COVID-19 and the New Death Calculus

When I was a child, my father, who made a point of conveying his respects when someone in the locality died, would send me along to funerals if he was working and could not attend himself. I would take the Mass card to the priest to get his signature, hand over the pound note and receive in return a sixpenny bit by way of commission, and show up at the removal or funeral Mass. There, I would place the card in the box at the head of the coffin and, after having queued for an hour or more, would walk along the line of relatives, incanting, “Sorry for your trouble.”  I remember many things about these occasions, but one of the most abiding is the way, when the deceased was an older person, people would console the relatives—and themselves—by repeating, mantra-like, the phrase “But she had a good innings.”

The phrase comes from the—English—game of cricket, something that always struck me as strange, since nobody in Ireland—other than a few Protestants up around Dublin—played cricket, which was categorized, and not in a good way, as a “foreign game.”

It is consoling, when an older person passes away, to focus on the duration and richness of the life that person has lived. But just a little consoling. What we tend to find when we bury a parent or grandparent is that this is rarely—aside from cases in which death arrives as the culmination of extreme and painful illness—a convincing argument. On those occasions, the protocol requires the use of phrases like “It’s a great release for the poor creature,” or, “She’s gone to a better place.” But for those left behind, almost regardless of the circumstances, the moment of the death of a beloved one obliterates any consolatory meaning deriving from the deceased's chronological age. Our loved ones die as themselves, as who they are and have been, as ageless beings in this universe of exiles, unique and irreplaceable. That the deceased has embarked upon the next stage of his eternal journeying is another matter altogether. We, the left behind, are inconsolable.

Now, in the first rush of the coronavirus crisis, I sense that the phrase “a good innings” has taken on an ominous ring. Its logic has begun to be applied not to the dead but to the still living. You hear it all the time: Those who die will be the old. It is not matter-of-fact observation, but a kind of death sentence. It is preparing us for something: the next phase.

Many European authorities and medics are already speaking in rather blithe terms about triaging in favor of younger, more “productive” virus victims. The context is usually the “hard choices” that have to be made when resources and staff become overstretched. And because, unless a particular health system succeeds in “flattening the curve,” no system on earth is capable of coping adequately with the virus, it has the ring of reasonableness about it. But only because we have already been primed for such a shift in our culture.

I have noted evidence of such cultural priming even within myself. Having twice been seriously ill over the past couple of years, I have had occasion to note, in my frequent visits to various hospitals, waiting around to be scanned or x-rayed, a syndrome that never struck me before. I would call it a premonition rather than a mere intuition or feeling. It would usually be triggered by the sight of a gurney being pushed along a corridor carrying an elderly person to an operating theater or scanning room. A decade ago, such a sight would have carried no ominous portent. But in an Ireland where murder has become legal, I found myself involuntarily asking: How much longer will such sights be seen? How much longer will our society continue to support the right of elderly people to live for as long as God decrees, and avail themselves of the medical care our society offers them as an integral part of the social contract?

My sense has been that our culture is already desensitizing us for this next phase by “training” us to see illness as a kind of luxury, treatment as a concession, and the old as a separate category of the human. Because the old are increasingly hidden away from everyday society in purpose-built nursing homes, when we happen upon the old we are already beginning to look away from their frailty, and therefore their, and our own, humanity.

An article in the financial pages of the U.K.’s Daily Telegraph on March 3 raised the possibility that, unlike the Spanish flu pandemic of 1918, which had “disproportionately affected” younger “bread winners,” the coronavirus crisis might have the benefit of primarily killing the elderly. “Not to put too fine a point on it,” wrote Jeremy Warner, “from an entirely disinterested economic perspective, the COVID-19 might even prove mildly beneficial in the long term by disproportionately culling elderly dependents.”

It should be obvious that there is no such thing as a “disinterested” economic perspective. An economics centered on discounting the deaths of categories of human beings would be the calculus of homicidal tyranny.

