Duke Medical Ethics Journal

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When scarcities in medical resources can not be resolved by improving efficiency or increasing investment, rationing decisions must be made [1]. In many macroallocation systems, age has been used as a primary factor for determining how to distribute medical resources [4]. 

 

I will explore the implications of using age as a primary factor in determining medical resource allocation, specifically in the case where adults, who are aged above the average lifespan, are denied potentially life-saving or life-lengthening procedures. 

 

To spell out age-based rationing, Daniel Callahan, one of the founding fathers of biomedical ethics, developed the natural lifespan principle. This principle marks that once the elderly have reached the average lifespan, their healthcare needs should be considered inferior to those of younger persons [4]. Other ethicists have followed suit in supporting age-based rationing in favor of denying expensive medical treatment to those below the average lifespan over those above it. Robert M. Veatch, for one, notes that “older persons have had more opportunity for wellbeing than younger persons” [2]. From this perspective, distributing medical resources by age is egalitarianistic since everyone theoretically receives access to the same decent minimum of healthcare. Such equal access is clear when treatment is denied to a seventy-seven year old man in order to ensure a newborn, who has had no previous access or use of healthcare, is able to receive treatment.

 

Of course, it is easy to see that the elderly man has had the time and autonomy over himself to visit the doctor and promote his own health, but the situation to which we would potentially apply age-based rationing doesn’t always follow the extreme, and hysteria-inducing rhetoric of the newborn child and seventy-seven year old man example. Many additional inconsistencies emerge because age-based rationing can not account for the heterogeneity of healthcare experiences. 

 

For one, age can not be a marker for opportunity for

wellbeing, like Veatch suggests, when there is a difference

in material circumstances. Consider the experiences of a

seventy-five year old upper-middle class individual and

that of a seventy-seven year old lower-middle class

individual. The upper-middle class individual has had the

opportunity to purchase healthy foods, visit the doctor

without financial risk, and the time to engage in health-

promoting behaviors. The lower-middle class individual,

on the other hand, is not financially risk protected, and

thus didn’t have equal access to medical resources. Let’s

say the lifespan is seventy-six. In this case, Callahan’s

rationing would dictate that a potentially life-saving

treatment should be denied to the lower-income seventy-

seven year old, but not the upper-middle class seventy-five

year old. However, the seventy-five year old has had access

to a greater share of healthcare opportunities, while the

seventy-seven year old has not even had access to the

decent minimum. More years lived can not be equated to more years of access to healthcare because access is restricted by cost. Thus, age fails to be an accurate measure of share of healthcare opportunities, negating what Veatch posits. 

 

Because our healthcare system is an open system, there are also immigrant patients who have had differential availability to healthcare, including patients who have never had interactions with medical resources until old age. Perhaps an immigrant from a severely underdeveloped locale has never had healthcare available. Late in life, this individual moves to a place where healthcare is readily available. Because they are above the average lifespan age, they are denied a life-saving procedure. This situation illustrates again that age-based rationing is not egalitarian since those who have had no share of healthcare opportunities could be denied treatment, even when those who have had a share continue to receive treatment. 

On a large scale, age-based rationing has the potential to undermine the healthcare system. Setting age as the standard for resource allocation sends a message to elderly patients: you are not the priority. Healthcare providers are expected to not work toward the best interests of the individual, but rather follow policy, cutting off care when a patient’s age dictates. In turn, elderly patients and their close ones may start to distrust healthcare providers. In addition, rationing according to age potentially worsens the scarcities in medical resources. The need for rationing is because of existing resource scarcities—those resources including the physicians themselves. A 2019 assessment by the American Medical Association showed that 10.8% of US physicians are age 70 or older [3]. As an increasing amount of the physician workforce becomes the elderly, how are these physicians likely to respond knowing that their lives are not prioritized? There is less incentive to save people in a system where you’re not protected. Even if elderly physicians choose to care for the patients who are prioritized, elderly physicians in need of medical interventions will not receive them if they are above the average lifespan. The diseased providers who would have been treated and able to return to work will no longer be able to practice medicine, leaving more patients in need untreated.

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