Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=uajb20 The American Journal of Bioethics ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/uajb20 Saving the Babies or the Elderly in a Time of Crisis? Joona Räsänen To cite this article: Joona Räsänen (2020) Saving the Babies or the Elderly in a Time of Crisis?, The American Journal of Bioethics, 20:7, 180-182, DOI: 10.1080/15265161.2020.1779866 To link to this article: https://doi.org/10.1080/15265161.2020.1779866 Published online: 27 Jul 2020. Submit your article to this journal View related articles View Crossmark data DISCLOSURE STATEMENT No potential conflict of interest was reported by the author(s). REFERENCES Cavolo, A., B. D. de Casterle, G. Naulaers, and C. Gastmans. 2019. Physicians' attitudes on resuscitation of extremely premature infants: A systematic review. Pediatrics 143(6): e20183972. doi:10.1542/peds.2018-3972. Cummings, J. and Committee on Fetus and Newborn. 2015. Antenatal counseling regarding resuscitation and intensive care before 25 weeks of gestation. Pediatrics 136 (3): 588–595. doi:10.1542/peds.2015-2336. Dirksen, K. M., J. W. Kaempf, M. W. Tomlinson, and N. W. Schmidt. 2017. Decision zone at the margins of life and good health: The role of medical staff guidelines for the care of extremely early gestation pregnancies and premature infants. The American Journal of Bioethics 17(1): 89–91. doi:10.1080/15265161.2016.1251634. Guillen, U., E. M. Weiss, D. Munson, et al. 2015. Guidelines for the management of extremely premature deliveries: A systematic review. Pediatrics 136(2): 343–350. doi:10.1542/peds.2015-0542. Haward, M. F., A. Janvier, G. P. Moore, N. Laventhal, J. T. Fry, and J. Lantos. 2020. Should extremely premature babies get ventilators during the COVID-19 crisis? American Journal of Bioethics 20(7): 37–43. doi:10.1080/ 15265161.2020.1764134. Kaempf, J. W., and K. M. Dirksen. 2018. Extremely premature birth, informed written consent, and the Greek ideal of sophrosyne. Journal of Perinatology 38(4): 306–310. doi:10.1038/s41372-017-0024-4. Kaempf, J. W., M. W. Tomlinson, and J. Tuohey. 2016. Extremely premature birth and the choice of neonatal intensive care versus palliative comfort care: An 18-year single-center experience. Journal of Perinatology 36(3): 190–195. doi:10.1038/jp.2015.171. Kaempf, J. W., N. Kockler, and M. W. Tomlinson. 2018. Shared decision-making, value pluralism and the zone of parental discretion. Acta Paediatrica 107(2): 206–208. doi: 10.1111/apa.13971. Paris, J. J. 2005. Resuscitation decisions for "Fetal infants." Pediatrics 115(5): 1415. doi:10.1542/peds.2004-1950. Raju, T. N. K., D. J. Burchfield, and G. F. Joseph. 2014. Periviable birth: Executive summary of a joint workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists. Journal of Perinatology 34:333–342. THE AMERICAN JOURNAL OF BIOETHICS 2020, VOL. 20, NO. 7, 180–182 https://doi.org/10.1080/15265161.2020.1779866 OPEN PEER COMMENTARIES Saving the Babies or the Elderly in a Time of Crisis? Joona R€as€anen University of Oslo In their important article, Haward et al. (2020) discuss whether guidelines for treating extremely premature babies should be altered to free up ventilators during crises such as COVID-19 pandemic.1 The authors' claim is that premature babies do not deserve special consideration for ventilator treatment but merely equal consideration. In this brief commentary, I continue their discussion by considering additional factors that may help us determine whom we should save in a crisis: babies or the elderly. To illustrate the problem, we can summarize the imaginary but very plausible case Haward et al. (2020) raises as follows: Jim, 75, has developed worsening respiratory distress from the COVID-19. He will likely die unless he is soon intubated and ventilated. At the same time, Louise gives birth to her and her husband's first, very eagerly awaited child: a healthy but premature newborn infant, Judy. Judy, like all infants at her age and stage of development (23weeks old and weighing only 600 g) needs to be intubated and ventilated or CONTACT Joona R€as€anen joona.rasanen@ifikk.uio.no Department of Philosophy, Classics, History of Arts and Ideas, University of Oslo, Postboks 1020 Blindern, Oslo, 0315, Norway. 1On March 2020, it was claimed that no matter which estimate we use, there simply are not enough ventilators for U.S. patients with COVID-19 in the upcoming months (Ranney et al. 2020).  