With well over a half-million confirmed cases of Coronavirus Disease 2019 (COVID-19) in Europe, a growing number of regional medical authorities have begun issuing guidelines and protocols that call for hospitals to prioritize younger patients over those who are older.
In Italy and Spain, the two countries most affected by the coronavirus pandemic in Europe, doctors in overwhelmed intensive care units have for weeks been making life or death decisions about who receives emergency treatment. The new protocols, however, amount to government directives that instruct medical personnel effectively to abandon elderly patients to their fate.
In addition to the ethical questions raised by the rationing of healthcare according to age, the denial of medical attention to the elderly, many of whom have paid into the social welfare system all their lives, also casts a spotlight on the shortcomings of socialized medicine in Southern Europe, where austerity measures imposed by the European Central Bank have resulted in massive budget cuts for public healthcare.
In Spain, the regional government in Catalonia, an area hit hard by the coronavirus, issued a confidential protocol which effectively advises that elderly people afflicted by the coronavirus should die at home.
In documents leaked to several Spanish media outlets, the Catalan Emergency Medical Service (Servicio de Emergencias Médicas, SEM) instructed doctors, nurses and ambulance personnel to inform the families of older patients suffering from coronavirus that "death at home is the best option."
The document stated that dying at home was more humane as it avoids suffering: patients can die while surrounded by their families, something that is not possible in overcrowded hospitals. The protocol also advised medical personnel to avoid referring to the lack of hospital beds in Catalonia.
The recommendations, endorsed by the Council of Physicians' Associations in Catalonia (Consejo de Colegios de Médicos de Cataluña), stated that patients over 80 years of age should not be intubated and be offered only "oxygen mask therapy." The guidelines recommended that patients over 80 who are suffocating be administered "comfort treatment with morphine to alleviate the sensation of dyspnea."
SEM also advised healthcare professionals to optimize medical resources in the current emergency situation and "avoid admitting patients with little benefit." Medical personnel were asked to reserve the material "for those patients who can benefit the most, in terms of years of life saved."
The Catalan Minister of Health, Alba Vergés, denied that the directive discriminates against elderly patients. SEM medical director Xavier Jiménez also denied it, but he admitted that the document exists. "All we are doing is offering patients the best option for their situation," he said.
Elsewhere in Spain, the Madrid-based Spanish Society of Intensive and Critical Medical Care (Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias, SEMICYUC) recommended that maximum therapeutic efforts should be reserved for younger people with more possibilities of survival. If there is a shortage of hospital beds, people over the age of 80 or those with Alzheimer's disease should be denied treatment.
In Italy, a document prepared by a crisis management unit in the northern city of Turin also proposed that coronavirus victims aged 80 or older or those in poor health should be denied access to intensive care if there are not enough hospital beds.
In a document leaked to the British newspaper The Telegraph, the civil protection department of the Piedmont region, stated:
"The criteria for access to intensive therapy in cases of emergency must include age of less than 80 or a score on the Charlson Comorbidity Index [which indicates how many other medical conditions the patient has] of less than 5.
"The growth of the current epidemic makes it likely that a point of imbalance between the clinical needs of patients with COVID-19 and the effective availability of intensive resources will be reached.
"Should it become impossible to provide all patients with intensive care services, it will be necessary to apply criteria for access to intensive treatment, which depends on the limited resources available."
A Piedmont health councillor, Luigi Icardi said:
"I never wanted to see such a moment. It [the document] will be binding and will establish in the event of saturation of the wards a precedence code for access to intensive care, based on certain parameters such as potential survival."
In the Netherlands, doctors have been accused of trying to ration scarce beds in intensive care units by advising elderly patients suffering from COVID-19 to waive hospital treatment, according to the Reuters news agency.
Dutch MPs raised concerns after senior citizens complained about receiving calls from doctors. MP Henk Krol, who leads the 50PLUS party for seniors, warned against age discrimination:
"One octogenarian is not the same as another. There are eighty-year-olds who are fit and running marathons, and there are fifty-year-olds who are in ill health."
Health Minister Hugo de Jonge denied that the doctors' calls were official government policy. He told Reuters that "advanced care planning" discussions between general practitioners and patients with serious medical conditions were not unusual:
"This is standard practice for doctors. We call it advanced care planning, it means having the conversation with people about 'what you would want to happen if you get sick.'
