Preparation at the ExCel centre. Photo:Stefan Rousseau/PA Wire/PA Images

The duel: Is it more important to save younger lives?

If coronavirus presents medics with a stark ethical choice, which considerations should determine their course of action?
YES—Peter Singer

 If we are faced with a tragic choice, as doctors already have been in some countries because they do not have enough ventilators for all the Covid-19 patients who will die without one, then—other things being equal—it is more important to save younger lives, because younger people are likely to live longer.  

The “other things being equal” clause is essential. I am not suggesting we should put a 40-year-old with incurable cancer on the last ventilator rather than a healthy 70-year-old. The illness eliminates the usual expectation that the younger person will live longer. 

For most people, life is positive. They don’t want to die. To be diagnosed with a disease that will bring about death in a short time is one of the worst things that can happen to them. Putting aside those suffering from severe depression, or in chronic pain, or with other major health problems, people want to continue to live. They do things like eating healthy food, exercising, and having regular medical check-ups to avoid dying. That is why we try to save lives.

[su_pullquote]“The more years of high-quality life enjoyed, the greater the intrinsic good”[/su_pullquote]

We all know, however, that we are going to die. No one thinks that healthy food, exercise or medical check-ups will enable us to live forever. So when we try to stay healthy, what we are trying to do is to live as long as we can, compatibly with having a positive quality of life for the years that remain to us. 

This common sense attitude is entirely reasonable. If life is a good, then, other things being equal, it is better to have more of it rather than less. And the same judgment is reasonable when it comes to saving the lives of others. It is a greater tragedy to die at 40 than to die at 80, and if we cannot prevent both deaths, we should choose the less tragic one. 


NO—Lucy Winkett

 Of course on the surface of it, it looks reasonable enough to prioritise saving younger lives, a bit like women and children first onto the lifeboat (although I suspect that was always more chivalry than biology). But no. Because hidden in this seemingly reasonable choice in extremis is a set of assumptions that become more worrisome the more they are explored. 

Two initial questions occur: for whom is it more important to save a young life than another life? Of course it will be more important for the individual concerned, just as clearly as it will be bad for the lives not chosen. But how is it more intrinsically good? For society? For the survival of the species? Certainly not for the planet. And how is it beneficial to society as a whole that a definition of a disembodied “good” be the guiding principle for the inevitably messy and contingent decisions made in an emergency room?

The second question is that of value. By answering “yes,” are we not simply replacing quality of life with length? The apocryphal stories of the saving of a young Adolf Hitler—sometimes by a soldier during the First World War, sometimes by a priest when he nearly drowned—may not be “true” in close detail but express something of the paradoxical nature of this question. 

And perhaps this is my greatest objection to the answer “yes” to this question. It’s very good to debate these things publicly and openly, but in the end, the whole project is flawed: the project of making comprehensive (closed) ethical statements about decisions that should be as much based on the clinical experience of human beings in the room as on any imposed rules about length of life. With guidance, of course, and some regulation to prevent abuse, in the end, experience, wisdom, humanity and trust in judgment are just as important. And this, even if—although I have no idea how this can be determined either—“other things” are judged to be “equal.”



 You ask: “for whom is it more important to save a young life than another life?” Adding: “Of course it will be more important for the individual concerned, just as clearly as it will be bad for the lives not chosen.” Yes, but that raises a further question: “Would it be equally bad for each of the two individuals not to be chosen?” Suppose that both are female UK citizens, one 30 and the other 90. The younger one can expect to live an additional 50 years, while the older one can only expect 4.6 years. If longer life is generally good—and if not, why save anyone?—then saving the older -person can be expected to bring about less than a tenth as much of this good as saving the younger one.

You then ask: “But how is it more intrinsically good?” There are many different theories about what is intrinsically good, and I can’t go into that debate here, so I will have to be dogmatic and say that continuing to enjoy life with a positive level of wellbeing is intrinsically good, and—yes—the more years of such life are enjoyed, the greater the intrinsic good.

Should we set aside such ethical principles in favour of relying on “experience, wisdom, humanity and trust in judgment,” as you suggest? For those who think that this is likely to work well, even when healthcare professionals are under pressure in an overburdened hospital, I recommend reading Sheri Fink’s account of what happened in a New Orleans hospital after Hurricane Katrina, Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital. Without clear ethical guidance, people’s biases come to the fore, and they are likely to favour those with whom they identify over those who are less like them. 



 The last point you make is an excellent one; but I take it also to be a powerful illustration of some of the challenge I am trying to make to any notion that an overarching ethical rule can satisfactorily be applied in matters of life and death. Because ethics themselves are necessarily contingent, and change over time depending on contemporary attitudes towards ontological difference, along with differences of geography, ability, nationality and so on. 

