"Discard me not in my old age; as my strength fails, do not abandon me" (Psalm 71)
Events in Italy — one of the countries where the suffering from COVID-19 is taking a particularly heavy toll — provides a sobering example of what may happen as the coronavirus continues to spread.
Numerous reports speak of Italian medical facilities being overwhelmed. As a report in the Atlantic by political scientist Yascha Mounk notes, doctors are unable to care for everyone who seeks treatment. There is also a critical shortage of ventilators needed to help those in the greatest danger.
If, as experts continue to suggest, the problem gets worse before it gets better, then choices will have to be made. The published guidelines of the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care for nurses and doctors to follow provide a shocking preview of what awaits the demographic group that is most vulnerable to the coronavirus: the elderly.
Their prescription for coping with the crisis is utilitarian. Their conclusion is as shocking as it is obvious: "It may become necessary to establish an age limit for access to intensive care." Those who are too old to have a good chance of recovery or with few years left to live will be allowed to die.
As Mounk writes, this means the coronavirus crisis could present us with impossible moral choices. Moreover, if even the extraordinary efforts now being made in many countries fail to contain the contagion, then hospitals could be forced to conduct the sort of battlefield triage decisions that will likely mirror the Italian recommendations.
If worst-case predictions about the virus — or the next pandemic challenge — prove either accurate or insufficiently gloomy, then respirators may well be allocated along criteria that we already accept with respect to organ transplants where waiting lists have always taken into account age and likelihood of recovery.
Triangulating these moral choices with Jewish values in particular will most clearly face healthcare workers in Israel, where there is a long history of grappling with triage and priorities, not least between terrorists and their victims.
But the more pertinent question to ask is whether our values — and, in particular, those ethical teachings handed down by Jewish tradition and faith — require us to take actions to prevent the elderly from being put in that position even if they impose hardships on the rest of the society.
Even a cursory study of Jewish texts — starting with the Ten Commandments and all the way through Talmudic teachings and the writings of modern Jewish thinkers like Rabbi Abraham Joshua Heschel — mandate that every possible effort should be expended to promote policies that will seek to avoid such dilemmas.
The problem is not just the avalanche of snark on Twitter from those who oppose closing public venues and "social distancing" on the grounds that they don’t see why they should be inconvenienced for the sake of the over-80s.
The real problem is the fact that we are already being prepared for rationing care to the elderly. That groundwork has been laid by the debates about how to administer government-funded health care even when we are not threatened by pandemics.
Citizens of countries with national health care programs overwhelmingly reject the notion of discriminating against the elderly. But such systems are generally better at providing routine care than in allowing all patients access to the most advanced treatments. While not explicit, all financing of health care — whether by government agencies or insurance companies-involves some form of rationing.
The debate about rationing was part of the discussion in the United States about the implementation of the national health care program implemented by the Obama administration, popularly known as ObamaCare. One of the architects of that scheme was Dr. Ezekiel Emanuel, a University of Pennsylvania professor who is also the brother of President Bill Clinton chief-of-staff Rahm Emanuel.
Emanuel is now the most prominent member of a committee formed to advise former Vice President Joe Biden, the likely Democratic Party presidential nominee, about the coronavirus crisis.
That is significant because Emanuel has been a prominent advocate not merely of rationing,but of more general utilitarian attitudes about health care for the elderly. In 2014, the then-57 year-old Jewish bioethicist wrote in the Atlantic about how he only wished to live to the age of 75, which he saw as the optimal life-span for Americans. While in no way explicitly advocating eugenics or denying care to the elderly, Emanuel argued that most of those who lived into their late 70s and beyond were experiencing diminished, uncreative lives as well as falling prey to dementia and debilitating illnesses.
In his view, those living in developed societies are living too long and becoming burdens not only to themselves but also to their children and society. Health care should not be denied to those who are over 75, but from thatpoint on, it should no longer be about prolonging life.
Chillingly, in light of today’s crisis, he also recommended that the over 75 should not have flu shots, especially in the event of a pandemic where shortages might occur. He quoted approvingly a classic medical text that spoke of pneumonia as "the friend of the aged," since it allows the elderly to escape distressing years of "decay."
That such attitudes may beinforming the 77-year-old Biden about health care is alarming as well as ironic. Yet while Republicans have long embraced critiques of health care rationing as part of their ideological opposition to any government health care program, the Trump administration has yet to put forward anycoherent response to questions about how the elderly will be treated if the coronavirus crisis should overwhelm American health care facilities.
While that can be put down to the Trump administration’s general slowness to react to the pandemic, it’s not clear that the U.S. government will be any more prepared to make informed ethical decisions about rationing if events where to move in that direction than their counterparts in Rome.
President Donald Trump’s remarks about the coronavirus threat have, from the outset of the crisis, been all over the map. Until the last week, it was clear that he viewed it primarily as a political issue and an attempt by his political foes to undermine his re-election chances. While he was right that Democrats wanted to weaponize the issue against him, he was far too slow to realize that there actually was a potentially catastrophic public health crisis that transcended politics.
But the problem wasn’t merely Trump’s characteristically uninformed comments. The administration was clearly unprepared for the virus. A 2018 consolidation of a reduced National Security Council staff combined those professionals tasked with global health and biodefense with other bureaus and may have called into question its ability to get the attention of their West Wing superiors.
But even after a hastily organized crisis management team headed by Vice President Pence was put in place, it was too caught up with coping to even consider who would be tasked with offering bioethics input into fateful federal decisions.
Presidents Bill Clinton and George W. Bush had bodies that formally advised them on bioethics, while Barack Obama chose to have a Commission for the Study of Bioethical Issues. But Trump has chosen not to have any group working on the topic.
The White House has been focused, not without reason, on the enormous damage that these events have had on the economy. But there has been relatively little said by the president or those in charge that spoke about the need for a compassionate response to victims and nothing at all about ethical guidelines for how medical facilities should cope with the possibility of shortages of resources should the number of those seriously ill start to soar.
The tone taken by Israel’s leader has been different. Though his opponents have accused him of exploiting the crisis, it is at least to Prime Minister Benjamin Netanyahu’s credit as well as to the emphasis that the Jewish state has always placed on the importance of families, that in advocating for Israel to take urgent action to combat the spread of the virus, he spoke of its primary victims as grandfathers grandmothers, fathers and mothers, rather than merely the elderly or those over 65.
It may be that the only way to avoid awful decisions about allocating life-saving measures should an illness like COVID-19 generate millions of patients needing care is to stop it before it gets to that point. But since it is unclear whether efforts to make up for the U.S. administration’s relatively slow response to the crisis will succed in containing it, that makes it all the more vital that Trump now appoint his own national bioethics commission.
That body should advise Pence — a man whose public devotion to religion became a source of controversy when he was given the coronavirus portfolio because he was widely and unfairly mocked when he began a meeting of his group with a prayer — and help craft a response to the problems that Americans may soon face that will be informed by ethical as well as logistical and economic considerations that will ensure that the needs of elderly victims are not sacrificed to expediency.
Treating the lives of older citizens as a precious and loved resource rather than a group who has lived too long to be of any use is an imperative for an ethical society that is faced with difficult health care policy questions. That is true for a nation, such as Israel, that is avowedly informed by Jewish faith, teachings and ethics. But in the midst of this crisis, it is vital for the Trump administration to reaffirm that these are mainstream American values too.
Jonathan S. Tobin is editor-in-chief of JNS (the Jewish News Syndicate) and a contributing writer for National Review. Twitter: @jonathans_tobin
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