2020 The author(s). Published with license by Taylor and Francis Group, LLC 180 OPEN PEER COMMENTARIES else she will likely die. Judy and Jim are in the same hospital. The adult ICU is full. There is only one ventilator left, and it can be used for either Jim or Judy. Who should get the ventilator? Haward et al. (2020) raise several possible criteria for making the decision. One such criterion is the total number of life years lost when dying. For instance, a newborn infant that dies can be expected to lose roughly 80 life years, while a 75-year-old is likely to lose just a few years. However, because some adults who need ventilators have a survival rate higher than some extremely premature infants, it is not obvious which we should save. Accounts that consider only the total life years lost-such as the deprivation account-cannot successfully explain which loss of life is the greatest loss to the one who dies. That is because what must also be considered, in addition to the life years lost, is the possible psychological connectedness and continuity of the one dying to his or her future self. For instance, healthy 75-year-olds have strong psychological connections to their past and future selves. They remember what has happened to them, and they anticipate and care what will happen to them in the future.2 However, in the relation between premature newborn infants and their future, adult selves, there is a much weaker degree of psychological connectedness. McMahan (2002) has developed perhaps the most sophisticated theory relating the psychological continuity of one's future self to the ethics of killing and saving. According to McMahan, because of the very weak psychological link between infants and their future selves, an infant's time-relative interests in continuing to live are extremely weak. What this means is that death matters less for an infant at the time than it matters for the otherwise healthy septuagenarian. The belief that death is not seriously bad for the fetus or the premature infant itself, explains, for instance, why we do not generally use more medical resources to prevent miscarriages (Ord 2008; Simkulet 2017). None of this necessarily means that the death of an infant does not matter at all, only that it does not matter much in comparison to the death of what can be called a standard human adult.3 This line of reasoning would further mean that if, during pandemics such as COVID-19, we decide whom we should save based on the intrinsic features of humans, we should prioritize adults over premature infants, since the death of an adult harms that adult more than the death of an infant harms the infant.4 Be that as it may, when we take into account other, extrinsic features, such as the distress and grief of the parents of the dying baby and the similar emotions of the relatives of the beloved dying elder, things get more complicated. While the death of someone aged 75 undoubtedly brings sorrow and grief to those left behind, such death often is anticipated and considered a natural occurrence. However, the death of a young child is a very different thing. Many feel it is unnatural to outlive one's child. Losing a child might feel like the ultimate violation of the rules of life; people should die when they are old, not when they are young. Losing a young baby, especially, can be emotionally overwhelming. At least one study shows that even six years after the loss of an extremely premature infant, the parents still suffer a lot from their bereavement (B€uchi et al. 2007). The emotional impacts on the relatives can thus be assumed to be more severe when a premature baby dies than when an elder dies – despite the fact that according to the time-relevant interest account death harms an infant less than it harms an adult. Taking into account the grief, distress, and sorrow that others will experience when Jim or Judy dies, there seems to be a compelling moral reason to save the infant rather than the elder: the death of the latter is less painful to his family members. Therefore, whether we should save infants or the elderly in time of crisis depends, at least in part, on how much weight, if any, we give to the emotional impact of people's deaths on others or whether we make the decisions based solely on the intrinsic features of those at the risk of dying. ORCID Joona R€as€anen http://orcid.org/0000-0002-7383-6138 REFERENCES B€uchi, S., H. M€orgeli, U. Schnyder, et al. 2007. Grief and post-traumatic growth in parents 2–6 years after the 2However, this is likely to change if the elderly is, for example, in an advanced stage of Alzheimer's disease. Then, his time-relative interests to live are reduced, perhaps to the level that of an infant. In related to this, it is argued elsewhere that according to utilitarianism we should save a patient who has normal brain function but fewer years to live than an unconscious dementia patient if we cannot treat them both (Savulescu et al. 2020). 