Carrieri et al. International Journal for Equity in Health
https://doi.org/10.1186/s12939-020-01193-5
(2020) 19:72
COMMENTARY
Open Access
COVID-19: a plea to protect the older
population
Daniele Carrieri1 , Fedro Alessandro Peccatori2*
and Giovanni Boniolo3
Introduction
A recent WHO declaration1 reports that over 95% of
COVID-19 related deaths in the European Region (currently the epicentre of the pandemic alongside with
North America) occurred in people older than 60 years.
Elaborating on these figures, we want to make a clear
statement to reinforce the protection of each nation’s
older adults and to promote intergenerational equity and
solidarity. This message deserves to be fully understood
in light of the potential discrimination against older
people in the current public debate regarding the allocation of scarce medical resources during the present
pandemic.
Priority setting in healthcare, i.e. “the task of determining the priority to be assigned to a service, a service development or an individual patient at a given point in
time” [1], is unavoidable, because the demand for healthcare exceeds resource availability, particularly in pandemic circumstances. However, even under conditions
of resource scarcity, priority setting processes should not
compromise the basic human rights to health and wellbeing of any stratum of the population, especially that of
older people and other vulnerable groups. Yet, there is a
real risk that the immense pressure on resources exerted
by the COVID-19 pandemic may result in the prioritisation of key services across different age groups based on
actual or future contribution to society, or on other utilitarian criteria.
In this context, older people may be seen as a particularly large and vulnerable group, and one which plays a
less active role in society, especially from an economic
point of view. Therefore, in an attempt to optimise resources, older people might be considered as having a
priori less rights to high-quality healthcare than younger
generations, who tend to be seen as less vulnerable and
more active members of society. On the contrary, we
want to emphasise that resource scarcity and utilitarian
calculus should not undermine older people’s rights to
receive high-quality healthcare: societies have a moral
imperative to protect and respect the dignity and autonomy of older people [2]. Moreover, in line with philosophical accounts which regard ‘vulnerability’ as valuable
[3], we also wish to highlight that older people can enrich societies.
We are not claiming that age parameters should not
be considered while facing the allocation of scarce
sources. Our aim is to strongly oppose the idea of setting
an a priori age cut-offs to decide who should get access
to healthcare, as such ideas discriminate against older
people. We believe that, especially during the COVID-19
pandemic, there is the need to focus on this issue, since
there are some initial signs of such discrimination. Thus,
we wish to show how these discriminatory phenomena
can cause severe negative outcomes not only from the
moral standpoint of respect for dignity and autonomy of
older people, but also from the utilitarian perspective of
achieving the greatest good for the greatest amount of
people.
1
http://www.euro.who.int/en/health-topics/health-emergencies/
coronavirus-covid-19/statements/statement-older-people-are-athighest-risk-from-covid-19,-but-all-must-act-to-prevent-communityspread
* Correspondence: fedro.peccatori@unimi.it; fedro.peccatori@ieo.it
2
Department of Oncology and Haemato Oncology, University of Milan and
European Institute of Oncology IRCCS, Via Ripamonti 435, 20141 Milan, Italy
Full list of author information is available at the end of the article
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Carrieri et al. International Journal for Equity in Health
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(2020) 19:72
Initial signs of discrimination of older people?
In Italy – one of the first European countries hit by the
pandemic and one among those with a significant proportion of older individuals– SIAARTI2 guidelines on
admission to intensive care units (ICU) envisage (or at
least do not exclude) the possibility of a priori age cutoffs. The main argument is that elderly patients may
need longer intubation time and have less chance of survival than younger patients. The argument is also underpinned by the utilitarian calculus of maximisation of
benefit for the greatest amount of people [4].
“An age limit for the admission to the ICU may ultimately need to be set. The underlying principle
would be to save limited resources which may become extremely scarce for those who have a much
greater probability of survival and life expectancy, in
order to maximize the benefits for the largest number of people. In the worst-case scenario of complete
saturation of ICU resources, keeping a “first come,
first served” criterion would ultimately result in
withholding ICU care by limiting ICU admission for
any subsequently presenting patient.” (Recommendation 3; their emphasis).
This discrimination against older people seems to have
spread to other countries which are dealing with the
COVID-19 ‘tsunami’. In the US – where there are triage
frameworks which do not categorically exclude large
groups of patients (therefore also older people) [5],
opinion-leader bioethicist A. Caplan, interviewed by a
major national newspaper, makes similar age cut-off
claims (which are also underpinned by utilitarian
calculus):
“Although a patient’s age is not the only consideration, it is one. It would be dishonest if we didn’t
say age is a driver. Age is correlated with resilience.
