Vulnerable and Valuable: Ageism and Covid-19

The Rise in Ageism during the Covid-19 Pandemic in Relation to Scarce Resource Allocation

By Lizzy Washburn

This paper will focus on how the Covid-19 pandemic has disproportionately affected the elderly community and has shed light on systemic issues threatening the safety and wellbeing of the elderly community. Additionally, it will explore the value of life as it relates to the allocation of scarce resources, specifically in relation to the elderly. The social status of elderlies in other countries will be discussed to shed light on how the United States can still improve in its treatment of elderlies. The ethical issue that will be addressed is: can ageism be justified during a time of crisis, such as the Covid-19 pandemic? Additionally, should age be a deciding factor when it comes to allocating scarce resources? Values such as respect and productivity will be examined to show possible consequences of creating a social hierarchy based on age in medicine during a time of crisis.

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Table of Contents

• What Is Ageism?
• Examples of Ageism Seen Prior to the Covid-19 Pandemic
• Elderly Hospitalization and Mortality Statistics within Covid-19
• Covid-19’s Impact on Elderly’s Mental Health
• Ageism Seen during the Covid-19 Pandemic
• How Aging is Viewed in Korean, Indian, and British Cultures
• How Covid-19 has Affected the Elderly in India, South Korea, and the United Kingdom
• Ethical Question and Introduction to Arguments
• Model Case Scenario
• Conclusion

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Life is a complicated process in which an individual will inevitably go through various stages of life. From the infant stage, to adolescence, to adulthood, and inevitably the elderly stage of life. Unfortunately, discrimination towards the elderly community is increasing at an alarming rate. Ageism can be defined as:

“Ageism is a type of discrimination that involves prejudice against people based on their age. Similar to racism and sexism, ageism involves holding negative stereotypes about people of different ages”

– Kendra Cherry

The focus within this paper will be on how ageism negatively affects the elderly community, which is defined as anyone who is above the age of 65.

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To provide context as to how ageism has been able to rise during the pandemic, I would like to provide examples of ageism seen prior to the pandemic.

Ageism in the Workforce

A commonly seen form of ageism is through offensive remarks and actions toward the elderly, specifically in the workplace. Due to the rise in technologies to increase the lifespan of older adults, the elderly population is growing. According to the United Nations, in 1980, there were approximately 382 million adults above the age of 60. In 2017, there were estimated to be 982 million adults above the age of 60, which is more than double what it was in 1980. Similarly, it was estimated that the elderly population will reach a total of 2.1 billion people by the year 2050. In the workplace, there has also been a growth in employees above the age of 70. Since 2000, the amount of people above the age of 70 in the workforce has increased to a total of 15%. Similarly, the 50+ age group are large contributors to the economy. In 2018, the 50+ age group contributed $8.3 trillion to the economy, and they would have been ranked the third-largest economy in the world by GDP, sitting right behind China, which has a GDP of $13.4 trillion (Terrell). It is evident that the elderly population specifically in the workforce is growing, but this has led to an increase in ageism, specifically through hateful remarks such as the term “Ok Boomer.” Scott Warrick, an Ohio-based employment attorney, told the Society for Human Resource Management,

“Somebody being treated differently because of age — whether it is ignoring or ostracizing or saying ‘OK, boomer’ — may create an environment so hostile that a person can’t function.”

-Scott Warrick

As the number of individuals in the workforce increases, and if ageism continues to spread, there could potentially be a decrease in the number of older adults willing to work. 

Elder Abuse

The US National Academy of Sciences has defined elder abuse as:

“(a) intentional actions that cause harm (whether or not harm is intended), to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder or (b) failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm.”

