Saturday, April 04, 2020

COVID-19 and the Aged; Cruelty and Hard Choices in Times of Stress and A View From the UN – UN expert urges better protection of older persons facing the highest risk of the COVID-19 pandemic [Experta de Naciones Unidas califica de “inaceptable” el abandono de las personas de edad, que corren riesgos más graves por el COVID-19]

Coronavirus: Europe's care homes struggle as deaths rise

Care homes have seen appalling outbreaks leading to a collapse in staffing. Last month the military was called in to help at retirement homes and found elderly patients abandoned and, in some cases, dead in their beds. In two facilities alone there are reports of almost 90 deaths linked to the crisis (Coronavirus: Europe's care homes struggle as deaths rise).
The issue of the relationship of the elderly and the COVID-19 pandemic  is remarkable both for the focus of its coverage, and for the indifference of that coverage, with the fate of the elderly in the shadow of pandemic. The character of that coverage, as well as the necessity of that indifference appears over and over: "The sister of one resident told local media that the home's managers had been pleading for tests to be carried out and it was only after someone died that they took notice" (Ibid.).  That indifference is culturally driven. Indeed, it is the cultural inevitability that makes the coverage both horrifying and inevitable--and therefore likely to be displaced especially as society confronts epidemic in which death is infused in all of the calculus of societal responses. Re-cast in other terms (since it appears that all cultures share this view even as it is expressed through different practices)--indifference is grounded in an almost universal acceptance of the premise that the old must die, and that they be counted on to die sooner than those who are younger.

That sounds silly at first; yet it is a powerful ordering principle of society--and of medicine. Inherent in that premise is the powerful cultural signifier of "counting," of the ability to p`redict and thus order (and if necessary intervene to enhance) the underlyiong premise of an order to death grounded on age.  But it si more than that, it is also attachjed to another cultural premise--that of the alignment between value (personal and societal) and age. If, as Pythagoras  suggested, mankind is the measure of all things, then the yardstick against which that measure is taken for each individual is notched with the anniversaries of birth.  Inherent then in the cultural calculus of the value of an individual is the reduction of that person to a fixed sum. It is the measure of that sum, then, that determines the extent to which a society might feel obligated to an individual (society calculates the "profit" to be made by such exchange in terms of the social costs versus the individual's value to society). This calculus is applied with a vengeance in crisis (e.g., "women and children fist," etc.).  That also sounds cruel. Buty societies that trade obligation for the value of the individual is common enough in the history of human organization.  What enhances the cruelty are the means by which that assessment is implemented by a society in crisis.  It is then that the true meanness of spiriut of a society is revealed, and where cruelty is extended nit merely to the act of valuation (and its conseqeunces), but to the extent of the indifference to the pain (individual and collectivem, physical and mental) the the implementaiton of these these chpices produce. The cruelty with which  societies, especially when beset by pandemic, embeds that notion almost casually in law, in administrative practice, and in the way that social actors approach the way it "deals" with the elderly, more tuely exposes the real meaning (and the valuation) of human dignity than all of the pieties with which its elites drive cultural narrative.

This post considers the cruelty inherent in submerged but operative principles of how human societies value human lives and what that produces in times of stress.  More significantly, it suggests the way in which these measures, enhanced by law and regulation, produce a halo of cruelty that substantially undermines the way in which the principle of human dignity is itself undermined in fundamental ways. These very preliminary thoughts are wrapped around a recent Appeal issued by  Rosa Kornfeld-Matte (Chile) the first Independent Expert on the enjoyment of all human rights by older persons.

The treatment of the elderly has always been subsumed within the core principles that one fo the ultimate consequences of age is death, and that, as a consequence, the elderly are, as they age, increasing consumers of medical services with increasingly small returns (if, as societies tend to do, is such returns are measured by length and quality of life after treatment).  The COVID-19 pandemic has merely exposed what had been an underlying set of principles in its most harsh application:
Now the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) has published guidelines for the criteria that doctors and nurses should follow as these already extraordinary circumstances worsen. The document begins by likening the moral choices Italian doctors may face to the forms of wartime triage that are required in the field of “catastrophe medicine.” Instead of providing intensive care to all patients who need it, the authors suggest, it may become necessary to follow “the most widely shared criteria regarding distributive justice and the appropriate allocation of limited health resources.” The principle they settle upon is utilitarian. “Informed by the principle of maximizing benefits for the largest number,” they suggest that “the allocation criteria need to guarantee that those patients with the highest chance of therapeutic success will retain access to intensive care.” * * *

Those who are too old to have a high likelihood of recovery, or who have too low a number of “life-years” left even if they should survive, would be left to die. This sounds cruel, but the alternative, the document argues, is no better. “In case of a total saturation of resources, maintaining the criterion of ‘first come, first served’ would amount to a decision to exclude late-arriving patients from access to intensive care.”

