Fair Innings? Against Healthcare Rationing in Favour of the Young over the Elderly

Who Are the Elderly?

When still an auxiliary bishop in Sydney I was charged with organising fraternal activities for the younger clergy. ‘Younger clergy’ were defined as ‘those ordained after Bishop Anthony’. That line moved inexorably and became increasingly comical, so I was translated to another diocese and replaced by a younger auxiliary. Defining the elderly is equally complex. Janet Roebuck. in ‘When Does “Old Age” Begin? The Evolution of the English Definition’ puts it at 50, ³ which I now think the prime of life. Many countries have adopted 65 as the statutory retirement age, a point first chosen by Bismarck for the cynical reason that most working-class men were dead by then and so would not draw the social security he was supposedly offering. The Catholic Church, never one to follow the Iron Chancellor, retires its priests and bishops at 75, its voting cardinals at 80, but popes can still be going strong at 85. Grace of state—or is it celibacy?—apparently slows ageing of the Catholic clergy.

We might be tempted to say ‘it’s all relative’ or ‘you’re only as old as you feel’. But I do think there is something in the idea of ‘the elderly’ even if the group has fuzzy edges. We need some definition if we are to give the elderly particular attention, even privileges. One starting point is the natural or ‘species-typical’ life-span, ‘the life-span of most of us in the absence of specific mortal diseases and fatal accidents’. ⁴ There does seem to come a stage beyond which most people would not feel cheated were they to die sooner rather than later—which is not to say they yet want to die. Likewise, there does seem to be a juncture at which we would not judge someone else’s death as premature; we might still grieve their passing, but not with the special grief associated with untimely deaths.

At some point, then, people are thought to have had a fair innings—to use the English and Commonwealth idiom. At such a stage a virtuous person might think it appropriate to prepare himself and others for his death and might no longer apply as much effort to postponing it. Just when that is will be partly a matter of traditional expectations—Psalm 90 offers ‘threescore years and ten or fourscore for those who are strong’—and partly a matter of present-day averages. It will be part-biological, part-environmental, part-cultural.

Whatever the age at which people are expected to die sooner rather than later, the stage immediately preceding it might be called ‘old age’ and its inhabitants ‘the elderly’ or ‘seniors’. If life is divided into youth, middle age and old age, it might be roughly the last third; or it might be seen as the stage after retirement from full-time work. Once people have entered that phase of life they are expected to engage in different projects, might be honoured as ‘elders’, and may warrant assistance of various sorts (pensions, appropriate housing, transport concessions, spiritual care and so on). Healthcare obviously comes in here, and there is a whole specialty of gerontology aimed at this phase of life and its particular challenges.

The Young and the Old

Recently I read a complaint that ‘Young people today are addicted to luxury, have terrible manners, contempt for authority and no respect for elders… They don’t stand for their teachers, they contradict their parents, they chatter endlessly and gobble their food’. The complaint is, of course, attributed to Socrates and so was already being made four centuries before Christ. Pete Townshend’s generation was not the first to know the ‘generation gap’, even if it was unusual in so publicly glorying in it. But the Socratic idea, oft repeated down the centuries, was that such gaps must be bridged, principally by the recognition that elders have a proper authority, deserving of respect, and that the young should be ready to be led and taught by them. Thus the longest paragraph of the Hippocratic Oath is about reverence for teachers and for passing on the art of medicine. Without respected elders, the thought goes, you cannot have effective leadership or transmission of wisdom; you cannot have education.

The Christian story begins, of course, not with an ancient philosophy but with God taking flesh of a young woman as an embryo and newborn babe. Yet that same opening story is framed by several older people—Zechariah and Elizabeth, Simeon and Anna, and of course Joseph—and their role is not only to close the Old Testament but to herald the New. Theirs is not just the rich treasury of Israel’s history and promises, but also the present task of contemplating that patrimony and interceding for the future. The ancient Anna haunts the Temple with constant prayer—as so many elderly people before and since, retired from previous work to engage in preparing themselves and all humanity for eternity.