-US National Academy of Sciences

Elder abuse, a form of ageism seen frequently in society, is broken down into five major categories: psychological or emotional abuse, physical abuse, sexual abuse, neglect, and financial abuse. The National Council on Aging has estimated that 1 in 10 Americans above the age of 60 have experienced some form of elder abuse. That number has been estimated to be about 5 million per year, but only about 1 in 24 cases of elder abuse are estimated to be reported each year. Additionally, aging can cause a series of problems as the body is more worn down. For example, a disease that can be present in older adults is Alzheimer’s, which is a form of dementia that destroys memory and other mental functions. This can lead to vulnerability towards the end of life. The Abuse of People with Dementia Representative Survey was conducted through interviews with dementia patients. In the survey, 52% of respondents reported some type of abuse in the past 3 months; 34% of respondents reported abusive behavior; 33% of respondents reported psychological abuse, and 1% of respondents reported physical abuse. All of these abuses are facilitated through their caregiver or family member. Additionally, in a US-based study conducted in Florida, it was discovered that 60.1% of caregivers for dementia patients reported verbal aggression as a means of conflict resolution (Kohn and Verhoek-Oftedahl). Additionally, caregivers in nursing homes who are caring for dementia patients may use “elderspeak” which is inappropriate child-like speech that is used when talking to patients with dementia. Although it may seem harmless, this is seen as a micro-aggression within ageism because it furthers stereotypes about dementia patients and belittles the patients. In nursing homes, it has been discovered that when elder-speak is frequently used, there are double the rates of challenging behavior of residents with dementia. (Williams, Shaw, Lee, Kim, Dinneen, Turk, Jao, and Liu). 

Neglect in the Medical Field

Another prevalent form of frequently seen ageism is the neglect of elderly patients in the medical field. Yale School of Public Health conducted a study that revealed that ageism in the medical field against individuals who are 60 and over is responsible for 17 million cases of the 8 most expensive illnesses, which adds up to around $63 billion a year. Neglecting patients because of their age leads to increased intensity in diseases and can lead to additional increased cardiovascular stress, which can cause strokes and heart attacks along with other age-related comorbidities. Neglect leads to increased spendings due to diseases intensifying, and money can be saved if all elderly patients are granted equitable care. Through thorough care, diseases can be prevented early on but neglect can prevent this from happening (Kalter).

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Research collected by the Centers for Disease Control and Prevention revealed how vulnerable the elderly truly are during the Covid-19 pandemic. In the research conducted, the reference group was 5-17 years old and they were being compared to older adults for cases, hospitalizations, and deaths. Below is the chart:

According to the table above, it is evident that the number of hospitalizations and deaths rises dramatically as age increases. For example, the 85+ age group has 2x the amount of cases, are 95x more likely to be hospitalized, and 8700x more likely to die. Similarly, data collected by the Kaiser Family Foundation revealed that individuals below the age of 50 account for less than 25% of the total deaths from COVID-19 in all states. When this data was published on July 22, 2020, there were no deaths due to COVID-19 for people who were under 55 in Idaho. Additionally, 80% of all COVID-19 deaths have been from the older adult community (CDC).

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COVID-19 has negatively affected the elderly community socially, medically, and emotionally. To keep elderly people safe from the virus, many were instructed to stay at home and stay isolated from friends and family. This isolation has been detrimental to their mental health. Self-isolation can cause depression, anxiety, and death by suicide or mental decline. Mental illnesses are increasing within this community as many elderly people are becoming anxious as life is slowly beginning to look normal. 46% of older adults (65+) in July 2020 said that stress-related to COVID-19 had a negative impact on their mental health. This percentage is up from May where 31% of older adults reported that COVID-19 was currently negatively affecting their mental health. In 2010 11% of adults above the age of 65 had reported some form of mental illness, and in August of 2020, it was reported that 24% of elderlies were currently experiencing depression or anxiety (Koma, True, Fuglesten Biniek, Cubanski, Orgera, Garfield). It is evident that Covid-19 has placed an immense amount of stress on all individuals, and especially the elderly.

Case Study

To understand the severity of the situation even more clearly, let’s focus on the case study of Chester Peske. Chester was a 98-year-old man who had Alzheimer’s, but he was a very happy guy. The Covid-19 pandemic occurred and he contracted Covid-19 but survived due to being asymptomatic. After months of self-isolation and with no contact with his family, he slowly started to decline and he became increasingly depressed. This mental drain of being alone coupled with his Alzheimers sped up his decline and before his family could even get to him, he passed away. He had survived Covid-19 and was living with Alzheimer’s but social isolation ended up taking his life (Henninger). This is only one example of how Covid-19 is causing immense mental health issues, which are resulting in additional casualties. According to the National Institutes of Aging, depression and mental illnesses are frequently overlooked within the elderly community because caretakers may be unaware of how to assess their emotions or they may associate the mental illness with a sign of aging

Comparison To SARS Outbreak

During the SARS pandemic, a similar situation occurred. Research collected in Hong Kong in 2003, which was when the SARS pandemic occurred, showed that 48% of the Korean population experienced depressive feelings in relation to the pandemic. In Daegu, which had a large outbreak, 65% of the population experienced depressive emotions due to the stress related to the pandemic (Lee, Jeong, Yim). Through this comparison, it has become apparent that mental health issues are intensified during a pandemic and/or epidemic, especially those within vulnerable groups such as the elderly since their specific mortality rate is extremely high when it comes to infectious diseases such as SARS and COVID-19.

