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In South Africa and abroad the elderly are systematically discriminated against at all levels of healthcare allocation decision-making. Such discrimination is perhaps surprising in light of the National Health Act and the Older Persons Act, which explicitly recognise the elderly as a vulnerable group whose equal rights require special protection. However, ethical theory and public opinion offer some reasons to think that discrimination against the elderly may be justified. This paper examines possible ethical grounds for age discrimination. I claim that there are very few cases in which the aged may be discriminated against, and that age alone is never sufficient grounds for discrimination.
May 2015, Vol. 8, No. 1 SAJBL 37
The South African (SA) Constitution is committed to
the progressive realisation of the right to healthcare.[1]
However, in South Africa and abroad, it is not always
possible for optimal medical treatment to be provided
for every patient. This is due to resource scarcity:
shortfalls in equipment, personnel, and funds make it impossible for
every person to receive the treatment that would be best for them.[2]
Practitioners and policymakers alike are painfully aware that such
shortfalls mean that allocation decisions will involve trade-offs,
prioritising some patients or patient groups at the expense of others.
But on what basis are such trade-offs made? What criteria should be
used to decide who gets treatment and who does not? It is important
that these criteria are explicit and ethically defensible as they affect
who gets treatment and who does not, who lives and who dies.
It has become increasingly common for ethical theorists in the
developed world to consider employing the criterion of age: where
there is competition for health resources, the young should be
favoured.[2–6] This type of discrimination can be employed at micro-,
meso-, and macro-levels[7] of healthcare allocation. For instance,
at the micro-level of individual practitioner decisions, it could
mean that practitioners do not refer the elderly to more specialised
secondary and tertiary levels of care. At the meso-level of hospital and
practitioner policy, training for geriatric care may be deprioritised. At
the macro-level of national or provincial health decisions, policies may
favour the treatment of HIV/AIDS at the expense of geriatric medicine
programmes because the former predominantly afflicts the young.
Significantly, age discrimination is already practised both tacitly
and explicitly: all of the above are real examples from a South African
health context and many more could be supplied.[8] This is worrisome,
not least since the elderly are a vulnerable population whose rights
require special protection.[9] The Older Persons Act explicitly states
that the elderly are entitled to be respected, to be treated fairly and
equitably, and to be protected against ‘unfair discrimination on any
ground’.[10] This means that it is vitally important to bring out potential
justifications for age discrimination and question whether examples
like those above involve unfairness.
Developed world bioethicists have debated these justifications
extensively. However, bioethicists, healthcare practitioners, and
legal experts in developing world contexts such as SA have been
slower to comment on the ethical significance of age discrimination.
In focusing on a SA context, this article contributes a different
perspective to the broader debate about age-based rationing.
However, the central contribution of the paper is to draw attention
to highly questionable premises that underlie age discrimination,
which nonetheless remain largely unquestioned in SA bioethics and
health policy.
Many argue that there are good, principled reasons for favouring
the young. In particular, it is sometimes suggested that the elderly
provide a reduced social contribution, that the elderly have already
had their fair share of life, and that they will benefit less from health
resources. I will assess the criteria implicit in each of these claims, and
the extent to which they apply to the elderly, and suggest that they
fail to justify age discrimination.
Social contribution
It’s sometimes thought that the degree to which individuals contribute
to society should play a role in who gets medical resources. For
instance, prioritising breadwinners is thought to be justied because
they have many dependants who rely on them.[11] The elderly on the
other hand are often regarded as a burden on society. Older people
extract a pension and after pensioning age may not contribute as
much economically.
Interestingly, this type of consideration is reflected in one
of the most prominent measures of the burden of disease: the
Disability Adjusted Life Year (DALY) is endorsed by the World Health
Organization and increasingly by health researchers and the South
African government. The measure commonly ‘weights unhealthy
middle years as contributing more to the burden of disease than
unhealthy later years, since those in middle age are likely to provide a
greater social and economic contribution.
