Locking Down the Elderly

Julian Savulescu and James Cameron argue that a policy which locked down the elderly whilst allowing greater freedom to younger people during the covid-19 pandemic wouldn’t be ageist, see practical ethics . The purpose of such a policy would be to protect health services from being overwhelmed. They further argue if such a policy isn’t ageist that it isn’t wrong. In this posting I will accept their argument but suggest that an alternative policy would be preferable. Before proceeding I must make it clear that I am over seventy and one of the elderly however I hope this doesn’t affect the validity of my argument. In the rest of this posting I will use the term ‘older persons’ rather than elderly as this better reflects that the elderly remain persons.

Before making my argument I will briefly outline that of Savulescu and Cameron. They base their argument on Aristotle’s principle of equality. This requires that we treat like cases alike, unless there is a morally relevant difference. They use two examples to illustrate the principle. Firstly if men were allowed to vote and women weren’t this would be sexist and wrong because differences in sex don’t make any difference to the capacity to vote. Secondly government investment in screening women for breast cancer whilst not doing the same for men who sometimes also develop breast cancer isn’t sexist or wrong because men are far less likely to develop this cancer. Let us turn to Savulescu and Cameron’s argument that it wouldn’t be ageist to lockdown older persons whilst allowing younger people greater freedom. They point out that because the cost of the lockdown is massive it is desirable to lift the lockdown. Unfortunately lifting the lockdown might result in health services being overwhelmed. They further point that older persons are much more likely to require health services due to covid-19 than younger ones. They proceed to argue that because that older persons are much more likely to require health care that it wouldn’t be ageist or wrong to require older persons to remain lockdown whilst lifting the lockdown for others due to Aristotle’s principle of equality. When considering the need for health services due to covid-19 outbreak there is a significant difference between older persons and others. It follows that it wouldn’t be ageist to follow a policy which discriminates against older persons in this way.

Let us accept that the above is a perfectly good argument. However it would appear that BAME people are dying at twice the rate of others in the UK. If we accept Savulescu and Cameron’s argument about lockdown for the elderly then the same argument could be applied to BAME people. If it isn’t ageist to lockdown older persons then it shouldn’t be racist to lockdown BAME people. Most would be uneasy about accepting such a conclusion. Let us now consider a different policy which achieves the same ends and which might alleviate our unease. Let us assume that older persons are warned prior the lockdown being lifted, that if this leads to an increase in covid-19 cases which threaten to overwhelm the health services, that they might receive a lower standard of care compared to others. This lower standard is justified because of the disproportionate burden they place on these services. This policy means that older persons might be denied places in ICU and just receive palliative care. Older persons would face a choice of whether to self-isolate or not in order to protect themselves. Let us further assume that the lockdown is lifted and this leads to an increase in covid-19 cases which threaten to overwhelm the health services and as a result older persons start receiving a lower standard of care. Should this policy be regarded as ageist? Let us consider Aristotle’s principle of equality in this scenario. Clearly older persons are treated differently to others but are there any reasons which might justify this difference? I would suggest that there are two reasons which might justify treating older people differently. Firstly older persons are much less likely to survive treatment in ICU. Secondly if treatment in ICU has to be rationed then saving a younger patients at the expense of the elderly means saving patients who will usually live longer and can be justified by utilitarian principles. It would appear that if we accept Aristotle’s principle of equality then a policy which discriminates against older persons in this way wouldn’t be ageist.

I’m self-isolating and believe it is sensible for most older persons to remain in lockdown even if the lockdown were to be partially lifted. I have outlined two policies to protect our health services from becoming overwhelmed in both of which it wouldn’t be ageist to discriminate against older persons. Let us assume that each of these policies would be equally effective in preventing the health from being overwhelmed. Which of these policies should we choose if we accept that it isn’t a question of whether to discriminate but rather when to discriminate.