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COVID-19 has been able to bring to light systemic issues in American society relating to the treatment of elderlies, and further create issues for this community.

“Clearing the Deck” Mentality in relation to QALYs and SOFA Score

An example of ageism has been the “clearing the deck” mentality. When caring for patients in a time of crisis, such as the COVID-19 pandemic, not every patient can be saved. This is a fact, yet some healthcare professionals have been using a rather ageist/utilitarian outlook on this issue. This issue has been prevalent among the elderly community because healthcare professionals have been trying to maximize the number of lives being saved, and this comes at the expense of elderly lives. Two methods that contribute to clearing the deck are the SOFA score and QALYS. SOFA score or (Sequential Organ Failure Assessment) is a triage tool used by hospitals that are operating under ‘crisis standards of care.’  It provides a way to evaluate patients on 6 medical parameters and judge their condition relative to other patients. Patients with lower scores/better organ function are thought to have a better prognosis.  SOFA may favor younger patients because they may be in better health overall/may be less likely to have health conditions affecting any of the 6 critical parameters (Lambden, Francois Laterre, Levy, Francois). According to Justice in Aging’s fact sheet, the issue that arises with the SOFA score is that this method works by comparing the current state of a patient’s organs and their potential with using the resources in the long term, as a tool to allocate resources. This method favors younger patients because if a patient is older, their score will be higher since they may not be able to live as long as the younger patient can. They also may have more age-related comorbidities, which will additionally raise their score. Higher scores are placed in groups that are last to receive resources such as ventilators. Additionally, in the event that two patients have the same SOFA score, there are no measures in place that ban using age as a tiebreaker. QALYs, or quality-adjusted life years, are rates calculated to measure how intervention from a medical treatment can extend and improve quality of life. The issue that arises with QALYs is that it uses life years ahead and quality of life to determine if a treatment is suitable for a patient. If a treatment is being compared on a younger adult and an elderly person, the elderly person will have fewer QALYs since they have fewer years ahead of them and a potentially lower quality of life due to age-related comorbidities (Smith). Both the SOFA score and QALYs use age as a major factor in allocating scarce resources.

COVID-19 Clinical Trials and Vaccine Production

Another form of discrimination has been the vaccine production and clinical trials for the COVID-19 vaccine. With the numbers of COVID-19 cases constantly rising, it has become increasingly important for a vaccine to be produced, and thankfully many have been. In the past, older adults have been excluded from vaccine trials and other clinical trials, and to combat this the National Institutes of Health implemented the Inclusion Across Lifespan policy which requires that older adults are included in clinical trials. A study was conducted to see how adults above 65 could potentially be excluded in 847 clinical trials. After examining many clinical trials, they were able to estimate that 50% of older adults (above 65) are likely to be excluded from Covid-19 clinical trials due to high selectivity based on age and health. One recent study revealed that their median age for their clinical trial was 40, which concluded that there is most likely not any individuals over the age of 75. Many companies argue that they do not want to run the risk of hurting older individuals with clinical trials and that herd immunity, which is 67%, can be reached by only vaccinating the young. This statement is true, but in places such as nursing homes, all of the individuals must be vaccinated to keep everyone safe, since they are all vulnerable. Additionally, not including them in trials means that later on there is uncertainty on how the vaccine will affect them. As adults age, their antibody response may decrease, which means that not testing them with the vaccine before distributing it could lead to additional issues (Helfland, Webb, Gartaganis).

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The US is considered a youth-centered country, which means that they value the young strongly as they believe they are the future of the country. In places such as India and South Korea, the culture is very different.

The US is considered a youth-centered country, which means that they value the young strongly as they believe they are the future of the country. In places such as India and South Korea, the culture is very different.