However, the social contribution criterion, and the idea that
the elderly contribute less are, respectively, morally and factually
In South Africa and abroad the elderly are systematically discriminated against at all levels of healthcare allocation decision-making. Such
discrimination is perhaps surprising in light of the National Health Act and the Older Persons Act, which explicitly recognise the elderly as a
vulnerable group whose equal rights require special protection. However, ethical theory and public opinion oer some reasons to think that
discrimination against the elderly may be justied. This paper examines possible ethical grounds for age discrimination. I claim that there are
very few cases in which the aged may be discriminated against, and that age alone is never sucient grounds for discrimination.
S Afr J BL 2015;8(1):37-39. DOI:10.7196/SAJBL.374
Youngest rst? Why it is wrong to discriminate against the
elderly in healthcare
C S Wareham, BA, MA, PhD
Steve Biko Centre for Bioethics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
Corresponding author: Christopher Wareham (
38 May 2015, Vol. 8, No. 1 SAJBL
dubious. If social contribution is a relevant criterion, it requires
discriminating in favour of those regarded as making greater
economic, social and cultural contributions, such as presidents,
politicians, celebrities, factory owners, and rich people who pay more
tax. We would also be forced to discriminate against individuals who
make smaller contributions, such as poor people, children, those
without dependants or jobs, and the mentally ill. All of these provide
a reduced contribution, but healthcare decisions that discriminate
against these groups are rightly regarded as unacceptable.
The social contribution criterion therefore provides grounds for
preferring people we don’t think deserve preference, and for dis-
criminating against groups who require the most social support.
Such a criterion should be rejected. Even if we accepted it, however,
it is false to claim that the elderly contribute less to society. A brief
look at the pages of history will show many elderly figures who
have made disproportionate social contributions. Nelson Mandela
is a prime example of a person who contributed massively well
beyond his 75th year, but the contributions of elderly people are
not limited to those who are famous. In SA, in particular, the aged
are responsible for looking after families decimated by HIV/AIDS.[8]
They are also stores of cultural knowledge that have immense social
It might still be maintained that the elderly make a reduced
economic contribution, since they draw from benefit schemes and
do not earn a wage or pay taxes. However, this contention entirely
ignores the lifetime contributions of the elderly, which surely incur
an obligation of reciprocity. Moreover, it should be noticed that, to
the extent that there is a reduction of economic contribution, this
is in part due to the fact that the elderly are often forced to retire
by mandatory retirement ages. It would be grossly unfair to prevent
someone from working, and then deprive them of medical treatment
because they no longer work.
The social contribution criterion is deeply problematic, as is
the idea that the elderly provide a reduced social contribution.
Discriminating against the elderly in resource allocation decisions
cannot be justified on this basis.
A further attempt at justifying age discrimination is provided by the
idea of a fair innings. Some argue that one goal of health services
should be to ensure that each person has the same opportunity for
a fair number of healthy years: we should all get a fair opportunity to
play the game of life for the same time. Williams[3] suggests that, on
this basis, it may sometimes be justied to discriminate against the
elderly, since they have had a greater share of the good of life. The
young should get healthcare resources, so as to give them a better
opportunity for a ‘complete life’.[2]
The fair innings criterion is certainly more convincing than the social
contribution criterion, and evidence suggests that many people
endorse this reason for deprioritising the elderly.[12] However, the fair
innings view is also ethically questionable. Once again, employing
the criterion would mean discriminating in favour of individuals
we do not think should be preferred. For instance, fetuses have
had only a fraction of their fair innings. Nonetheless, only the most
zealous pro-lifer would think that we should save a fetus’s life over
that of its mother, who has had a greater share of her fair innings. It
could be claimed that the preference for mothers in this case is due
to the fact that the fetus is not a fully-fledged person. As a non-
person, perhaps its share of life should not figure substantially in our
weighing-up. Although many reject the idea that the unborn embryo
is not a person, accepting this controversial view might rescue the fair
innings criterion from one counter-intuitive consequence.