3This view has some significant implications for the abortion debate as well, with regard to how much killing fetuses and infants harms them (see, for instance, McMahan 2007; R€as€anen 2016). 4Another point worth mentioning is that if we understand resuscitating extremely preterm infants as creating life rather than saving it, as previously suggested by Rieder (2017), since we normally have a stronger reason to save a life than to create one, we should save the elderly. THE AMERICAN JOURNAL OF BIOETHICS 181 death of their extremely premature baby. Psychotherapy and Psychosomatics 76(2): 106–114. doi: 10.1159/ 000097969. Haward, M. F., A. Janvier, G. P. Moore, N. Laventhal, J. T. Fry, and J. Lantos. 2020. Should extremely premature babies get ventilators during the COVID-19 crisis? The American Journal of Bioethics 20(7): 37–43. doi: 10.1080/ 15265161.2020.1764134. McMahan, J. 2002. The ethics of killing. Oxford: Oxford University Press. McMahan, J. 2007. Infanticide. Utilitas 19 (2):131–159. doi: 10.1017/S0953820807002440. Ord, T. 2008. The scourge: moral implications of natural embryo loss. The American Journal of Bioethics 8(7): 12–19. doi: 10.1080/15265160802248146. Ranney, M. L., V. Griffeth, and A. K. Jha. 2020. Critical supply shortages – The need for ventilators and personal protective equipment during the COVID-19 pandemic. The New England Journal of Medicine 382(18): e41. doi: 10.1056/NEJMp2006141. Rieder, T. 2017. Saving or creating: Which are we doing when we resuscitate extremely preterm infants? The American Journal of Bioethics 17(8): 4–12. doi: 10.1080/ 15265161.2017.1340988. R€as€anen, J. 2016. Pro-life arguments against infanticide and why they are not convincing. Bioethics 30(9): 656–662. doi: 10.1111/bioe.12281. Savulescu, J., I. Persson, and D. Wilkinson. 2020. Utilitarianism and pandemic. Bioethics 34(6): 620–632. doi: 10.1111/bioe.12771. Simkulet, W. 2017. Cursed lamp: The problem of spontaneous abortion. Journal of Medical Ethics 43(11): 784–791. doi: 10.1136/medethics-2016-104018. THE AMERICAN JOURNAL OF BIOETHICS 2020, VOL. 20, NO. 7, 182–184 https://doi.org/10.1080/15265161.2020.1779399 OPEN PEER COMMENTARIES Racial Disparities in Preemies and Pandemics Marin Arnoldsa , Rupali Gandhib , Mobolaji Famuyidec, and Dalia Feltmana aEvanston Hospital; bAdvocate Christ Medical Center; cUnivesrity of Mississippi Medical Center As COVID-19 related hospitalizations surged in other countries and began to rise sharply in the United States, hospitals, healthcare systems, and states began to grapple with the terrifying question of what to do if ventilators became scarce. Centers began to develop protocols to guide how scarce resources would, if necessary, be allocated among different patients. Extremely preterm infants continue to be born during the pandemic and require critical care resources, including ventilators (not because of COVID-19 but because of their immature organ systems). Haward and colleagues address the question of how these fragile newborns should factor into scarce resource allocation protocols (Haward et al. 2020). The authors address important realities commonly encountered by the neonatology community. Their compelling arguments for supporting the claims of extremely premature infants to continued ventilator provision within these protocols include: existing bias against extremely premature infants, the difficulty in predicting the outcome of a given extremely premature infant, and the absence of acceptable tools to compare long or short-term prognoses for an extremely preterm baby ("Judy") against those of an adult ("Jim"). The authors rightly caution against the use of QALYs as potentially leading to ableist and ageist discrimination. Haward and colleagues acknowledge that many groups have historically and currently encounter discrimination, however, the conversation of scarce resource allocation is not complete without addressing such inequities. Healthcare disparities are too closely intertwined with prematurity and COVID-19 outcomes to discount in hopes of "leveling the field" when considering whether Judy (the premature infant) or Jim (the septuagenarian) gets the ventilator. We must recognize disparities as they pertain to ventilator allocation protocols and wish to highlight racial disparities that have been exposed by the COVID-19 pandemic, and how these same disparities affect premature newborns. CONTACT Marin Arnolds marnolds@northshore.org Pediatrics, Evanston Hospital, 2650 Ridge Avenue, Walgreen #1505, Evanston, IL, 602011797, USA.  2020 Taylor & Francis Group, LLC 182 OPEN PEER COMMENTARIES