What’s Age Got To Do With It? A Lot, It Turns Out

In an episode of the docuseries “Pretend It’s a City,” filmed in 2019, director Martin Scorsese asks humorist Fran Lebowitz about her persistent cigarette habit. He points out that everyone else in their circle has quit smoking, so why does she keep doing it? “I’m pushing 70,” she retorts in her baritone rasp. “If a seven-year-old dies, it’s a tragedy. If I die, it’s not a tragedy.” They both chuckle.

Lebowitz was expressing a banal truth: A young person’s death is more tragic than the death of someone approaching the normal human lifespan. Of course it is. Everyone knows this.

Then along came COVID-19 and everyone stopped knowing it. The Overton Window lurched before our eyes, locking into an unfamiliar new position: All lives carry the same weight—age has nothing to do with it. A 95-year-old’s death is every bit as tragic as the death of a five-year-old child. Shutting down society in the hope of giving grandma a few extra months in her nursing home makes perfect sense. Those who timidly suggested otherwise got the window slammed on their fingers. “How dare you insinuate that frail, elderly people’s lives don’t matter as much! Sociopath! Ableist! Eugenicist!”

Four years in, emotions have calmed down enough that we can hopefully revisit the topic without hurling mudballs at one another. It’s an important area of discussion, one that reaches far beyond pandemics and calls us to examine our attitudes toward medical intervention, resource allocation and the cycle of human life.

What’s Your Life Worth?

The idea that all lives are equally worth saving is a tidy concept. It simplifies our moral calculus. It feeds into our instinctive recoil against putting a value on life or prioritizing one life over another in times of scarcity. But when it comes to policy decisions about how to allocate our public resources, we need to distinguish between life’s inherent value—a philosophical abstraction that none of us can quantify—and its health-economic value. While we may agree that life has immeasurable value in the abstract, society has always placed limits on the resources it is prepared to deploy to save lives. This is where many people get tangled up: They confuse the two categories of valuation.

An example of this confusion occurred during a January 2021 televised discussion of the COVID lockdowns, when former U.K. supreme court justice Jonathan Sumption told a woman that her stage 4 cancer made her life “less valuable.” Predictably, the online warriors took great offense at this locution. They squawked noisily enough that Sumption had to walk back the sentiment.

Sumption was clearly talking about the health-economic value of the woman’s life: She had an advanced and terminal disease, so it would not make sense to pour as much money and effort into keeping her alive as one might do for, say, a young child with a curable condition. Any self-respecting health economist would agree. But the mob, ever on the lookout for the next pretext for offense, disingenuously took Sumption’s words as a pronouncement on the intrinsic value of the woman’s life. Cue the paroxysms of indignation.

Sumption also maintained that he considered his children’s and grandchildren’s lives more valuable than his own, for the simple reason that “they’ve got a lot more of it ahead.” Well, yes, of course. Didn’t all older people feel this way?

At 67 years old, I hope to spend several more decades on the planet. I plan to learn Turkish and bass guitar when I turn 70. I won’t be going gently. At the same time, I recognize that the spotlight now belongs to my children and their peers. It doesn’t make me feel “less than” to prioritize their lives over my own. “Give place to others, as others have given place to you,” said Montaigne, and I’m happy to oblige. If I had stage 4 cancer, I would not expect my government to devote limitless resources to keeping me alive. I would rather see the money go to a children’s cancer ward or to a leg prosthesis for little Chloe. That is the natural arc of life.

When and why did it become a taboo to say this?

Aging and Triaging

We can begin to answer this question by considering recent developments in medical ethics. For years, front-line health providers used age as a triaging criterion. If two people needed a kidney and only one kidney was available, the younger person would get it (all other variables being more or less equal). The philosophy underpinning this decision has been called “utilitarian aging,” a.k.a. the “fair innings” argument: Older people have lived more life than younger ones and have experienced more of what life has to offer. Denying treatment “steals” more years from a younger patient than from an older one, so the younger one should have priority.

But moral frameworks never stay in one place. Like all humans, ethicists seek novelty, which they often confuse with improvement. A 2022 analysis published in the journal Bioethics, conducted in the thick of the COVID-19 pandemic, argued against age-based crisis protocols. Author Nancy Jecker, a professor of bioethics at the University of Washington School of Medicine, rejected the fair innings argument with this rationale: “Whether an individual has had a fair innings depends not just on the numbers of years they have, but what those years have been like. If someone has been disadvantaged throughout their life, deprioritizing their care only perpetuates a pattern of injustice experienced throughout life.” This logically porous argument fails to address the obvious question: What if a younger and an older patient have had the same level of privilege or disadvantage? Who then gets the kidney?

A U.K. study, also conducted during the pandemic, explored the public’s attitudes toward different approaches to healthcare rationing. The study uncovered a strong rejection of age-based frameworks. The idea of “stepping aside” to make room for younger people offends modern sensitivities, including those of older people. The “gray class” now has a voice, which it uses to argue noisily for its right to keep on living.

A similar sea change has washed away previously established standards of medical cost-effectiveness. Not only has the former threshold of $50,000 per quality-adjusted life year (QALY)—the maximum figure deemed cost-effective for a medical intervention—soared far beyond inflation, but the very notion of QALY has come under scrutiny. Some of the new reasoning makes sense: The old QALY calculations drew a direct line between quality of life and physical health, insinuating that quality automatically declines in disabled people. The disabled community has raised justifiable objections to this presumption. But the new cost-effectiveness thresholds, which governments and insurers appear to make up as they go along, exceed all bounds of reasonableness: Spending hundreds of thousands of dollars on a treatment that prolongs a dying person’s life by an extra three months, such as the late-stage prostate cancer drug Xofigo, is difficult to justify in a world that allows millions of homeless people to roam the streets and forage through garbage bins in the dead of winter.

