Richard Smith: Are all lives and deaths equal?

The question of whether all lives and deaths are equal inevitably evokes strong emotions, but it’s a question that lies behind much of our thinking on how to respond to covid-19. Most deaths from covid-19 occur in people over 70 (“three score and ten”), and deaths under 40 are vanishingly rare. (Many young people died in previous pandemics: how would we cope if that was the case now?).

We discussed the question on the Lancet Commission on the Value of Death, and some thought that it was wrong even to discuss the question. I tried to write something for the Commission to consider, but with so much else to consider it fell by the wayside. The increasingly emotional debate over how best to respond to the pandemic has prompted me to share the piece. I saw it as a starting point for discussion not a final statement.

The covid-19 pandemic has brought into sharp focus the questions of whether all lives and deaths are equal and who should take priority if life-saving resources are limited. The religions of the book believe that only God should decide who will live and die and that man overreaches himself by making such decisions. This belief was not challenged when medicine had little or no capacity to defeat death, although the religions had to deal with war and capital punishment.

Some deaths are preventable and avoidable, whereas others are inevitable. Deaths of children from diarrhoea or measles, usually in low and middle income countries, are qualitatively different from deaths of frail older people in care homes in high income countries. It seems sensible and right to prioritise resources to prevent deaths that can be prevented and avoided.

Medicine does have powers to hold off death even in frail older people, and within some specialties, particularly intensive care and organ transplantation, decisions have to be taken over who will be given priority. In many ways these decisions were more acute when life-extending treatments first appeared and were in short supply—for example, fifty years ago in Britain people over 40 or people with renal failure and diabetes would not be offered renal dialysis.

Nobody argues that decisions on priority should be based on income, social class, ethnicity, disability, or sexual orientation, or any social factor, but two factors promote continuing debate—age and whether a person’s condition is self-inflicted (they have, for example, smoked or drunk or eaten too much). 

Many would argue that it is to oversimplify to consider conditions being “self-inflicted” in that people’s social circumstances, genes, and personalities rather than rational choice lead them to adopt unhealthy behaviours. Nevertheless, surgeons may require patients to lose weight or stop smoking before agreeing to operations which are expected to prolong life or refuse liver transplants to patients with alcoholic liver disease who are unable to stop drinking.

Doctors argue that they take these decisions simply on clinical grounds rather than on moral or social grounds. They give priority to the people most likely to benefit from any medical intervention. This is a principle of intensive care and means in circumstances as in many low and middle income countries where intensive care facilities are very limited a young man shot in a gang fight will take precedence over a middle-aged priest with diabetes and a heart attack simply because the young man, who was healthy until the moment he was shot, is more likely to benefit from intensive care than the older man.

Clinical decision making will thus mean that the young will often taken precedence over the old and that those who have damaged themselves through tobacco, alcohol, food, or drugs will come behind those who are healthier (and possibly older).

But should age always be a factor when deciding priorities? There are three main arguments for this position. Firstly, the concept is widely accepted. It is captured in the well-known phrase “women and children first,” but also in the thought experiment where only two of a grandparent and grandchild can be saved: very few opt for tossing a coin to decide. Secondly, the “fair innings” argument says that those who have had a full life (or at least the chance of one) should give way to those who have not had the same chance. Thirdly, giving priority to the young means that more lives (and certainly more life-years) will be saved.

One argument against using age is that invoking a particular cut-off age may be little better than a lottery if somebody a day before his or her 70th birthday is given precedence over somebody who is a day over 70; and this can be further complicated if the 70-year-old is much fitter than the 69-year-old. A second argument is that the “fair innings” argument is also arbitrary: for all sorts of reasons—for example, prolonged time as a political prisoner—an older person may have had less chance of fulfilling him or herself than a younger person. Thirdly, to discriminate against older people is to suggest that they are of less worth or importance than younger people.

Governments understandably shy away from being explicit about giving priority to the young, but in practice they do. Consider, for example, how in Britain and most European countries health services have been given attention, funding, and equipment far greater than that for care homes, which serve old people almost entirely. Then England’s National Institute for Health and Care Excellence uses cost per QALY (quality adjusted life year) to make decisions on which treatments should be available, and by definition a treatment that cures a 20-year-old will produce more QALYs than one that cures an 85-year-old.

This is as far as I got in the piece I wrote for the Commission, but I’ve added this now:

Perhaps in the end we answer this question for ourselves through personal experience. My mother, who is approaching 91, has been eight years in a care home and has had no short-term memory for 12 years. When she was in her 60s (as I am now) she wrote a letter with me to The BMJ calling for the right to assisted dying for people with oncoming dementia. She dreaded dementia because she’d see it overtake her mother. During her years in the home my mother has been cheerful and brought joy to many, but when I saw her two weeks ago she was miserable and told me she’d rather be dead. I simply can’t see how her death would be equivalent to the death of any of my four grandchildren.

Richard Smith was the editor of The BMJ until 2004.

Competing interest: RS is the unpaid chair of the Lancet Commission on the Value of Death.