"Patients can then say, 'if it gets to the point where I need a ventilator, where I need to go into the ICU, I would prefer not to do that.' That is a possibility, but those conversations are not based on the age of patients."
In a March 15 interview with the Dutch television program WNL Op Zondag, Marc Bonten, a microbiologist at the University Hospital of Utrecht, said:
"What is the best way to serve humanity? Aspects such as who has the greatest chance of surviving an admission to intensive care will come into play. It's up to the doctors to see who has the best chance of survival."
Back in Spain, Óscar Haro, director of a motorcycle racing team, described in a viral YouTube video how his elderly father died from coronavirus after being denied a respirator because of his age:
"My father started working at the age of 14 until he was 65. He never asked for anything. On March 18, he needed a respirator to avoid dying and was denied.... This is the Spain we have. My father's generation built this country, its reservoirs, roads, agriculture, working 14 hours a day, coming out of a postwar period. And they are being left to die.
"I do not understand how a person like my father, who has been working all of his life, contributing to social security in this country, could die because there are no respirators, because he was unable to receive treatment, because of regulations which state that with people older than 75, it is no longer interesting to take care of them and they are left to die. We are leaving to die a generation that built this country.
"We are saying that we have incredible social security, when healthcare personnel do not even have gloves to wear. This morning they had no robes or masks. I do not understand that my father, who has been together with his wife since the age of 15, was not allowed to say goodbye to her."
Meanwhile, Ivan Calle Zapata, a football coach in Martorell, a municipality in Catalonia, wrote about how he lost his paternal and maternal grandparents to coronavirus:
"My 82-year-old grandmother and 71-year-old grandfather did not die from #COVID-19, they were LEFT TO DIE. @salutcat [Catalan health authorities] denied them respirators and admission to the ICU, just like other older people in Catalonia. Following is an open thread, for them, and for all the broken families:"
Faced with growing public outrage over the lack of treatment for the elderly, the Spanish government on April 3 issued a statement in which it said that denying healthcare to the elderly was unconstitutional:
"In case of extreme scarcity of healthcare resources, older patients should be treated under the same conditions as the rest of the population, that is, according to the clinical criteria of each particular case. Accepting such discrimination would lead to an underestimation of certain human lives due to age, which contradicts the foundations of our Rule of Law, in particular the recognition of the equal intrinsic dignity of every human being."
The government's statement does not have legal effect, which means that regional governments in Spain are not expressly prohibited from ending the practice of denying healthcare to the elderly.
The scarcity of healthcare resources in Spain and Italy, the two European countries most affected by the coronavirus pandemic, can be directly attributed to a decade of austerity measures.
During the European debt crisis in 2011 and 2012, when many Italian and Spanish banks were on the brink of collapse, Northern European countries imposed strict budgetary conditions in exchange for bailouts. As a result, government spending on public healthcare was drastically reduced.
In Spain, the government in April 2012 unveiled austerity measures designed to slash 65 billion euros from the public deficit by 2014. The cuts, imposed by the European Central Bank, reduced Spanish spending on public healthcare by a whopping 10%. Spain's then-Prime Minister Mariano Rajoy explained: "These measures are not pleasant, but they are necessary. Our public spending exceeds our income by tens of billions of euros."
In November 2019, two months before the coronavirus first appeared in Spain, the Spanish government revealed that nearly 700,000 patients were on a waiting list for surgeries. Nationwide, patients had to wait on average 115 days to receive surgery; in Catalonia, patients had to wait nearly six months; in Madrid, patients had to wait for six weeks.
A similar scenario occurred in Italy, where the government cut billions of euros in spending for public healthcare since 2012 in exchange for bailout monies from the European Union.
Many economists have said that Italy and Spain should never have joined the euro, the single currency used by 19 of the 27 Member States of the European Union, because by doing so they lost their monetary sovereignty: they lost the ability appreciate or depreciate their currency to manage their economies and respond to economic shocks.
The severity of the coronavirus crisis in Italy and Spain, where elderly patients are being allowed to die for the benefit of the young, is due in large measure to the austerity measures associated with their membership in the eurozone. The large numbers of dead, especially among the elderly, appears to be the price that Italians and Spaniards are paying to be part of a monetary union which they never should have joined.