Society is clearly willing to spend a lot more money to stave off death than to ensure people have enough food for dinner and a bed to sleep in. Paradoxically, the medical advances enabling us to live longer have done nothing but increase our fear of dying.

‘If You Can, You Should’

I am not the first to observe that we live in a death-phobic culture. In contrast to our great-grandparents, few of us see a loved one die at home. Modern death typically occurs in a hospital against a backdrop of IV tubes and beeping machines. By the time the attending nurse gives us the call—“I’m so sorry”—the body has already been whisked away to an unseen place from which it emerges some time later in a coffin or an urn.

With the technological advances that have enabled us to treat some previously intractable diseases, we have stopped viewing death as a part of life, but instead as a sort of aberration—a bug, rather than a feature. Canadian grief literacy advocate Stephen Jenkinson devoted his book “Die Wise” to this theme. He calls modern medicine a religion—“a fundamental creed that grew out of its own success.” Underpinning the ethos of modern medical treatment, he argues, is the idea that “if you can, you should.” If you’re eligible for a mammogram or colonoscopy, you should get it. If a chemotherapy drug that makes you throw up and blasts the hair off your head is available, you should take it. If a doctor tells you about a new clinical trial for people who haven’t responded to standard treatment, you should enroll. You have a duty, both to yourself and to your loved ones, to stay alive as long as possible.

Arthritis? Dementia? Doctors assure us they’re neither natural nor inevitable, but enemies that can be vanquished. Aging is “a disease, one that is treatable,” says nutritionist and longevity authority Serena Poon in a 2023 article for The Washington Post. If it’s a disease, we can fight it. And if we can, we should—which means we are never ready to die or to yield to the experience of dying.

This resistance always exacts a price. “When we exercise our right to not die until we are ready,” writes Jenkinson, “when we employ enormously expensive drugs and technology, expensive both materially and spiritually, to stand in the way of life being itself and us joining the parade, something begins to starve.”

Jenkinson declined treatment at the end of his life. So did Albert Einstein. After a blood vessel burst near his heart, Einstein refused surgery with the rationale that “it is tasteless to prolong life artificially. I have done my share; it is time to go.” I’m not suggesting we send our elders to meet their fate on an ice floe. But there is strength and poetry in saying, “I’ve been here long enough. It’s other people’s turn now.” In our insistence on keeping dying people’s vital signs going at all costs—what I call preserving metabolic life—we’ve lost sight of this spiritual truth.

Staying Alive

We’ve all heard the old joke, variously attributed to George Bernard Shaw, Winston Churchill and Mark Twain, about a man who asks a woman if she would be willing to sleep with him for a million dollars. “Of course,” she says. He then asks her if she would sleep with him for five dollars. “What kind of woman do you think I am?” she cries out. “We’ve already established that,” he responds. “Now we’re just haggling over the price.”

And so it is with health economics. We agree there are limits to the project of keeping people alive—not even the most stalwart right-to-life advocates would expect a government to shell out a million dollars to prolong a person’s life by one day—so what we’re really haggling about is the threshold.

If a million-dollar drug can extend and improve life for someone with cystic fibrosis, many of us would agree it’s a worthwhile investment. The calculus becomes more problematic with some of the pricey new drugs for advanced cancer, such as the previously mentioned Xofigo, or with the array of costly but only marginally effective drugs for dementia.

Daniel Callahan dared to dive into this ethical minefield in his book “Taming the Beloved Beast,” which takes issue with the ever-increasing costs of modern medicine. His solution: “The priorities for technologically oriented healthcare should begin with children, remain high with adults during their midlife, and then decline with the elderly.” As Callahan sees it, a properly functioning healthcare system should help young people become old, rather than help the very old become still older. Helping octogenarians with multiple diseases hang onto another day comes at the expense of other public goods, including basic medical care for the general population.

U.K. epidemiologist Sunetra Gupta brought this perspective to bear on the response to COVID-19. Before the pandemic, she noted in a June 2022 interview with Brownstone Institute founder Jeffrey Tucker, “There was an understanding that, especially when resources are limited, they have to be allocated in a way that is fair with respect to what each generation has already received or not received, rather than being across the board.” The COVID response flipped this societal pillar on its head. Our fear of death led us to hide behind our children, sacrificing their mental, social and economic health to the chimera of immortality.

There is a curious dichotomy in how we treat our frail elderly: On the one hand, we ship them off to “old age homes” and become bit players in their lives. On the other hand, we want them to live forever. The pandemic accentuated this split: Grandma came first. The media kept reminding us of our duty toward the elderly but stayed curiously silent on our obligations to the young.

Texas governor Dan Patrick took a stab at it in the spring of 2020. “Those of us who are 70-plus, we’ll take care of ourselves, but don’t sacrifice the country,” he told Tucker Carlson on Fox News. The social media vultures pounced on his “callousness,” entirely missing the spirit of his comments: He wasn’t suggesting we kick oldsters to the curb, just expressing the biological imperative to prioritize the young—those whose lives still lie ahead. The biggest irony is that, to preserve grandma’s metabolic life, we isolated her from the one thing that still held meaning for her: human connection.

Insisting that all deaths are equally tragic dishonors the natural arc of life. Little Chloe should come first, as people have always understood until medical technology turned us away from our sturdiest intuitions. Here’s Jenkinson again: “Our deaths can, in every sense the word can be meant, feed life—unless we refuse to die, or fight dying, or curse dying, or spend all our dying time not dying. When we do that we exempt ourselves from the biodynamic imperative and the great caravan of how it is.”