In addition to age, doctors and nurses are also advised to take a patient’s overall state of health into account: “The presence of comorbidities needs to be carefully evaluated.” This is in part because early studies of the virus seem to suggest that patients with serious preexisting health conditions are significantly more likely to die. But it is also because patients in a worse state of overall health could require a greater share of scarce resources to survive: “What might be a relatively short treatment course in healthier people could be longer and more resource-consuming in the case of older or more fragile patients.” (The Extraordinary Decisions Facing Italian Doctors: There are now simply too many patients for each one of them to receive adequate care)
Yet it is one thing to rank the elderly down a hierarchy of treatment in the face of scarse resources.  It is quite another to act on that impulse in determining whether such decisions will be implemented ina humane manner.  Reports from Europe indicate that this is not always the case, especially in the face of popular hysteria that tends to attend pandemic and its fear, generally, of infection and either agony or death. In Spain, elder care facilities were abandoned, and those left behind were abandoned to their fate (Spanish Military Finds Dead Bodies And Seniors 'Completely Abandoned' In Care Homes). "Staffers at a California nursing home left more than a dozen elderly patients in the care of a cook and a janitor when they walked off the job this week" (Abandoned elderly residents discovered covered in filth in care home after staff walked out leaving them to fend for themselves). In Italy and France those stricken in nursing homes may neither be tested nor identified, in part to reduce the official tally of the dead and the infected (570 people have died in nursing homes in France's eastern region since the coronavirus outbreak). In many places nursing homes are strictly quarantined, making visits of (and oversight by) relatives nearly impossible (Uncounted among coronavirus victims, deaths sweep through Italy's nursing homes ("Immediately after the virus emerged in northern Italy on Feb. 21, care homes cut off access to visitors to limit the contagion risk to elderly patients most vulnerable to the disease")).

 But more importantly, what is emerging is a clear propensity for cruelty in the shadow of pandemic--but a cruelty made meaner  by its veiling in the cold and utilitarian language of the administrator, of process, and of the reductionism at the heart of the turn toward the dehumaization of the elderly by reducing them to little more than an aggregate of measures against which their value to society is assessed. What had become a "natural" tendency of societies obsessed with the measurable in tiemes of plenty is now exposed for its darker consequences in times of crisis.  That it is facilitated through the legitimating structures of law, of administrative regulation, and of a souless utilitarianism the core premises of which (and the means by which it derives its measures) has never really be an object of societal, political or economic discussion, adds the most distressing level of cruelty to the entire enterprise.  It may well be that a society must jettison its elderly in situations of stress.  But to keep that principle hidden until it is time for some to take it on themselves to trigger that choice (and who chose them to make thast decision under what circumstances?) appears to undermine the very fundamental character of the political-economic model in defense of which those same elderly gave much of their lives to sustain.  Here, again, one encounters another set of fundamental issues exposed by COVID-19, whose resolution will await calmer time, but whose resolution is nonetheless necessary to protect the integrity of the political-economic model.  

There is a small step from alleviation of pain to euthanasia.  And euthanasia is as well based on a valuation of life, in part based on the years of "useful life" left in the patient.  This reductionist valuation is so common as to be unremarkable, but it  represents an important societal consensus on the way n which life is valued.
In Spain, a former member of Catalonia's parliament claimed some elderly patients and those with pre-existing conditions are being given morphine to avoid the 'futility of health care'. Alfons Lopez Tena wrote in a tweet: 'Catalonia's govt decides to let die coronavirus patients who have "less years to live", [and recommends] no "admissions in hospital of patients with little benefit". * * * Yahoo news reported that according to regional newspaper LaVanguardia, the document cited by Mr Tena also recommends that medics do not use ventilators for patients older than 80." (Doctors facing 'temptation of euthanasia': French medic warns of terrible decision facing staff in coronavirus hit care homes while Spanish doctors are 'ordered to stop using ventilators for patients older than 80').

Corpses of the elderly found abandoned in Spanish care homes

At its limits, the cumulative effects do not merely illustrate the application of cultural presumptions in the ordering of society, and its harsher expressions when societies are in crisis.  They might well point to a contradiction between the practice of these cultural presumptions about the alignment of age and death, with the fundamental concepts of human dignity and the value of life irrespective of life's inevitable march toward death (a march usually marked by age).  It is in that connection that Ms Rosa Kornfeld-Matte (Chile) appointed by Human Rights Council as the first Independent Expert on the enjoyment of all human rights by older persons sought to bring a human rights perspective to these issues.  She has released a Statement on the Treatment of the Elderly that may be worth reading.