Thus the Gospels, while delighting in children and young people, do not idolise youthful physique, as the ancient Greeks did, nor write off elderly spirit, as our contemporaries do. Christian pietas, as articulated by St Thomas Aquinas, ⁵ begins with the thought that God is owed our reverence and gratitude and that this is not for His sake but ours. To modern ears piety suggests old ladies at their devotions, whereas the Christian thought is that it is about right relations, especially with the God who is the source of our being and all we have. If old ladies are good at that it is to their great credit! But for Aquinas young men need it every bit as much if they are to be saved and communities need it if they are to function well.

We have all at some time seen some wonder, such as the Milky Way, our own newborn baby or the Triduum at Blackfriars, and experienced open-mouthed awe, wonder, humility, delight in the goodness and beauty and sheer undeserved gift of it all. That emotion and instinct, and the response of reverence and thanksgiving, is at the heart of pietas, of many social relations and of all true religion.

Pietas, on Aquinas’s account, extends from God as source of all being to those who mediate that being to us: those giants upon whose shoulders we stand who built our Church and country and made us heirs to so much that is good in our institutions, traditions, values and beliefs; the long genealogy of those who passed on life and love and truth and beauty to us—saints, ancestors, countrymen, above all our parents and grandparents. Key to piety is deep respect for that which we have received and from whom. Without such a sense we will fail not only to honour father and mother, as the Decalogue directs, but our history and context, and so we will lack perspective and vision for our future.

In the great bioethical encyclical, Evangelium Vitæ, Bld John Paul II built upon this tradition in calling for ‘a climate of mutual interaction and enriching communication between the different age-groups’. He asked young and middle-aged people to offer their elders that acceptance, reverence, solidarity and love which they received from them as children and to recognise ‘the rich treasury of experiences’ that those older people have acquired over the years and that make them ‘sources of wisdom and witnesses of hope and love’. Denied such pious reverence and humble docility, John Paul feared, the elderly will increasingly be abandoned as ‘useless burdens’ and offered only the euthanasist’s hemlock. ⁶

The Meaning of Life and Ageing

In Janáček’s 1923 opera, The Makropulos Affair, an esteemed alchemist, Hieronymus Makropulos, concocts an elixir of youth for his daughter Emilia whose subsequent long life allowed her to become one of the greatest singers of all time. Around this Bernard Williams wove his classic article on why it is wrong to aspire to endless mortal life. ⁷ He argued that a human being who will always be there, and whose condition can get no worse, has no motivation for friendship, education or striving. Without vulnerabilities men cannot demonstrate excellences. Much of life only makes sense in a form in which we rise and fall, start and finish. The shape and curve of life are given by the inevitability of death, and of old age if we are lucky. Old age, Williams concluded, has its own particular value and the whole of life cannot be understood without a conception of old age, its meaning and value.

Martha Nussbaum is one of several recent philosophers reflecting upon the emotions. ⁸ On her neo-Stoic ‘cognitive-evaluative’ account emotions are a kind of intelligence indispensable for our ethical lives. It is because of our vulnerability, our susceptibility to sickness, ageing and eventual dying, that we have the characteristically human emotions of grief, compassion and love—emotions that present us with opportunities to care for each other in ways that express genuine altruism. From very different angles Stanley Hauerwas and Alasdair MacIntyre have likewise drawn attention to the defining experiences of vulnerability and dependence in human life, especially at the beginning and end, but often enough in between. ⁹ Once again, without ageing and the elderly we cannot make sense of human life.

We could say many more things about the metaphysics of elderliness. My main point here is: being senior is not just being ‘past your use-by date’ and a useless burden; it is not even principally about being a babysitter for grandchildren or a consumer of healthcare, geriatric cruises and funeral services. Rather, I suggest, without ageing and the elderly we will lose our sense of the shape and meaning of life, the emotions proper to it, education for living it, tradition for carrying it forward, and God for appreciating it.

Context

If the London Olympics closed with the antiphon ‘I hope I die before I get old’, they opened with a different tune. The highly-praised spectacle, playing to a billion people worldwide, chronicled the rise of modern Britain. An agricultural idyll was rolled up to make way for satanic mills, suffragettes, 007, Mr Bean, Lord Valdemort and multiple Mary Poppinses. Christianity was absent from this account and royalty relegated to entertainment, but some things are still sacred: the National Health Service, according to Nigel Lawson, is ‘the closest thing the English have to a religion’. ¹⁰ So hundreds of dancing doctors and nurses, with 320 children bouncing up and down on hospital beds, delivered an extended sequence culminating with the letters N-H-S. As director Danny Boyle explained, ‘Everyone is aware of how important the NHS is to everybody in the country. One of the core values of our society is that it doesn’t matter who you are, you will get treated the same in terms of health care’.