Korean Culture

For example, in Korean culture, aging is a blessing and a tremendous feat. They rely on the Confucian principle of filial piety, which means that children and young adults should respect their parents. Koreans believe that it is their moral obligation to care for their parents and to show respect and honor elders in their everyday lives. The combination of filial piety and brotherhood is what shapes humanity according to the Koreans, so respect is necessary at all times. To show their love and honor for the elderly community, when a Korean turns 60, they have a large party that celebrates the individual’s entry into old age. Additionally, they have another large party when someone turns 70. These celebrations take place to honor these individuals since many of their ancestors were unable to live as long of a life as people are able to now.

Indian Culture

India views their elders similarly to Korean culture. India places their elders on a pedestal. They are the head of the household and play an important role in raising the children. They are looked upon as the wisest and offer advice to their loved ones. Additionally, since they have the most power, they usually have the last say in arguments and are responsible for making important decisions within the family. Since the elders are seen as an important member of their families, placing them in nursing homes or disrespecting them is negatively looked upon. 

British Culture

The United Kingdom views its elders similarly to the United States. In the UK, elders are frequently viewed as a burden to society. Their country is very youth-centered, so people believe that elders are a burden to society since they may not be able to work as well as younger individuals, causing them to waste potential earnings. The media is a common way in which stereotypes are spread about the elderly population and the effects of aging (Huffington Post).

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To examine how culture can affect fatalities, I looked into the case fatality rate (CFR) of each country for all individuals, then dove deeper into how the elderly have specifically been affected in each country. Case fatality rates are defined by Dr. Osman Shabir as:

“The severity of a particular disease by defining the total number of deaths as a proportion of reported cases of a specific disease at a specific time.”

-Dr. Osman Shabir

These rates are measured as a percentage from 0-100 and it compares the deaths due to the disease compared to the total number of cases. The rates listed below for each country are as of February 2021 except for the CFR rate for India, which was the rate as of early March.

South Korea

In South Korea, the case fatality rate was 1.8% for all ages. (Ritchie, Ortiz-Ospina, Beltekian, Mathieu, Hasell, Macdonald, Giattino, Appel, and Roser). Specifically, older adults above the age of 60 account for 95.55% of all deaths in South Korea (So).

India

In India, the case fatality rate was 1.3% for all ages in the country in late March (Mullick). 51% of the total deaths in India due to Covid-19 have been from the 60+ age group (Sharma). In the United Kingdom, the case fatality rate is 2.9% for all ages (Shabir).

United Kingdom

Looking at mortality rates reveals that the elderly are among the most vulnerable in the United Kingdom. Research collected by the United Kingdom government revealed that the mortality rate during January 2021 for someone who is between the ages of 30-39 is 28.9, while the rate for someone above the age of 80 is 7,856.9. Similarly, for someone who is between 60-69 it is 668.4, which is still high above the rate for individuals between 30-39. Although each country’s cultures and values shape the way they view their elderly community, each country has been negatively affected by Covid-19.

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My main ethical question is, can ageism be justified during a time of crisis? Additionally, should age be a determining factor when allocating scarce resources? When thinking about both of these questions, I was also pondering the effects that ageism can have on society. I have broken it down into two standpoints on this issue: ageism can be justified, which focuses on public health, versus, ageism cannot be justified, which focuses on private health. I used values, frameworks, and principles, to help create both arguments.

Argument I. Ageism can be justified: Public over Private Health

The principle that I saw most pertinent to this standpoint was utilitarianism, which is the framework that states that actions are right if they benefit the majority. There must be more of a priority on saving the most amount of lives in a time of crisis. It is necessary to prioritize public health over individualized care. In a recent study conducted by a triage team, it was concluded that the elderly community does have a lower chance of recovering from infectious diseases and viruses, such as Covid-19, which places them in a lower prioritization group (Peterson). To support this, Toby Young, a right-wing political commentator expressed:

“Spending 350 billion pounds to prolong the lives of a few hundred thousand mostly elderly people is an irresponsible use of taxpayers’ money.”

