Introduction of home exercise program for current circumstance worldwide

“…However, it is the astonishing fact that such triage has to be used owing to COVID-19 infection. 15 In other words, it showed the impact of overturning the medical ethics that underlie geriatrics and rehabilitation medicine.…”