Maybe. Though rock singers never really retire, Townshend’s generation of baby-boomers are doing just that, are living longer and expect access to a much more expensive, high-tech care than was on offer when they started singing. ¹¹ Who will provide it? There were a hundred centenarians in Britain a century ago when the monarch started sending telegrams; nowadays there are 10,000+ warranting a card. Eventually it will have to be royal e-cards, as a quarter of all babies born this year are expected to live beyond 100. By then there may be only one working adult for each person pre- or post-work, funding the pensions, NHS and care of the elderly, as well as the upkeep and education of the young. ¹² Already the UK Department of Health reports that around 45% of NHS hospital and community health expenditure goes to those over 65, though they are only 16% of the population; as their numbers rise both proportionately and in absolute terms the strain on the NHS will also. Across the sea Medicare for the over-65s will jump from the current 46 million beneficiaries to 79m by 2030, with costs per person also doubling in the same period. ¹³ Something, people are saying, has to give.

Calling it ‘the intergenerational fairness agenda’, some commentators now openly ask whether younger people should be expected to fund benefits for older ones. ¹⁴ In The Pinch: How the Baby Boomers Took Their Children’s Future—and Why They Should Give It Back David Willetts speaks for the increasingly common idea that the over-65s are a burden on the young and their expectations of endless pensions, health and aged care must be curtailed. ¹⁵ Daniel Knowles declared in the 31 March 2012 Spectator that ‘the baby-boomer generation is the most cosseted, untouchable, powerful generation in our history’, that they ‘are living far longer than was envisaged’ and so costing too much, and that younger people cannot be expected to keep them in the style to which they are accustomed. The elderly should pay their ‘fair share’ themselves and draw less upon the public purse. ¹⁶ Interestingly, in the NHS scene from the London Olympic opera, all the patients were children.

Allocating healthcare on the basis of age—what I call hereafter age rationing—is the policy of excluding persons over a certain age from certain treatments, scaling back care as they get older or preferring the young when there is competition for some intervention. This already goes on, directly or indirectly: in many countries older people have less medical contact than their condition warrants and ‘ageism’ on the part of health workers is well documented. ¹⁷ When I was researching here two decades ago it was clear that older renal patients who would receive dialysis in other countries were routinely denied it in Britain. ¹⁸ The same was true in cardiac, stroke, cancer and intensive care—with older patients being told ‘nothing more could be done’. ¹⁹ Despite public unease with age discrimination, ²⁰ health professionals and bureaucrats contained costs by age rationing. ²¹ Behind this unspoken compact seemed to be the idea that the oldies had already had a fair innings and so should not expect as much help.

The National Service Framework for Older People of 2001 was supposed to end NHS age rationing. ²² A subsequent review by the King’s Fund found age discrimination endemic in the NHS. ²³ Enthusiasm for ‘do not resuscitate’ orders and advanced care planning for the elderly may also reflect this. A 2008 survey found most gerontologists believe the NHS is institutionally ageist and fear how they’ll be treated in old age. The British Medical Association (BMA) insisted this is a society-wide problem, not just in healthcare; the government again promised to fix it. A series of Departmental reviews followed, finding even more evidence of substandard care of the elderly with heart disease, stroke, depression, diabetes, eye and ear problems, hypertension, arthritis, osteoporosis, falls, pain and incontinence. ²⁴ Home Secretary Theresa May announced that from October 2012 it will be illegal to withhold help on the basis of age. ²⁵ If I look at the question again in twenty years’ time I may well find that, for all the protestations, things haven’t much changed in this regard…

The Clinical Case

It is often difficult to untangle people’s reasons for favouring age rationing: clinical, economic and philosophical rationales are often intertwined, as well as a sense of emergency, prejudice towards the elderly and personal fear of ageing. The clinical rationale is that older people receive little or no benefit or are less likely to benefit from particular treatments than younger people; age is thus a useful rule of thumb both for appropriateness of an intervention (even were resources unlimited) and for sorting according to capacity to benefit.