There are, however, additional, less easily escapable criticisms
of the fair innings view. The fair innings requirement might also
condone extreme discrimination against the very old. If one lives
110 good years one has drastically exceeded one’s quotient. Because
the extreme elderly have already had much more than their fair
share, the fair innings argument may recommend denying them
any opportunity to access interventions even if they would benefit
much more than a younger person. Similarly, even inexpensive care
or treatments might be entirely denied to the elderly just because
they have exhausted their fair share of resources. A criterion that
recommends such neglect must be rejected.
Moreover, even if the fair innings criterion were accepted, being
old is an unreliable indicator of fairness: it is often false to say that
an older person has had his or her fair share of life’s goods. Many
older persons will have lived lives of deprivation, hardship and
disability. This is particularly true in nations, such as SA, in which
the vast majority of elderly people have been the victims of unjust
deprivation and discrimination throughout their lives. Often elderly
black persons who have lived through apartheid will not have had
their fair share of life’s goods. If applied correctly, then, the fair
innings criterion may require favouring the elderly in nations such
as our own.
The fair innings requirement seems to have a degree of appeal.
Nonetheless it should once again be clear that the criterion is
flawed. And even if it was not, it provides inadequate grounds for
discriminating against the elderly, particularly in SA.
Degree and likelihood of benet
The strongest basis for discriminating against the elderly is the
principle that we should do the most good and provide the most
benet with the resources at our disposal. This common sense idea is
related to the bioethical principle of benecence and has a theoretical
foundation in utilitarian ethical theory.[13] On the face of it, it seems
likely that more benet will accrue by treating the young rather than
the elderly. A person who receives a heart transplant at the age of 40 is
likely to gain many more healthy life years than a person who receives
a transplant at the age of 85. The older person is likely to have poorer
health and die from other causes before he or she can enjoy the full
benet of the intervention.
Despite its intuitive appeal, though, the benefit criterion has some
unpalatable implications. If we accept it, we should discriminate
against all groups with reduced life expectancy. Smokers and the
overweight become obvious candidates to be deprioritised in health
allocation decisions. Some find this consequence acceptable. Less
easy to defend, though, is the implication that we should discriminate
on grounds of race, class, or occupation. It is an unfortunate fact
that certain races and classes live shorter lives.[14] Similarly, those
in dangerous professions such as soldiers, policemen, and miners
are likely to have reduced life expectancy. The benefit requirement
unacceptably provides grounds for health decisions to discriminate
against these groups along with the elderly.
Nonetheless, as discussed earlier, we do need some method of
May 2015, Vol. 8, No. 1 SAJBL 39
making allocation decisions, and perhaps a refined benefit criterion
is the best of a bad bunch. Even if we accepted a benefit requirement,
though, this would not provide grounds for generalised discrimination
against the elderly. This is because the range of treatments from
which the elderly are less likely to benefit appears to be extremely
limited. These include life-saving treatments with very long-term
benefits, such as organ transplants and heart surgery. Moreover, even
deciding that the elderly should not get these is questionable. There
is huge variability in humans’ age-relative health profiles, which gives
rise to differences in expected healthy life years. This means that it
would be far better to assess individual chances of benefit rather than
generalise according to chronological age.
Once again, the benefit criterion is flawed. And once again, even
its acceptance would not justify blanket discrimination against the
An objection: the elderly are willing to
take a back seat
Before concluding, it is worthwhile to pre-empt a common objection
to the claim of this paper. The objection is that the elderly themselves
often wish for young people to be treated ahead of them. It is
certainly true that the opinions and decisions of the elderly, with
regard to their own care, must be respected. It is arguably wrong for
a practitioner to supply care that any capable patient, old or young,
does not want.