-Toby Young

Medicare is projected to have to pay between $3.5 billion and $6.2 billion in covering for elderly care during the Covid-19 pandemic (Hackett). In a time when the economy is still being hit hard from the aftermath of the pandemic, it can be understood that the government would want to cut back allocating scarce resources because they are responsible for paying back large amounts of money. The government could want to pour money into supporting the younger generations, as it will most likely be less costly. Additionally, social utility is also a prevalent issue with the allocation of scarce resources. If the elderly are prioritized over the younger generations in regards to the allocation of scarce resources, there could be lasting consequences. If fewer lives are saved because older lives were preserved, there could be a lack of youth in the near future to contribute to the economy. Additionally, in a time of crisis such as the Covid-19 pandemic, to eliminate biases procedural equality must be maintained. Each person should be treated equally to maximize the lives that can be saved. It is evident that not all lives can be saved, so each person should be granted equal access to care, but not guaranteed extra support.

Argument II. Ageism Cannot Be Justified: Private over Public Health

When thinking about ageism and scarce resource allocation during COVID-19, it is necessary to consider the framework of consequentialism. If ageism is justified during the pandemic, such as denying care and/or resources solely based on age, then down the line trust will be broken between the medical field and the elderly population. If both younger and older generations see how the elderly community is being denied care, they may not have the same trust with healthcare professionals. They may fear that they will not get the equitable care they deserve, solely because of their age. Additionally, the 50+ age group is a large contributor to the economy. In 2018, the 50+ age group contributed $8.3 trillion to the economy, and they would have been ranked the third-largest economy in the world by GDP, sitting right behind China, which has a GDP of $13.4 trillion (Terrell). It is evident through these statistics that sacrificing the elderly would have negative effects on the economy since they contribute significantly to the success of the United States specifically. Additionally, the reasoning for allocating scarce resources could lead to a diminished quality of life for the elderly community. Frequently, when allocating resources healthcare professionals have been considering whether the elderly should even receive care because they may die soon anyways. Also, considering whether or not to give resources because they may take up resources that can be used to save many other patients and the cost benefits of that has led to the community feeling like a burden to society. Viewing the elderly community with money and the economy at the forefront of the mind has the potential to create a diminished quality of life for those in the elderly community.

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It is helpful to see a real case play out to see how ageism can potentially manifest through medicine. Here is a model case scenario to discuss how age is related to the allocation of scarce resources and the potential outcomes: Two individuals (both male) walk into the hospital on the same day, and healthcare professionals come to discover that they have identical SOFA scores. One man is 28 years old and the other is 68. Both men need a ventilator, but only one is available. Who should be prioritized in this scenario? I have developed three different perspectives on this issue and used values to determine their ethicality.

1st Perspective for Model Case Scenario: The elderly population should be sacrificed to benefit the younger generations.

When allocating resources, the scarce resources should always go to the younger patient, so in this scenario, the younger man (28) should be granted the ventilator. By focusing on the value of utility it is evident that by focusing the resources on helping younger generations, there will be increased benefits in the years to come. By granting them care now, they will be able to contribute to the economy for many more years to come through both working and spending. Due to the age of the 68-year-old man, he will most likely have fewer life years ahead to contribute to the economy. The Centers for Disease Control has concluded that adults 85+ are 95 times more likely to be hospitalized compared to the 5-17 age group, and are 8700 times more likely to die compared to that group. Consequentialism must be used here to show that older adults are more likely to die, hence why resources should be given to the younger generations as they will most likely be able to recover.

2nd Perspective for Model Scenario: When allocating resources, the elderly should be granted resources over the younger generations. In this scenario, the 68-year-old man should be granted the ventilator.

The older generations have spent years working towards creating a better future for generations to come. Denying them the equitable care that they need would be disrespectful. To maintain fairness, they should be granted resources since they already have contributed time and money to the economy. When allocating scarce resources, the question that has been frequently asked is “how will they recover and what are the long-term effects?” While that is important, it is also necessary to consider the question: “how severe is this patient, and what will happen if they do not get the resources they need?” Statistics clearly show that the elderly are at a higher risk of dying from COVID-19, so they should be prioritized when allocating resources because of their high risk of dying from COVID-19.

3rd Perspective for Model Case Scenario: A lottery or coin flip should be used to allocate the resources when no one patient is more severe than the other:

Frequently, age can become a deciding factor when methods such as the SOFA score place two patients in the same severity group. Creating a bias-free lottery or coin flip can help to give both patients an equal opportunity at receiving the care they need. This egalitarian perspective prevents age from becoming the deciding factor when a decision cannot be made on how to allocate the resources. But, if one patient does become more severe, they should be given the ventilator. Similarly, other factors such as race, gender, and zip code should be evaluated to prevent prejudice against any one person. This method should only be followed when no other decision can be made.