The problem with this is that age is at best a very rough guide to prognosis: it is the multiple diseases and physiological impairments that commonly accompany old age which affect a decline in average outcomes from some medical interventions, not age itself. Individuals vary enormously in their rate of biological ageing and it would therefore seem more logical to use the particular, relevant, physiological impairments as the clinical basis for rationing rather than the surrogate of age.

Though counterintuitive, the elderly often respond better than the young to treatment and a surgical stitch in time can save nine down the track. Thus dialysis patients over 65 have a better survival rate than those between 55 and 64; renal transplants are as successful in the elderly as in younger people. Similarly, there is little difference between young and old patients in many cardiac interventions, yet the elderly are commonly denied treatment on the grounds of ‘poor prognosis’. Gerontologist Sir John Grimley-Evans called this ‘aggravated ageing’. ²⁶ Surveying the evidence John Young concludes that age-based rationing of treatment is now ‘unsustainable’ on clinical grounds. ²⁷

The Economic Case

All over the world healthcare systems are said to be in financial crisis and people are searching for ways to contain costs and distribute resources better. ²⁸ Even if some communities should spend more on healthcare, provision cannot be endless. Indeed, the healthier Western societies become, the more healthcare they seem to crave. Some limits and some principled way of informing policies and individual decisions about who gets what are required.

Some health economists and utilitarian philosophers have suggested that the gain from treatment of the elderly is insufficient to warrant the cost: other uses of those resources would be more efficient. This claim is commonly associated with the influential National Institute for Health and Clinical Excellence. Despite its acronym NICE, this Institute engages in not-so-nice cost-benefit and QALY (quality-adjusted life-years) analysis that many conclude is irreparably ageist. ²⁹ These utilitarian approaches are also associated with a view that at a certain point patients are better off dead and that care should be reduced to zero as they approach that point. Thus QALYists would, in principle, defund all terminal care. ³⁰ Some have even argued that society should divert other resources—not just medical ones—from older, less productive members to younger, more productive ones. ³¹

In an attempt to discredit the Hippocratic-Christian alternative NICE has dismissed needs-based allocation as paternalistic, ineffective and even Marxist. ³² The father of health economics, Alan Williams, favoured weighting QALYs against the elderly because they had already had a fair innings. ³³ In his most recent work the doyen of age rationing, Daniel Callahan, has shifted towards the NICE proposal that QALYs be used for all age groups and then the elderly sifted out. ³⁴ Thus like Williams he would refuse expensive treatments with low QALY yield to all patients, but even cheaper and high QALY-yielding ones to older patients. Callahan also now supports withdrawal of basic care from demented and unresponsive patients. ³⁵

Elsewhere I have examined the utilitarian underpinnings and troublesome conclusions of such approaches, as have many others. ³⁶ Suffice it here to say that ‘quality of life’ is a highly tendentious concept and attempts to apply it to healthcare rationing are dogged with theoretical and practical problems. No very coherent account of benefit is usually offered; no valid basis for measuring and comparing choices or policies; and attempts to produce action guides are fraught with further difficulties. It is logically impossible to judge if such an allocation process is ‘efficient’ while eschewing an account of the human good, moral reason, community and the purposes of healthcare. Health economists may simply be showing us how to get most efficiently to the wrong place. In the process we may be led to compromise basic moral principles against killing, harming and abandoning, and favouring respect for the dignity and equality of all, promotion of health, reverence for the elderly and support for the disadvantaged.

The Fair Innings Case for Age Rationing

While most people are troubled by pragmatic or economic-rationalist approaches that would seriously reduce treatment for the elderly or exclude them altogether from treatment, there is some intuitive appeal to age-based rationing: if you’ve got one ICU bed or one heart-for-transplant and two patients that need it, one young and one old, many people think that ceteris paribus the younger person should get it. ³⁷

The best known ethical cases for this were first elaborated in the 1980s by Daniel Callahan in Setting Limits: Medical Goals in an Ageing Society and Norman Daniels in Am I My Parents’ Keeper? An Essay on Justice between the Young and the Old. ³⁸ Both began with the notion of the fair innings, ‘natural life-span’, or as Callahan put it, ‘a life long enough’ to experience ‘those opportunities that life typically affords people and which we ordinarily take to be the prime benefits of life’. ³⁹ Soon after these books were published, Pete Townshend spoke again for the spirit of the age when asked by an interviewer whether he still hoped to die before he got old. He said yes, but that this meant he hoped to live long enough to accomplish everything he wanted and short enough to be finished before he had run out of things to achieve. ⁴⁰ A ‘fair innings’ is about opportunities.