Even so, two responses should be made to this objection. First, it is
highly likely that the elderly themselves may have internalised some
of the above flawed arguments for discrimination. When an elderly
person offers such arguments for favouring the young, there may be
a moral obligation to try to make the person aware of the unsound
basis of their preference.
The second response is that, like many of the arguments in favour of
age discrimination, it rests on a claim that is no more applicable to the
elderly than it is to others. While it is certainly true that some elderly
people prefer that others should be helped first, this is also true of
many younger altruistic people. Moreover, it is true of the elderly far
less often than many people think.[15] It is incorrect to assume that
elderly people simply accept that they should fall further down the
pecking order in resource allocation decisions. Policymakers and
healthcare practitioners should not base discriminatory resource
allocation decisions on this false assumption.
It is not just abuse of the elderly that is wrong. Although such abuse
is abhorrent and must be remedied, it is important to note that
the elderly are discriminated against in more subtle, passive, and
systematic ways. The non-provision of interventions to which they
are as ethically and legally entitled as younger people can be as
damaging as active abuse. As it stands, the elderly are tacitly, explicitly,
and systematically discriminated against at all levels of healthcare.
Policymakers and healthcare practitioners have an ethical and legal
obligation to ensure that the vulnerable elderly should not bear an
unfair burden due to unjustied resource allocation decisions.
In case this obligation to others is not motivational enough, it
is also worth pointing out that it is in each individual’s interest to
undermine unfair discrimination: we all grow old, so it makes sense
to defend our rights before we become vulnerable to their violation.
Acknowledgements. This paper has benetted from fruitful discussions
with members of the Philosophy Department at the University of
Johannesburg, as well as participants at the Philosophy Spring Colloquium
2014. Thanks also to the two anonymous reviewers for probing comments.
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3. Williams A. Intergenerational equity: an exploration of the ‘fair innings’ argument.
Health Econ 1997;6(2):117–132.
4. Callahan D. Aging and the ends of medicine. Ann N Y Acad Sci 1988;530(1):125–132.
5. Shaw A. In defence of ageism. J Med Ethics 1994;20(3):188–191.
6. Harris J. Does justice require that we be ageist? Bioethics 1994;8(1):74–83.
7. Dhai A, McQuoid-Mason DJ. Bioethics, Human Rights and Health Law: Principles
and Practice. Cape Town: Juta 2010.
8. Chenwi L (Ed). Economic and social rights in South Africa. Special edition on the
rights of older persons. ESR review 2011;12(1)
9. Republic of South Africa, National Health Act No. 61. Government Gazette 2003.
10. Republic of South Africa. Older Persons Act No. 13. Government Gazette 2006.
11. Murray CJL, Acharya AK. Understanding DALYs. J Health Econ 1997;16(6):703–730.
12. Dolan P, Tsuchiya A. It is the lifetime that matters: public preferences
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inequalities in health. No easy solution. JAMA 1993;269(24):3140–3145.
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age as a criterion for allocating health care resources. Gerontologist
... There may be different kinds of situational conditions, spanning from medical to social, from political to economic conditions, and these more likely result because of their overlap [45,50,55,63]. In line with this characterisation, older adults may be defined as vulnerable, for example, when they are subjected to ageism; that is, they are discriminated against in many contexts, including healthcare provision, simply due to their chronological age [61,64]. ...
... Low levels of social support are also frequently mentioned as a condition for sociocultural vulnerability [47,51,65,74]. Strictly related to sociocultural dimensions, some publications explicitly referred to forms of economic and political vulnerability [42,45,47,50,51,56,61,63,64,66,73,74], the latter including also discrimination in the provision of healthcare [61,63,64,73], and subjection to unjust judicial systems [56]. ...