The Statement would have been remarkable had it sought to invert the consequences of the traditional alignment between age and death, one that applies the principle that since the aged are more likely to die, or to live a shorter life than those who are younger, then society in a resource scarce environment ought to ration treatment to favor those whose present value of life-time is greater. But it raises that issue gently. 
"I am deeply concerned that decisions around the allocation of scarce medical resources such as ventilators in intensive care units may be made solely on the basis of age, denying older persons their right to health and life on an equal basis with others. "Triage protocols must be developed and followed to ensure such decisions are made on the basis of medical needs, the best scientific evidence available and not on non-medical criteria such as age or disability (“Unacceptable” – UN expert urges better protection of older persons).
More usefully, it seeks to draw attention to the inhumane treatment of the elderly within the premise that scarcity that may require treating the elderly least ort last.  It is not, then, the principle that scarcity allocation principles ought to be reconsidered (perhaps in terms of quality of life or of contribution or some other measure as yet unembraced).  Rather, it is that such a decision to permit a quickened march toward death ought not to be made mote horrible by the addition of indifference or cruel measures--indifference, abandonment, and refusals to alleviate pain. 

All of this suggests that thsi is a discussion that is both comlex and culturally embedded.  It is one that requires the unpacking and certering of cultural presumptions.  Thus centered, it is the cultural presumptions, and their manifestation as policy, that ought to be the focus of discussion of the way society allocates its resources, approaches issues of health, and ultimately shades its measure of "good" treatment of the aged. None of this is even remotely being contemplated at the moment.  That is a pity.  The Appeal, though, may at least serva s a remionder that such a conversaiotn is necessary--with or without the tragedy of the current pandemic.

The Appeal (English y Español) follows.

“Unacceptable” – UN expert urges better protection of older persons facing the highest risk of the COVID-19 pandemic

GENEVA (27 March 2020) – Society has a duty to exercise solidarity and better protect older persons who are bearing the lion's share of the COVID-19 pandemic, a UN human rights expert said.
"Reports of abandoned older persons in care homes or of dead corpses found in nursing homes are alarming. This is unacceptable," said Rosa Kornfeld-Matte, UN Independent Expert on the enjoyment of all human rights by older persons. "We all have the obligation to exercise solidarity and protect older persons from such harm."
Older persons do not only face a disproportionate risk of death but they are further threatened by COVID-19 due to their care support needs or by living in high-risk environments such as institutions, the expert said.
Kornfeld-Matte expressed particular concerns about older persons with underlying health conditions and those who are already socially excluded, living in poverty, having limited access to health services, or living in confined spaces such as prisons and residential care homes.
"This social exclusion is exacerbated by 'social' distancing measures, such as denying visitors to residential care homes. Social distancing must not become social exclusion," the expert said.
"Physical distance is crucial but creative and safe ways must be found to increase social connections. Older persons must be provided with ways to stay in touch online, including those in residential care homes and remote areas," she urged.
The Independent Expert noted that older persons are already facing particular old age discrimination ("ageism") and therefore require specific rights protection. She stressed the urgent need for a holistic human rights approach for older persons that ensures equal realization of all their rights, including access to health care.
"I am deeply concerned that decisions around the allocation of scarce medical resources such as ventilators in intensive care units may be made solely on the basis of age, denying older persons their right to health and life on an equal basis with others.
"Triage protocols must be developed and followed to ensure such decisions are made on the basis of medical needs, the best scientific evidence available and not on non-medical criteria such as age or disability.
"Older persons have become highly visible in the COVID 19 outbreak but their voices, opinions and concerns have not been heard. Instead, the deep-rooted ageism in our societies has become even more apparent. We have seen this in some cruel and dehumanizing language on social media and in the exclusive emphasis on older persons' vulnerability ignoring their autonomy," Kornfeld-Matte said.
She finally called on all stakeholders to ensure that essential support services at home in the communities can continue without putting older persons and their care providers at risk. "Communities and generations must come together to get through this crisis in solidarity," the UN expert concluded.
Ms Rosa Kornfeld-Matte (Chile) was appointed by Human Rights Council as the first Independent Expert on the enjoyment of all human rights by older persons in May 2014. Ms Kornfeld-Matte served as the National Director of the Chilean National Service of Ageing, where she designed and implemented the National Policy of Ageing. She has a long career as an academic and is the founder of the programme for older persons at the Pontificia Unversidad Católica de Chile.