Twenty-five years ago, Pope John Paul II warned in Evangelium Vitae of how choices once unanimously considered criminal and rejected by the common moral sense were gradually becoming socially acceptable, even among sectors of the medical profession. “Looking at the situation from this point of view,” he wrote, 

it is possible to speak in a certain sense of a war of the powerful against the weak: a life which would require greater acceptance, love and care is considered useless, or held to be an intolerable burden, and is therefore rejected in one way or another. A person who, because of illness, handicap or, more simply, just by existing, compromises the well-being or life-style of those who are more favoured tends to be looked upon as an enemy to be resisted or eliminated. In this way a kind of “conspiracy against life” is unleashed.

Some may argue that what we are dealing with here is in a different category. Resources have already become the enabling catchcry of the emerging dispensation. Resources means money, which in turn means “choices,” which extend differing levels of protection to different categories of humans. But though presented as the “hard choices” facing frontline medical staff, when we look deeper in it will be about money. Just a few weeks into the COVID-19 pandemic, it is already clear that many actors are prepared to countenance the exclusion of the old and the very ill from the protection of the human family.

On Irish radio last week, a doctor described as an “emergency physician and senior lecturer in public health” spoke about the necessity of prioritizing patients suffering from the virus in the (likely) event that the Irish health system would soon become overwhelmed. Since Ireland has only about 250 intensive care beds, and up to 6,000 people might be in need of emergency assistance at any given time, that moment is unlikely to be long delayed.

The doctor said that this, and the fact that COVID-19 disproportionately affects older people, “raises questions about the social contract.” We need, he continued, to reflect on “what it means to be a citizen of this country.”

“We are facing into really, really historically decisive considerations, such as triaging the relatively young as opposed to the relatively old.”

The presenter briefly woke from a deep sleep and interjected to ask what this meant. “Are we going to say,” the doctor replied,

We have too few intensive care beds in our hospitals to deal with the vast numbers of very, very sick, moribund numbers of people over the age of 75 and 80 and at the same time we have hundreds of people in their 40s and 50s, at their peak productivity in terms of their usefulness to the state and the social contract? Are we going to prioritise the young and the productive as opposed to those who are elderly?

The presenter interjected again, but in the most desultory fashion imaginable: “Is this a discussion we need to have?” The doctor replied:

I think one of the advantages of this coronavirus is that we are now having to have really difficult discussions that we have put off for years and years, about capacity, about the social contract and about the fact that we’re all living longer and longer and we haven’t got enough nursing home beds, never mind intensive care unit beds.

Like “she’s had a good innings,” the phrase “we’re all living longer and longer” has acquired an ominous ring. In our new culture it is a kind of criticism: Are you still here? Yet the ambiguous content of the doctor’s statements was ignored as the discussion immediately moved on.

Something else I hear quite a bit these days, dropped nonchalantly into conversations, is that, in times of national emergency, when medical personnel and resources are scarce, the logic of combat triage will be applied to the difficult decisions concerning treatment of those in need of emergency care.  

Already, from around the coronavirus trouble spots, there are reports of the implementation of processes and procedures reflecting these shifts in human ministering. In northern Italy, the spread of the virus was so exponential that doctors were making comparisons to wartime triage medics deciding who lives, who dies, and who gets access to the limited number of ICU beds.

“It’s a reasoning that our colleagues make,” Dr. Guido Giustetto, head of the association of doctors in northern Piedmont, said in a widely syndicated interview. “As in any war, we have to choose who to treat and who not.”

Normally, since Italy has universal health care, no one is turned away. Last week, however, an anaesthesiologist at a hospital in Bergamo, one of the most affected cities, told Il Corriere della Sera that the ICU was already at capacity, and that doctors were being forced to base their decisions concerning people in desperate need of mechanical ventilation on age, life expectancy, and other non-medical factors.  