... Low levels of social support are also frequently mentioned as a condition for sociocultural vulnerability [47,51,65,74]. Strictly related to sociocultural dimensions, some publications explicitly referred to forms of economic and political vulnerability [42,45,47,50,51,56,61,63,64,66,73,74], the latter including also discrimination in the provision of healthcare [61,63,64,73], and subjection to unjust judicial systems [56]. ...
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Background Vulnerability is a key concept in traditional and contemporary bioethics. In the philosophical literature, vulnerability is understood not only to be an ontological condition of humanity, but also to be a consequence of contingent factors. Within bioethics debates, vulnerable populations are defined in relation to compromised capacity to consent, increased susceptibility to harm, and/or exploitation. Although vulnerability has historically been associated with older adults, to date, no comprehensive or systematic work exists on the meaning of their vulnerability. To fill this gap, we analysed the literature on aged care for the meaning, foundations, and uses of vulnerability as an ethical concept. Methods Using PRISMA guidelines, we conducted a systematic review of argument-based ethics literature in four major databases: PubMed, Embase®, Web of Science™, and Philosopher’s Index. These covered biomedical, philosophy, bioethical, and anthropological literature. Titles, abstracts, and full texts of identified papers were screened for relevance. The snowball technique and citation tracking were used to identify relevant publications. Data analysis and synthesis followed the preparatory steps of the coding process detailed in the QUAGOL methodology. Results Thirty-eight publications met our criteria and were included. Publication dates ranged from 1984 to 2020, with 17 publications appearing between 2015 and 2020. Publications originated from all five major continents, as indicated by the affiliation of the first author. Our analyses revealed that the concept of vulnerability could be distinguished in terms of basic human and situational vulnerability. Six dimensions of older adults’ vulnerability were identified: physical; psychological; relational/interpersonal; moral; sociocultural, political, and economic; and existential/spiritual. This analysis suggested three ways to relate to older adults’ vulnerability: understanding older adults’ vulnerability, taking care of vulnerable older adults, and intervening through socio-political-economic measures. Conclusions The way in which vulnerability was conceptualised in the included publications overlaps with distinctions used within contemporary bioethics literature. Dimensions of aged care vulnerability map onto defining features of humans, giving weight to the claim that vulnerability represents an inherent characteristic of humans. Vulnerability is mostly a value-laden concept, endowed with positive and negative connotations. Most publications focused on and promoted aged care, strengthening the idea that care is a defining practice of being human.
... Individuals and groups of special vulnerability should be protected and the personal integrity of such individuals respected.' [3] The UDBHR is to my mind one of the most important instruments in the development of human rights and bioethics, as the international community (191 member states) accepted it unanimously in 2005. This means the declaration was the first global political and bioethical text to which all the governments in the world, also SA, committed themselves. ...
... What could be put forward as the reason for the above-mentioned discrimination against the elderly despite the fact that the National Health Act does indeed want to promote respect for vulnerability? One of the most important reasons according to Wareham is the following: [3] 'The strongest basis for discriminating against the elderly is the principle that we should do the most good and provide the most benefit with the resources at our disposal. This common sense idea is related to the bioethical principle of beneficence and has a theoretical foundation in utilitarian ethical theory. ...
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It is untrue that the elderly in South Africa (SA) are probably discriminated against in healthcare as the result of inadequate legislation that does not conform to international standards. The National Health Act recognises vulnerability and gives expression to it. Respect for vulnerability has not yet been introduced to fundamental political and bioethical frames of reference in SA and that is probably the reason why the concept and right have not become part of the ethical awareness in healthcare. The appeal of this article is that respect for vulnerability must be brought to conform to the Universal Declaration on Bioethics and Human Rights by declaring the ethical principle as an independent human right.
... Finally, the argument whereby the social value criterion can lead to arbitrary decision-making that discriminates some groups neglects to mention that this is also the case for clinical criteria. Note that the likelihood of survival is inextricably linked with ethnicity and social class [15,16]. Individuals from racialized groups such as Latinos and Black people, as well as the working class, are generally more likely to have less access to healthy food, health services, sports facilities, and so forth [17]. ...