Because younger patients, in general, get better faster, they may free up a ventilator more quickly for
the next patient”.3
Moreover, in the US social distancing measures have
been implemented rather late and/or sporadically across
different states (including states with populations older
2
http://www.siaarti.it/SiteAssets/News/COVID19%20-%2
0documenti%20SIAARTI/SIAARTI%20-%20Covid19%20-%2
0Raccomandazioni%20di%20etica%20clinica.pdf. SIAARTI is the Italian
Society of Anesthesia, Analgesia, Resuscitation and Intensive Care.
3
https://www.washingtonpost.com/world/national-security/new-yorksbioethics-experts-prepare-for-a-wave-of-difficult-decisions/2020/03/2
8/4501f522-7045-11ea-a3ec-70d7479d83f0_story.html
than the national average)4 effectively putting older
people, and other vulnerable groups, at risk. A common
argument for such inconsistent implementation was the
decision to assign more importance to the economy than
to the health of the population – alongside the ‘false
myth’ that younger people could not develop serious
complications from COVID-19.5
Reviving ideas of a ‘duty to die’?
These initial signs of age discrimination in time of
COVID-19 seem to go in parallel with a contemporary
dangerous trend. There are, indeed, some scholars supporting the idea both of a priori age-based cut-offs for
access to certain kinds of medical intervention, and
preaching that older people should sacrifice themselves
for the good of younger generations. Before the emergence of COVID-19, an American oncologist and bioethicist, E. Emanuel, sparked some controversy [6] after
writing about his plan to self-impose a cut-off of 75 years
for access to any ‘curative’ treatment and accepting only
‘palliative’ treatment.6 Such proposals echoed the previous 65 year cut-off advocated by D. Callahan [7], and
even arguments about the existence of a duty to die [8].
The common denominators of these positions include
the utilitarian idea that continuing to live after a certain
age can impose significant financial burdens to healthcare systems, as well as financial and emotional burdens
to family and/or caregivers, younger generations, and society as a whole. Another denominator is the critique of
the hype around biomedical innovation and the tendency to ‘overmedicalize death’ which may foster illusions of immortality. Finally, these positions share the
idea that living too long can also be a loss for the old
persons in terms of their own quality of life.
The same arguments used by those who sustain those
a priori age-based cut-offs have previously featured in
literature. For example, they are not too dissimilar from
the ones used by Trollope in his 1882 satirical dystopian
novel ‘The Fixed Period’ [9]. Here he depicts a society
that has progressed “beyond the limits of civilisation”
and has agreed upon euthanasia (a “decent and comfortable departure”) for the elderly when they reach the age
of 67 and a half.
Unfortunately, the abstract and fictional positions
sketched above are currently being actualised. For example, in Texas, Lieutenant Governor Dan Patrick, said
he would be willing to die to preserve the US economy
4
https://www.washingtonpost.com/outlook/2020/04/13/many-partsamerica-have-already-decided-sacrifice-elderly/?fbclid=IwAR0eVKnT85
Lqed_2UX-354RcIiHKrrangriSd2ERDC-1vpsxF_hUjFLYe3o
5
https://www.weforum.org/agenda/2020/03/coronavirus-young-peoplehospitalized-covid-19-chart/
6
https://www.theatlantic.com/magazine/archive/2014/10/why-i-hopeto-die-at-75/379329/
Carrieri et al. International Journal for Equity in Health
Page 3 of 4
(2020) 19:72
from COVID-19 public health measures: “as someone
who turns 70 next week, he was in the high-risk group,
but [ … ] he was willing to give up his life for his six
grandchildren”.7 In Italy, Father Giuseppe Berardelli, 72,
died after choosing to give his respirator to a younger
coronavirus patient.8
The importance of protecting older people
An important argument against potential age-related euthanasia or suicide and against the dangerous and immoral stigmatisation of aging, is the fact that older
people should have the same rights as others to receive
high-quality health care and the rights not to be spurred
– especially by key opinion leaders - to consider their
own death as something good. Moreover, not all (older)
individuals have the same clinical, psychosocial and
other contextual features and expectations. That is, what
could be good for Emanuel, Callahan, Patrick and Berardelli may not be good for others. A 70-year-old patient
may have a better chance of survival and benefit more
from intensive or other forms of medical treatment than
a 30-year-old one. Notably there are studies showing
how the so called “oldest old” – i.e. patients 90 years old
or older – with early stage lung cancer can benefit from
surgery [10]. Even in the context of the current pandemic, there is revealing news, e.g. in Italy a 101-yearold man9 and a 102- year-old woman10 have recovered
from COVID-19.