On March 10, a Registrar in Anaesthesia based in London, Jason Van Shoor, tweeted a series of messages he had received from “a well respected friend and intensive A&E consultant, who is currently working in Northern Italy.” His colleague reported that his hospital had become overwhelmed by COVID-19 patients and was working at “200% capacity.” This, he stressed, was “not a third world country” but a hospital in Lombardy, “the most developed region in Italy.” All their operating rooms had been converted to intensive treatment units (ITUs). All other cases were being deferred or diverted. There were hundreds of patients with severe respiratory failure “and many of them do not have access to anything above a reservoir mask.”

Patients over 65 or younger with co-morbidities are not even assessed by ITU. I am not saying not tubed, I’m saying not assessed and no ITU staff attends when they arrest. Staff are working as hard as they can but they are starting to get sick and are emotionally overwhelmed. My friends call me in tears because they see people dying in front of them and they can only offer some oxygen.

In Newsweek last week, an anonymous “senior doctor in a major hospital in Western Europe” wrote: 

Most of my childhood friends are now doctors working in north Italy. In Milan, in Bergamo, in Padua, they are having to choose between intubating a 40-year-old with two kids, a 40-year-old who is fit and healthy with no co-morbidities, and a 60-year-old with high blood pressure, because they don't have enough beds. In the hallway, meanwhile, there are another 15 people waiting who are already hardly breathing and need oxygen.

The Italian society of anaesthesiology and intensive care published 15 ethical recommendations to be applied to decisions on ICU admissions during the virus crisis and the ICU shortage. The criteria included the age of the patient and the probability of survival, and stressed “not just first-come-first-served.”

Spain, now the second most affected European country, has taken similar measures. On March 11, it emerged that the Hospital de la Paz in Madrid had commenced doing intensive care triage, under rules which excluded people over 80 unless a doctor made a specific clinical decision to treat them.

Those who talk blithely about “combat triage” appear to imply that the modern workplace is the equivalent of a combat zone and the primary issue is therefore prioritizing those who can be trussed up to get back into “battle.” What they appear to be saying is that, if someone has passed a particular number on the dial of chronological age—retirement age, more or less—that person should be left to die. The shifting needle has dropped into a death cycle.

Moreover, the idea that patients should be prioritized on the basis of “productivity” is a radical misreading of the operation of combat triage. Triage is essentially a sorting process that allows for “doing the greatest good for the greatest number.” Combat triage decisions are influenced by many factors, including: numbers of patients and their condition(s); reserves of medical supplies and capabilities of medical treatment facilities; numbers and capabilities of medical personnel. It provides also for prioritizing treatment of soldiers who may be capable of returning to the battlefield. To allow for this, other patients may be delayed who are not in imminent danger.

Under the rules of military triage, patients may be de-prioritized if, regardless of the level of care rendered, the patient is likely to expire. After all other patients have been treated, a re-triage of these patients is done and treatment instituted if appropriate. Triage, by definition, is a dynamic process, as the patient's status can change rapidly. Even military triage, in other words, is a long way from making decisions based purely on age or notional concepts of “productivity” or “usefulness.” It is a long way from dispensing with the old.

There are provisions, in the event of an influenza pandemic or similar, if vaccines are in short supply, for prioritizing the vaccination of healthcare workers, patients with a higher risk of complications and adverse outcomes, and those who contribute to crucial services such as national security, transport, and communication as well as energy, water, and food supplies. But any such prioritization has to reflect generally accepted medical and ethical criteria as well as economic and societal concerns.

Those comparing this pandemic to a war may be understating the coronavirus crisis. It could yet turn out to be much worse than that. Whether the crisis will escalate into next year or fizzle out by summer, we, the human inhabitants of our increasingly worrisome cultures—who may be old or merely growing older by the day—have reason to be concerned about the kind of legacy COVID-19 may leave.

John Waters is an Irish writer and commentator, the author of ten books, and a playwright.