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With the current pandemic, many scholars have contended that clinical criteria offer the best way to implement triage. Further, they dismiss the criteria of social value as a good one for triage. In this paper, I respond to refute this perspective. In particular, I present two sets of arguments. Firstly, I argue that the objections to the social value criteria they present apply to the clinical criteria they favor. Secondly, they exaggerate the negative aspects of the social value criteria, while I suggest it is reasonable to use this. I end the article by recommending how operative public values can be a good way to make triaging decisions
... However, especially the "youngest-first" approach may be considered a discrimination against the elderly (11) and cause increasing social injustice in the communities where people endure the lack of healthcare resources (12). Morally, it is questionable the younger's life has more merit than the elderly's life. ...
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The COVID-19 pandemic has necessitated revisiting the matter of allocating scarce healthcare resources. During pandemics and natural disasters, applying certain allocation methods is inevitable due to an uncontrollable surge in the need for scarce resources, and those methods should distribute potential benefits and burdens according to the principle of justice. This article briefly studies four allocation models and proposes a new approach to maximize total benefits with social and ethical acceptability, equality, and equitability. For accomplishing that goal, the Acceptability, Equality, and Equity (AEE) model recommends six principles, atransparency and equal treatment, b- objective assessment and supervision, c- sustaining ongoing treatments, d- priority to individuals performing crucial tasks, e- scoring system, and f- lottery for individuals with the same conditions. The AEE model suggests allocating scarce resources not only based on medical facts but also social and ethical considerations, such as sustaining ongoing medical procedures for patients who are undergoing medical treatment and winning public support through transparent, objective, and fair implications.
... Arguments appealing to a natural lifespan [12] or fair innings [13], express the idea that after reaching a certain number of years or having lived through each of life's stages, one has had a fair share of life and should step aside to give others a turn in situations where resources are scarce and a choice must be made. Against these claims, it has been argued that in determining whether or not a person has had a fair share of life, more than the number of years a person has lived is at stake [14]. It has also been claimed that standing up, rather than stepping aside, may be the braver course for someone who has been subject to discrimination or unfairness throughout life. ...
... Investigators associated with the United Nation's Global Burden of Disease study who initially drew on DALY reasoning eventually abandoned it, settling instead on the position that "we should treat a year of healthy life as equal irrespective of the age at which it is lived." 45 The reasoning leading to this modification stressed the equal dignity of persons at all ages and placed less weight on economic efficiency and return on investments. ...
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Is age discrimination ethically objectionable? One puzzle is that we sometimes assume that the target of both age discrimination and ageism must be older people, yet in poorer nations, older people are generally shown more respect. This article explores the ethical question. It looks first at ethical arguments favoring age discrimination toward younger people in low‐income, less industrialized countries of the global South, using sub‐Saharan Africa as an illustration. It contrasts these with arguments favoring age discrimination toward older people in high‐income, more industrialized countries of the global North, particularly the United States and United Kingdom. Finally, it considers what role, if any, differences in life expectancy, infant and child mortality, and prospects for healthy lives should play in the moral embrace of a particular view by a community. It argues that there can be reasons to favor different types of discrimination in different parts of the world.
Applied ethics is home to numerous productive subfields such as procreative ethics, intergenerational ethics and environmental ethics. By contrast, there is far less ethical work on ageing, and there is no boundary work that attempts to set the scope for ‘ageing ethics’ or the ‘ethics of ageing’. Yet ageing is a fundamental aspect of life; arguably even more fundamental and ubiquitous than procreation. To remedy this situation, I examine conceptions of what the ethics of ageing might mean and argue that these conceptions fail to capture the requirements of the desired subfield. The key reasons for this are, first, that they view ageing as something that happens only when one is old, thereby ignoring the fact that ageing is a process to which we are all subject, and second that the ageing person is treated as an object in ethical discourse rather than as its subject. In response to these shortcomings I put forward a better conception, one which places the ageing person at the centre of ethical analysis, has relevance not just for the elderly and provides a rich yet workable scope. While clarifying and justifying the conceptual boundaries of the subfield, the proposed scope pleasingly broadens the ethics of ageing beyond common negative associations with ageing.