 Experta de Naciones Unidas califica de “inaceptable” el abandono de las personas de edad, que corren riesgos más graves por el COVID-19

GINEBRA (27 de marzo de 2020) – La sociedad tiene el deber de ejercer la solidaridad y proteger mejor a las personas de edad, que son las más vulnerables ante la pandemia del COVID-19, afirmó una experta en derechos humanos de las Naciones Unidas.
“Las noticias sobre ancianos abandonados en asilos o el hallazgo de cadáveres en residencias de la tercera edad resultan escandalosas. Esos hechos son inaceptables”, declaró Rosa Kornfeld-Matte, Experta independiente de las Naciones Unidas sobre el disfrute de todos los derechos humanos por las personas de edad. “Todos tenemos la obligación de ejercer la solidaridad y proteger a las personas mayores de esos peligros”.
Las personas mayores no solo afrontan un riesgo desproporcionado de muerte, sino que también son más vulnerables al COVID-19 debido a su necesidad de cuidados especiales o por el hecho de vivir en contextos de alto riesgo, tales como las instituciones, afirmó la experta.
Kornfeld-Matte manifestó especial preocupación por las personas de edad que padecen patologías previas y por las que ya están en situación de marginación social, viven en la pobreza, disponen de acceso limitado a los servicios de salud o se encuentran recluidas en espacios confinados, tales como cárceles u hospicios.
“Esta marginación se agrava por las medidas de distanciamiento ‘social’, tales como la suspension de visitas a los asilos de ancianos. El distanciamiento no debe convertirse en exclusión social”, añadió la experta.
“La distancia física es decisiva, pero es preciso hallar métodos creativos y seguros para aumentar la conexión social. Debe dotarse a las personas mayores de instrumentos que les permitan mantener el contacto social a través de Internet, incluso a las que se encuentran recluidas en residencias para ancianos o viven en zonas remotas”, dijo la experta.
La Experta Independiente señaló que los ancianos ya son objeto de una discriminación particular dirigida a los mayores (“viejismo”) y, por consiguiente, necesitan que sus derechos sean protegidos de manera específica. Kornfeld-Matte hizo hincapié en la necesidad urgente de aplicar una estrategia holística de derechos humanos que garantice a las personas de edad la realización de todos sus derechos, comprendido el derecho a recibir tratamiento sanitario. 
“Me preocupa muchísimo que las decisiones relativas a la asignación de recursos médicos escasos, tales como los respiradores que se emplean en las unidades de cuidados intensivos, se tomen únicamente a partir de criterios de edad, lo que puede privar a los ancianos de sus derechos a la vida y la salud, en condiciones de igualdad con las demás personas”.
“Es preciso elaborar y aplicar protocolos de triaje según prioridad, a fin de velar por que esas decisiones se adopten en función de las necesidades médicas y los mejores criterios científicos disponibles, y no sobre la base de criterios extrafacultativos, tales como la edad o la discapacidad”. 
“La situación de las personas de edad ha adquirido gran notoriedad con motivo del brote de COVID-19, pero no se ha prestado la debida atención a sus opiniones y preocupaciones. Al contrario, el arraigado “viejismo” de nuestras sociedades ha pasado a primer plano. Esto resulta evidente en el lenguaje cruel y deshumanizador que circula en las redes sociales y en la insistencia en destacar la vulnerabilidad de los ancianos, haciendo caso omiso de su autonomía”, añadió Kornfeld-Matte. 
La experta concluyó con un llamamiento a que todos los interesados velen por la continuación de los servicios de apoyo en el hogar y la comunidad, sin poner el peligro a las personas de edad o a sus cuidadores. “Las comunidades y las generaciones deben mancomunar esfuerzos para superar esta crisis mediante la solidaridad”, terminó diciendo la experta de las Naciones Unidas.
Rosa Kornfeld-Matte (Chile) fue nombrada por el Consejo de Derechos Humanos primera  Experta independiente sobre el disfrute de todos los derechos humanos por las personas de edad en mayo de 2014. Anteriormente, Kornfeld-Matte había desempeñado el cargo de Directora del Servicio Nacional del Adulto Mayor de Chile, donde elaboró y puso en marcha el Programa Nacional del Adulto Mayor. La experta ha desarrollado una extensa carrera académica y es la fundadora del programa para adultos mayores de la Pontificia Universidad Católica de Chile.     

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