Let us accept that we have good reasons why we should adopt the first policy as proposed by Savulescu and Cameron. It might be argued that following such policy would protect older persons better than the second. It might be pointed out that if the second policy was adopted that older persons would have to protect themselves. In response it might be pointed out if the first policy is introduced that older persons would still have to protect themselves by remaining compliant. Nonetheless let us accept that we have good reason to adopt the first policy. However it is important to note that the reason to prefer the first policy over the second has nothing to do with protecting our health services from being overwhelmed, both policies do this adequately, the reason for preferring the first policy is to do with caring for older persons. If we choose the first policy then we are also acting beneficently.

Do we have any reasons to choose the second policy instead?  I would suggest that we have two. Firstly adopting the second policy might be more effective as it might be difficult to ensure that older persons remained in long term lockdown under the first policy. I won’t consider this reason further here. Secondly it might be argued that preferring the second policy protects autonomy better. Adopting the first policy serves the interests of all by protecting the health services but it doesn’t respect the autonomy of older individuals. It might then be argued that if the second policy adequately protects health services and respects autonomy that we have reason to prefer this policy. Two objections might be raised to the above argument. Firstly it might be objected that the first policy does respect autonomy. Secondly it might be objected that in times of extreme crisis such as this we should give preference to acting beneficently over respecting autonomy. I will now consider both objections.

What it means to respect autonomy depends on the concept of autonomy used. It might be suggested that an autonomous decision is one that is rationally made to concur with the agent’s best interests and is freely made. If we accept a substantive account of autonomy then these best interests include generally accepted interests such as safety and good health. If we accept a substantive account of autonomy then it might be argued that adopting the first policy is compatible with respecting the autonomy of older persons. Older people, if given the choice, would make an autonomous decision to remain in lockdown because it is in their best interests to stay safe and protect their health. I myself would make such a choice. However let us consider an elderly widow who lives alone and who is suffering from terminal cancer. Let us assume that she is still able to visit her family. If the first policy was adopted she would have to remain in lockdown whilst the rest of her family were free to socialise. I would suggest that if such a person could make an autonomous decision whether to remain in lockdown or not she would choose to socialise with her family. When she considers her best interests she might prioritise family life over staying safely in lockdown. It follows that in this case adopting the first policy wouldn’t respect her autonomy. It might be objected that I have used an extreme example and that we should still prefer the first policy.  I am prepared to accept that I have used an extreme example to illustrate my point but I still want to argue that if we prefer the first policy that we fail to respect the autonomy of older persons. Older persons in general have less future time to look forward to than younger people and many might make an autonomous decision, if they were able to do so, to prioritise family life over staying safe.

Let us accept that if we prefer the first policy then we must be prepared to accept either that acting beneficently is more important than respecting autonomy or that we can respect autonomy whilst acting beneficently. If we accept the second option then we must also accept a substantive account of autonomy. I have argued elsewhere that if we accept a substantive account of autonomy that autonomous decisions must be good decisions, see wooler.scottus . An autonomous decision cannot be a bad decision, it must concur with what is generally accepted to be in the maker’s best interests. However if autonomous decisions must be good decisions then the entire idea of autonomous decision making becomes redundant. We just need to consider good decisions. It follows that if we accept that autonomy is to remain a meaningful concept that we must be prepared to accept a content neutral account. It further follows that if we don’t accept that acting beneficently should be given priority over respecting autonomy that we should prefer the second policy.

However it might be argued that in times like these that acting beneficently is more important than respecting autonomy. Two objections might be raised to the above. Firstly if we prefer the first policy are we really acting beneficently towards older persons? An older person might well believe that leading a social life is in her best interests rather than remaining safe for her last few years. If we disagree we might be accused of epistemic arrogance. Secondly if we give precedence to acting beneficently we are taking acting beneficently to mean ‘caring for’ rather than ‘caring about’. People don’t want to be ‘cared for’ in much the same way as pets are they want to be ‘cared about’ as persons and this means taking their interests into account. It follows if we want to act truly beneficently that we should prefer the second policy.