The Covid-19 pandemic is disrupting our lives and raising many questions. They concern sometimes establishing the facts, sometimes the understanding of concepts - such as that of "collective immunity" -, sometimes again the ethical choices at work in the objectives to be pursued and the means to be deployed.
Cand article examines in particular three ethical questions relating to justice between different age groups. Fighting a pandemic does indeed raise issues of justice, particularly in access to healthcare. And the age, singular criterion, plays a significant role.
1. Age and flattening of the epidemic curve
First question : What is the link between the "flattening" of the epidemic curve and justice between ages?
The drastic policies put in place in many countries - and since March 17 in France - aim to flatten the growth curve of the epidemic, even at the cost of extending its duration. By reducing the intensity of the contagion, an attempt is made to keep health services afloat, especially intensive care units. We also save time to develop tests, treatments and vaccines.
While these measures aim to protect the health of all, they particularly benefit the most vulnerable. It is of course possible to identify variations in case fatality rates on axes other than the chronological axis. As we know, patients with cardiovascular diseases or diabetes are particularly at risk. But age seems to be a particularly significant marker too.
In Italy, for example, recent data indicate an average age of Covid-19-related deaths of 81 years, 42,2% belonging to the 80-89 age group and 32,4% to that of 70-79. Keeping the epidemic below the saturation threshold therefore primarily affects justice towards the elderly. And the fact that we are ready to make sacrifices to achieve this attests that many of us believe that a person's advanced age does not in any way take away their dignity.
2. Shortage of means and "sorting" by age
Second question: If our hospital capacities are exceeded, should age intervene in the choice of patients to be saved?
This is not a hypothetical question: it has already arisen in Italian hospitals lacking artificial respirators and will arise elsewhere. A March 6 recommendation last of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIIARTI) makes explicit considerations in this regard:
“It may be necessary to set an age limit for access to the intensive care unit. It is not a question here of making choices that are simply of value, but of reserving resources which may be very scarce for those who present above all a greater probability of survival and, then, for those from whom more can be saved. years of life, with a view to maximizing benefits for the greatest number of people. "
Is such an age limit - let's take 80, for example - compatible with equal dignity? Let us consider that it is possible to save a significant percentage of the over 80s admitted to intensive care and confront two possible logics justifying the use of an age limit for 80s in a situation of shortage.
The first logic is at the heart of the SIIARTI declaration: an advanced age can be seen as a good predictor of a reduced additional life expectancy, and thus of the number of years “saved” by a medical intervention. Saving an 80-year-old who can hope to live another 10 years would be less effective than saving a 60-year-old whose additional life expectancy would be XNUMX years.
An age limit can therefore reflect the wish to contribute to maximizing the number of years “saved” by each intervention. Yet alongside such a concern for efficiency, an entirely different justification for an age limit of 80 is possible. She postulates that people who have already had the opportunity to reach old age are less disadvantaged than young people who, without intensive care, would die.
It is no longer a question here of saying that it is preferable - because more effective - to allow 60 rather than 10 additional years of life. Rather, it is a matter of giving priority to the 30-year-old, even if their additional life expectancy after surgery was lower than that of the older patient. Because the objective this time is to ensure that this intervention contributes to reducing the inequalities in longevity between our two patients.
Why insist on the contrast between the logic of effectiveness of interventions and the logic of equalization of longevity?
First, to emphasize that they each proceed from normative choices, one not being more neutral than the other. Then, to draw attention to the fact that if, faced with the single criterion of age, the two logics tend to converge, this is no longer the case as soon as we introduce other vulnerability factors - such as pathologies. pre-existing - also deemed relevant by SIIARTI.
Imagine having to choose between admitting a 70-year-old diabetic patient to the intensive care unit and a patient over 80 with no medical history. In this case, the logic of efficiency invoked by SIIARTI will no longer necessarily be able to justify the age limit, while the logic of equalization may continue to do so.
This shows that it is important, if we are concerned with justice between patients, to be clear about the relative weight of two of the objectives that may be pursued by the choice of patients to be saved: maximizing the number of additional years (efficiency ) or ensure a fairer distribution of the number of years actually lived (equalization).
And it is also important to understand their link with the age criterion. This dimension is also present, for example, in the justification of the age criteria for the allocation of organs intended for transplantation in the Swiss system ([ Ordinance of 2007, art. 5]).
3. Selective quarantine of the elderly
Quarantine is a strong restriction on people's freedoms, their freedom of movement in particular. In theory, this restriction can apply to all or be limited to some. Hence our third question:
Is a more rigorous quarantine for the elderly compatible with their equal dignity?
Again, the question is not hypothetical. The Brussels parliamentarian Els Ampe thus proposed to quarantine those over 65. And the British political journalist Robert Preston predicted on March 14 that those over 70 would soon be quarantined for four months in the UK.
Let's compare two strategies. The first is to impose a quarantine on the whole of society aimed at slowing the epidemic, keeping it at a level manageable for health services and trying to stop it.
The other is to allow the epidemic to develop, continuing social interactions and aiming for rapid immunization of the population. The epidemic would remain manageable by health systems if all vulnerable people could be identified and quarantined, especially the elderly.
Some would therefore be encouraged to live normally, including in their leisure time, while others would be forced, not because they are contagious, but because they are vulnerable, to take a step aside, for a potentially significant period of time. .
The second strategy, initially considered by the British authorities, would aim to achieve so-called "collective" immunity (herd immunity) as quickly as possible, with as few casualties as possible. It has just been taken over by the dutch prime minister which designates it under the expression "maximum control".
This second strategy is problematic in the case of Covid-19: but is it because of the selective quarantine that it would impose on the elderly? I do not think so.
Imagine that a vaccine against Covid-19 is available soon and that the most vulnerable - especially the elderly - are subject to stronger forms of quarantine than the rest of society, the time to have vaccinated everyone. If the quarantine period is limited, and if we start by vaccinating the most vulnerable who support it, such a differentiated quarantine could be justified, even if it was based on an age criterion. This indicates that a differentiated quarantine based on age may be acceptable in some cases, even if the quarantined age categories are not the most contagious.
Rather, the central difficulty with the strategy initially envisioned by the UK government seems to stem from our inability to identify in advance and with sufficient precision who the most vulnerable are. Collective immunization by contagion rather than by vaccination thus endangers the lives of too many human beings, and in particular medical personnel.
If it is therefore the first strategy - first attempting to flatten the curve of the epidemic and stop it - which seems to be imposed in most countries, we understand how it affects in a central way questions of justice between age groups: it tries to better protect vulnerable people, and in particular the elderly, from a dangerous pathology; it also allows us to reduce the tragic situations likely to force us to choose to the detriment of the elderly. But it also undoubtedly makes it less easily justifiable quarantine differentiated by age if it were to last for months.
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