These examples are also in line with the WHO ‘Active
Aging’ policy framework, that is “the process of optimizing opportunities for health, participation and security in
order to enhance quality of life as people age” [11].
Moral imperative of respect for the autonomy and dignity of old people notwithstanding, discriminatory positions are problematic also from a utilitarian and
economic point of view. For example, US citizens aged
50 and older represent the 35% of the entire population,
account for 40% of the national gross domestic product,
and contribute 43% of US taxes [12]. While it is important to honour those who have survived into their later
years for their contributions to family and society, it is
7
https://www.theguardian.com/world/2020/mar/24/older-peoplewould-rather-die-than-let-covid-19-lockdown-harm-us-economytexas-official-dan-patrick
8
https://www.bbc.co.uk/news/world-europe-52015969
9
https://ph.news.yahoo.com/extraordinary-recovery-101-old-italian-1
75333011.html?guce_referrer=aHR0cHM6Ly93d3cuZmFjZWJvb2suY2
9tLw&guce_referrer_sig=AQAAANCHkM0SyBGHlVZWqNEDarfst6
YPYyUiH95o2ZHpbg4HI4S3VDQVhlbfgf9ZNXaX6HrrGSdfJ9Zsa3
QhyQcf6r8y8m4HVtUmPpjwrUvL96or9NK5ZzY9keNoJWH6y05
iFtOw0JwXmO5ncTIVn3h1ltBg7aO8R7qcEH9AYFbUO1
UN&guccounter=1
10
https://edition.cnn.com/world/live-news/coronavirus-outbreak-03-2
8-20-intl-hnk/h_621a06dfd17af984912e4d1c4d94cbac?fbclid=IwAR1
AVOzE3qRsFVT32lC8XHAh3T9GnIZG5nQHfF0Q9GQFLDt6
DptOYDnV-vw
also important to understand the practical and objective
contributions that older adults still make to their communities and their families and, occasionally, even to the
world.
It seems that there is a contradictory attitude towards
the older population. On the one hand, older people are
cajoled, especially for business reasons (the silver economy); on the other hand, as soon as the younger generation is under pressure, older people run the risk of
being stigmatised or discriminated [13]. It is also important to highlight that such forms of discrimination can
pit one generation against the other, seriously impoverishing the whole fabric of societies.
Conclusion
Exceptional and austere situations like the current and
previous pandemics can elicit the best and the worst of
humanity. Despite the current COVID-19 circumstances,
or possibly even more so, it is key to shape the public
sphere in ways that allow to recognise both the vulnerabilities and potentialities of all generations. One way to
do so is to respect the individual person, going beyond
categories such as age or age groups, and to promote intergenerational equity and solidarity by fostering connectedness across different generations.
Caring and protecting older people is not only about
respecting their dignity and autonomy. It opens up invaluable possibilities for all generations to engage with
collective memories and traditions – promoting the exchange of skills, knowledge and understanding.
Acknowledgements
Authors would like to acknowledge Mariko Asakawa-North for proofreading.
Authors’ contributions
All authors conceived, read and approved the final manuscript.
Availability of data and materials
Materials are not available for this paper.
Ethics approval and consent to participate
No ethics approval was needed for this paper.
Consent for publication
No consent for publication was needed for this paper.
Competing interests
Authors declare they do not have competing interests.
Author details
1
College of Medicine and Health & Wellcome Centre for Cultures and
Environments of Health, University of Exeter, Exeter, UK. 2Department of
Oncology and Haemato Oncology, University of Milan and European
Institute of Oncology IRCCS, Via Ripamonti 435, 20141 Milan, Italy.
3
Department of Biomedical and Specialty Surgical Sciences, University of
Ferrara (Ferrara) & Civitas Vitae Research Centre (Padova), Ferrara and Padova,
Italy.
Carrieri et al. International Journal for Equity in Health
(2020) 19:72
Received: 4 May 2020 Accepted: 12 May 2020
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