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Socioeconomic status (SES) is strongly associated with risk of disease and mortality. Universal health insurance is being debated as one remedy for such health inequalities. This article considers mechanisms through which SES affects health and argues that a broader and more comprehensive approach is needed. Published articles surveyed using MEDLINE and review articles and bibliographies. Research is reviewed on the association of SES with health outcomes in different countries, including those with universal health coverage. Socioeconomic status relates to health at all levels of the SES hierarchy, and access to care accounts for little of this association. Other mechanisms are suggested and implications for policy and clinical practice are discussed. Health insurance coverage alone is not likely to reduce significantly SES differences in health. Attention should be paid both in policy decisions and in clinical practice to other SES-related factors that may influence patterns of health and disease.
Scarce healthcare resources can be allocated in many ways. The National Institute for Health and Clinical Excellence in the UK focuses on the size of the benefit relative to costs, yet we know that there is support among clinicians and the general public for reducing inequalities in health. This paper shows how the UK general public trade-off these sometimes competing objectives, and the data we gather allow us to show the weight given to different population groups, for example, 1 extra year of life in full health to someone who would otherwise die at the age of 60 years is worth more than twice as much as an additional year of life to someone who would otherwise die at the age of 70 years. Such data can help inform the rationing decisions faced by all healthcare systems around the world.
The measurement unit disability-adjusted life years (DALYs), used in recent years to quantify the burden of diseases, injuries and risk factors on human populations, is grounded on cogent economic and ethical principles and can guide policies toward delivering more cost-effective and equitable health care. DALYs follow from a fairness principle that treats ‘like as like’ within an information set comprising the health conditions of individuals, differentiated solely by age and sex. The particular health state weights used to account for non-fatal health outcomes are derived through the application of various forms of the person trade-off.
Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing points systems, quality-adjusted life-years, and disability-adjusted life-years. We recommend an alternative system-the complete lives system-which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles.
Health care should be preferentially allocated to younger patients. This is just and is seen as just. Age is an objective factor in rationing decisions. The arguments against 'ageism' are answered. The effects of age on current methods of rationing are illustrated, and the practical applications of an age-related criterion are discussed. Ageist policies are in current use and open discussion of them is advocated.
We present the first systematic national survey of public opinion on age-based rationing of health care resources. Older people were oversampled in order to allow more precise comparisons of attitude by age cohort as well as by other demographic variables. We found that the majority of people accept the withholding of life-prolonging medical care to hopelessly ill patients, but few would categorically withhold such care on the basis of age. The majority of all ages felt that it was the duty of individual patients regardless of age to refuse medical care that is likely to be futile.
Many different equity principles may need to be traded off against efficiency when prioritizing health care. This paper explores one of them: the concept of a 'fair innings'. It reflects the feeling that everyone is entitled to some 'normal' span of health (usually expressed in life years, e.g. 'three score years and ten') and anyone failing to achieve this has been cheated, whilst anyone getting more than this is 'living on borrowed time'. Four important characteristics of the 'fair innings' notion are worth noting: firstly, it is outcome based, not process-based or resource-based; secondly, it is about a person's whole life-time experience, not about their state at any particular point in time; thirdly, it reflects an aversion to inequality; and fourthly, it is quantifiable. Even in common parlance it is usually expressed in numerical terms: death at 25 is viewed very differently from death at 85. But age at death should be no more than a first approximation, because the quality of a person's life is important as well as its length. The analysis suggests that this notion of intergenerational equity requires greater discrimination against the elderly than would be dictated simply by efficiency objectives.