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Through evaluation of different countries, it has become apparent that although countries such as Korea and India value their elders differently from the youth-centered UK and US, all countries have been devastated by the Covid-19 pandemic. The lack of education on the pandemic and delayed preventative measures in all countries can be held accountable for the extreme losses from the elderly community. It has become evident through the Covid-19 pandemic that the United States is youth-focused and neglects institutional and systemic problems relating to the elderly embedded in society.

My Personal Opinions and Necessary Changes Needed:

I do not think that ageism can be justified during a time of crisis. While topics such as the economy and life years ahead have been mentioned, I believe that the most important aspect to remember is that the elderly are people. They are not a statistic, rather they are individuals who deserve equitable care and respect. The economy should be put aside to help the elderly to gain the care they need. The United States has shifted from caring for the most severe to focusing on how the economy will be affected by caring for those in need. While maximizing the number of lives saved is important, it is unethical and immoral to push the elderly aside to care for younger patients. 

In relation to my model scenario, I believe that allocating scarce resources is more complicated than three perspectives. I believe more times than not the older generations are denied care because of age-related comorbidities and the stigma that they will not be able to recover quickly enough, which is direct ageism. I believe that if there is an elderly adult who is in critical condition, they should be treated immediately regardless of the long-term implications. I do believe that in the event of a tie between SOFA scores, a lottery (third perspective) could be the most efficient and unbiased way of providing care. I see the most benefits with using a lottery, but only after a thorough evaluation of one’s race, gender, income, zip code, and genetic illnesses that run through one’s family to ensure that no one patient is being neglected. In the event that one patient is in a “worse off” condition, they should be allocated the scarce resource. According to Justice in Aging, SOFA works to eliminate biases, but through this additional dilemmas are rising. SOFA does not take into account race which can shed light on potential comorbidities. Additionally, zip code and occupation are not taken into consideration, but both of these do play a role in the future of the individual. I believe that SOFA must be more inclusive to individuals of different socioeconomic statuses. In addition, it uses age as a means of settling ties between patients, which negatively impacts the older adult communities. Age should never be the sole deciding factor when resources are being allocated. Additionally, QALYs has issues as well as it directly uses life years ahead and quality of life (physical health), both of which will inherently be lower for older adults. The cost benefits of treating a younger patient will most likely be better than an older adult because the QALY system uses current health and life years ahead, which many elderly people have no control over, to allocate resources. Aging is a natural process, and the QALY system uses this to its advantage to discriminate against the older adult community. Additionally, it is necessary that there is stressed importance of including older individuals in clinical trials for vaccines, medicines, and treatments. Excluding the elderly in clinical trials can lead to potential harm since their bodies work differently compared to young adults. Discrimination of any form is morally wrong. Hateful remarks and actions towards the elderly community should not be tolerated. 

Next Steps Going Forward:

Going forward, you can donate and show support for organizations such as the American Association of Retired Persons, which is helping older adults with the needs and interests that come along with aging. Also, everyone should work to understand and explain ageism to others to raise awareness of ageism in the US and globally. Be an advocate! A great resource is The Agency on Aging of South Central Connecticut has a pledge that anyone can sign that makes a promise to yourself that you will prevent ageism from spreading:

“ I will recognize the diversity of older adults.”

“ I will appreciate the positive impact older adults continue to make.”

“ I refuse to mistreat anyone based on their age.”

“I will advocate for stopping ageism in my community.”

– The Agency on Aging of South Central Connecticut Pledge

It is imperative that younger generations advocate for the elderly community and stop the spread of ageism.

What Changes are Being Made to Battle Ageism:

To battle systemic problems, medical schools are reattempting to combat ageism by introducing more students to elderly mentors and living out real-life experiences that show them how the elderly community is feeling. Also, they are including more experiences for medical students to understand elderly lives better by using new technologies to feel their impairments (Kalter). Change can be made, but young adults need to stand up for the elderly voices that cannot be heard. Young adults need to destroy the stigma in their generations to prevent the spread of ageism. Differing in values is inevitable, but maintaining respect and compassion is necessary for creating a safe environment for all individuals.