If you and I were having this debate in a different generation, we might be arguing about the relative value of saving people with different skin tones, or genders. In toxic corners of the internet, this is still debated. But thankfully ethical rules have changed fundamentally over time, otherwise I wouldn’t have been taught to read or write in order to join the debate at all. 

Age is another thing people cannot change about themselves, yet is still used to set ethical rules. If we’re going down this route, I would be equally free to argue the opposite—to settle the saving of lives by rewarding their achievement, rather than their potential. Under this alternative way of ruling, an older person might be valued more highly because of the wisdom gained through their life experience—wisdom that is much needed to navigate a society through a crisis. The younger life might have potential, but as yet unproven and unfulfilled. Therefore the fewer years of proven sagacity from the old should be valued more highly than the longer life of (potential) foolishness from the young.

[su_pullquote]“Hard and fast rules give the illusion of clarity, but dissolve amid the dust and fury of actually saving lives”[/su_pullquote]

I don’t believe this by the way, but outline it as a way of illustrating that hard and fast rules give the illusion of clarity for the rest of us, while my experience is that this cool clarity dissolves amid the dust and fury of actually saving lives. An alternative way of equipping medical professionals is, rather than giving them a blanket rule about age, instilling in them a regularly scrutinised confidence in their own judgment, with ongoing robust debate in ethics and unconscious bias throughout their careers, rooted in real life cases. Then leave them to it. Of course, prosecute them when they abuse their power but by and large back them as the ones in the (emergency) room.



 The ethical judgments we make should take account of all the consequences of our actions, and these consequences are contingent, but ethics itself is not contingent. If some cultures think that it is right to give priority to people of one race or gender, all that shows is that some cultures get it wrong. You implicitly acknowledge this when you refer to those corners of the internet in which racism is defended not simply as different, but as toxic.

I am arguing that when we cannot save everyone, we should choose to save those who are likely to live longer, and this usually implies saving those who are younger. You are, of course, free to argue for different ethical priorities. But this is not simply a matter of expressing different tastes, nor of voicing the views that are dominant in our cultural backgrounds. We are seeking to persuade others that we are right, and to do that we must give reasons for our views. If saving the old really did lead to greater wisdom and better ways of navigating through a crisis, then that would be a strong reason against the position I am defending. But I see no evidence of this, and you acknowledge that you don’t believe it either.

You appear to believe that medical professionals prefer to be left to their own judgment. My experience is different. For many years, I taught intensive bioethics courses for healthcare professionals, and many senior people, including intensive care unit directors, spoke of the difficulty of making life and death decisions on the run, without guidance from rules or principles, and sometimes in the face of passionate opposition from the families of the patients. It would be much better, they suggested, to be able to appeal to general principles that they could use to justify and explain their decisions. “Give priority to the young” is such a principle.



 The beginning and end of life raise particularly acute and sometimes excruciating ethical questions, perhaps because the consequences of decisions taken at those points are not, unlike some outcomes provoked by racist or homophobic views for example, reversible or redeemable. I believe that all human life is of equal value, regardless of length, and am with the 18th-century poet Thomas Mordaunt whose pithy conclusion is sometimes found on the gravestones of those who die young: “one crowded hour of glorious life/ Is worth an age without a name.” 

Perhaps in the end it is that judgment of worth that might helpfully provide a place to rest, for my side of the argument at least. Of course I am persuaded by the argument that maximising the time a person has to live also maximises their capacity to live well and therefore seems a good choice. But it obviously maximises their capacity to do harm too. That’s why, in my view, time by itself can’t carry ethical worth. If ethics is about good and bad, value and waste, about our right and wrong action, our well- or ill-judged treatment of others, then having more time to do any of it must always be a double-edged sword. 

I take the point about confusion in ICU and having some parameters to work with, which I have accepted from the beginning. But doctors’ preference for rules also might betray a concern that in an increasingly litigious society, blame falls heavily and expensively on the individual without a clear demonstration that the rules have been followed, to the letter of the law. 

In a more mature, emotionally literate and (I would say it, wouldn’t I) spiritually attentive society, the ethics of birth and death would be narrated entirely differently—relying on excellent science, but also displaying a good deal more humility about the mystery of both. Death is very often a painful tragedy, most especially for the ones left behind. But it isn’t always a failure. For the flourishing of human society, it’s just as important for its members to learn how to die as to, say, organise a fair and functioning tax system. Saving the old is a sign that our values are rooted in the fundamental equality of all, and that’s the only society I really want to live in.