But when is enough life enough? For individuals to seek more than a fair innings, especially at the expense of other important goods, can represent lack of prudence or proportion about life-span, lack of fortitude in the face of sickness and death, and a kind of medical intemperance. St Basil the Great counselled Christians to avoid ‘whatever requires such undue thought or effort or expenditure as to make our whole life revolve around solicitude for the flesh’. ⁴¹ Callahan says accepting personal responsibility includes coming to terms with the inevitability of ageing and death, and not imagining one is exempt from the ‘change and decay in all around I see’. Different temperaments, commitments and life-plans mean people differ in the priority they give to the pursuit of life and health, but there comes a point where seeking more may be vain, in vain or require irrational expense. ⁴²

Daniels and Callahan argue their case more on the basis of justice rather than temperance, fortitude or prudence. Expecting others to foot the bill for one’s aspiration to endless earthly life and health represents, they argue, an unreasonable preference for self and disregard for others and the common good. ⁴³ Good healthcare systems try to give everyone a good chance of a reasonable length of life in reasonable health. But faced with competing demands they must taper off provision to those who have already had this in favour of those who have not. In 2012, Callahan claimed the elderly are now a hazard to the young because of their voracious appetite for healthcare, consuming far more than their just share. ⁴⁴ ‘A good society ought to help young people become old people, but is under no obligation to help the old become indefinitely older.’ ⁴⁵

Daniels and Callahan have also argued that most people would prefer their life’s healthcare entitlements skewed towards their younger years and that the healthcare system should reflect this. Similarly, Leonard Fleck has argued in his series on Just Caring ⁴⁶ that as rationing is inescapable it should be done in as visible and consultative a way as possible. He claims that prudent, risk-averse people, behind a Rawlsian ‘veil of ignorance’, would favour younger patients for life-prolonging treatments and older patients for palliative ones. Ezekiel Emanuel and colleagues have likewise proposed a ‘Complete Lives’ principle for distributing health resources, arguing that age rationing maximises the chances of everyone experiencing all stages of the life cycle. Older patients have less priority for life-prolonging treatments such as kidney transplants because they’ve already enjoyed a more or less ‘complete life’. ⁴⁷

All these ‘fair innings’ writers approach their subject from a liberal egalitarian perspective and make a more morally robust case for age rationing than those based on purely clinical, financial or utilitarian considerations. Their version of age rationing is not unjustly discriminatory in the way that distributing according to race, sexuality or religious beliefs would be because all people are subject to ageing and would be entitled to the same care over a life-time; there is no denial of equal access or opportunity across the life-cycle. ⁴⁸ Whether these fair innings approaches are nonetheless unjustly discriminatory is a matter to which I shall return.

An argument for some age rationing might also be made on the basis of the ends internal to healthcare. Rather than seeking the indefinite extension of life and health, healthcare properly has the humbler (and more attainable) goal of maintaining or raising health and extending life to the species-typical level; attempts to achieve superhealth or endless life are not the province of healthcare.

Fair innings theorists insist that age rationing should not mean abandoning the elderly. Any exclusions would need to be publicly defensible, applied consistently but gently and with a heavy heart, and represent no diminishment of respect. The elderly would still be entitled to a primary healthcare, good pain-relief, home and institutional nursing, hospices and so on. Such age rationing, they assert, would alleviate rather than heighten intergenerational rivalry and this will be necessary if the elderly are to receive any care at all in the future.

Philosophical Problems with the Fair Innings Case for Age Rationing

There are, however, a number of problems with the fair innings rationales for age rationing. What length of life might one reasonably expect and what health opportunities up till then? ⁴⁹ Callahan talks of a typical life but this depends very much on socio-economic circumstances: in many times and places few people achieved eighty years or even half that. Is it unreasonable for someone in Swaziland to aspire to more than the 31.9 years ‘typically afforded’ in that region? Daniels’ species-typical life-span seems more universal but is also problematic. ⁵⁰ As technology and economy improve so does life expectancy, and no one deplores this as a failure of respect for ‘nature’; indeed we rejoice that more people live to enjoy a longer period of old age, in better average health, than was common in the past, and so have the opportunity to enjoy the state, relationships and activities proper to that stage of life.

Even if there comes a point where many people feel they have had a fair innings and would not feel robbed were their life soon to end, others will want a longer life. ⁵¹ They may simply value life and health more or may wish to achieve some other reasonable end(s) such as: finish their magnum opus; care for their dependent spouse; or redress some past error—none of which need reflect a shortfall in rationality or virtue. And even if fair innings writers are right to claim that many people would willingly forgo care in their old age so that more might be available to themselves or others when young, we cannot generalise this to all. Joseph Boyle observes that we cannot morally leap from considerations which motivate some elderly people to volunteer to decline some healthcare to the conclusion that this might be imposed on all. ⁵²

Nor is it clear that prudence would counsel skewing healthcare entitlements towards one’s early years. Whatever theorists, patients’ own children or health workers think, many older people do want complex care (such as resuscitation); what older people judge as adequate ‘quality of life’ is also different. ⁵³ A 2007 study in Nursing Ethics found people over 60 feared younger people categorising them as ‘old’ because this means ‘low priority’ for healthcare. ⁵⁴ Even if people behind a ‘veil of ignorance’ would prefer age rationing—which is debatable—those who actually suffer the burden of such a policy are better placed to assess its reasonableness. ⁵⁵

Clinical Problems with the Fair Innings Case for Age Rationing

Fair innings accounts also seem to presume that the fairest way to allocate healthcare is more or less evenly to people rather than disproportionately to the elderly. ⁵⁶ But spreading limited resources evenly is not always the fairest way to distribute them. ⁵⁷ Every parent understands that larger and older children will need more food; every doctor understands that sicker people will need more healthcare. If healthcare is intended for the sick as such then prima facie the just way to allocate it will be to the sick, and first to the sickest; no wonder that the elderly receive much of this attention. No one complains that children chew up a big share of education resources because that is precisely whom they are for!

In this respect and others, fair innings theorists seem to ignore the internal ends of medicine (and nursing…) as understood over millennia and treat healthcare instead simply as ‘a resource’ like water or fuel that could be turned to various social purposes and required to be allocated to people. In fact we are dealing with healthcare professionals who enter and sustain that profession with a view to achieving certain ends and with a profound human service which others seek for reasons that are not well captured by talk of ‘resource allocation’. Without romanticising the doctor–patient relationship one can acknowledge that it would be radically affected by expecting healthcare professionals to assess (or follow assessment by accountants) when patients have had their ‘fair share’ of life-span or health opportunities. ⁵⁸ Age rationing tends to homogenise ‘the elderly’ in the eyes of carers as a demographic rather than several individuals, indeed as a swarm of voracious but unworthy consumers of a resource which doctors must guard from them. ⁵⁹

It should also be recognised that the rescue imperative of traditional Hippocratic and Judeo-Christian medicine—which has been justly criticised at times for encouraging a kind of healthcare addiction or profligacy—has also been very fruitful not just in assisting particular patients but also in advancing medicine itself. Gerontology and healthcare more generally would little improve if we systematically abandoned the attempt to extend the life or improve the health of the elderly. ⁶⁰

Metaphysics of Ageing and Implications for Healthcare Rationing

Apart from the various weaknesses that might be identified with respect to fair innings (and other) cases for age rationing, there are positive arguments in favour of providing healthcare at least on an equal basis for the elderly as for younger patients. One reason is that the elderly are the ones who, on average, have made the greatest contribution to the health system as taxpayers, as well as many other areas of society, in the reasonable expectation that their healthcare needs would be accommodated in due course. To deny them healthcare could amount to unjust enrichment, even theft, by the young.

Furthermore, healthcare has traditionally expressed and been governed by Hippocratic ideals of valuing all people as of equal dignity; it has therefore been allocated on the basis of need—as far as possible, addressing equal needs equally—an attitude which informs most welfare policy. ⁶¹ There are good reasons to think that contemporary Western societies already undervalue their older members. While the young, productive and physically perfect are idolised in various ways, ageing is often treated as shameful, its signs to be warded off by medical, sartorial and cosmetic artistry and, once undeniable, as warranting exclusion from various contexts. ⁶² Examples of neglect and elder abuse are countless in the British tabloids. To take away much of healthcare—one of the last examples of care supposedly offered to all—could reflect and would generate further bias against this already vulnerable group. ⁶³ Those who live ‘too long’ would be seen as burdens; sensitivity to their needs would be dulled. ⁶⁴

One way in which societies, that treat the elderly less well than they might, still demonstrate that they value older people is by providing dignified health and aged care. Such care expresses fundamental values such as equal respect for persons, the sanctity of life and the rescue imperative, concern for the weak and suffering, and reverence for elders. The quality of health and aged care provision to the elderly speaks volumes for the quality of pietas, and thus of justice and mercy, in a particular community. As the costs of healthcare generally and care of the elderly in particular continue to rise, there will be a pressure to scapegoat, abandon, even kill, the elderly as a cost-cutting measure. ⁶⁵ There are good reasons, then, to resist that pressure now by a strong insistence that age not be a criterion of healthcare distribution. ⁶⁶ Further research might usefully be done on differing cultural understandings of age and ageing and the implications for providing healthcare as a token of valuing older people.

Needs-Based Rationing Rather than Age Rationing

A satisfactory resolution of healthcare allocation dilemmas must begin with a more substantive conception of the human person than many ‘liberal’ attempts to answer these questions have been willing to elaborate. We need some account of the place of life and health in a human story and what is needed to promote those goods; of personal responsibility for health and healthcare; of the traditions, norms and virtues appropriate to the practice of healthcare; of the responsibilities of all societies to provide for the needs of their members in healthcare; of the capacities and proper goals of our particular society; and of the scope and limits of the right to healthcare. ⁶⁷ While there is not the space to argue it fully here, a richer philosophical account of what healthcare is about will suggest that patients, health-workers and health services should give priority to people’s most important needs over less important ones, and to those with more important needs over those with less important ones. So would an account based on Christian faith such as is articulated in the next section, though it might give an ever stronger preference to those suffering greater disadvantage.

On this needs-based account of healthcare rationing, priority should be given ceteris paribus to the patient:

Covenant between the Generations

Age rationing, on this account, is unjustly discriminatory and socially dangerous; needs-based rationing is the only just way of distributing healthcare. ⁶⁸ But the distribution of healthcare is not just about justice, narrowly construed. Healthcare systems also tell a story of the kind of people we are and wish to be. The inclusion or not of the elderly, and on what terms, reveals the quality of intergenerational relationships, attitudes to ageing and the elderly themselves, filial affection and duty, veneration of elders and gratitude for their contribution. Their inclusion in the community of those served on the basis of need demonstrates how much we value life and health, but also how much we value persons—frail, vulnerable, sick or suffering persons of whatever age. ⁶⁹ To embrace age rationing of healthcare would be to tell a very different story.

If healthcare is a narrative, Christians hope to retell by such care the story of the Good Samaritan. This is a tale of neighbourly compassion and generosity, of Christ the Physician of bodies and souls responding to crying need. We cannot imagine the Good Samaritan assessing whether the man beaten and left for dead had already had a typical life-span or range of life opportunities, or doing a QALY and cost-benefit analysis before deciding whether to invest. We don’t know whether the victim in that story was young or old because it is irrelevant to such a corporal work of mercy. ⁷⁰

The Good Samaritan and his charge were strangers to each other; generations should not be. Daniels says children have few or no filial obligations because they had no choice in coming to be; the duties are all at the parents’ end. ⁷¹ Callahan has a more mutual view, acknowledging that: ‘All of us are subject to the common threat of illness, aging, and death. That is a powerful bond to draw us together. The young and the old need each other to cope with, and mutually bear, the economical and social burden of our shared fate.’ ⁷² But what does it mean to bear this shared fate mutually? In Evangelium Vitæ John Paul II wrote of the ‘intolerable’ neglect that some of the elderly, handicapped and dying experience even—perhaps especially—in affluent nations. He exhorted us ‘to preserve, or to re-establish where it has been lost, a sort of covenant between generations’, a relationship of acceptance, solidarity, closeness and service. ⁷³