The age-rationing debate of fifteen years ago will inevitably reemerge as health care costs escalate. All age-rationing proposals should be judged in light of the current system of rationing health care by price in the U.S., and the resulting pattern of excess and deprivation. Age-rationing should be rejected as public policy, but recognized as a personal virtue of stewardship among the elderly.

In this article I investigate the nature and extent of filial obligations. The question what (adult) children owe their parents is not only philosophically interesting, but also of increasing relevance in ageing societies. Its answer matters to elderly people and their adult children, and is relevant to social policy issues in various ways. I present the strongest arguments for and against three models of filial obligations: the ‘past parental sacrifices’ model, the ‘special relationship’ model, and the conventionalist model. There is (...) something to be said—and after consideration of objections something remains to be said—for all three models. In other words: filial obligations have more than one source, and an adequate model of filial obligations should reflect this. On its own, each of the above models is one-sided. They also fail to show the connections between the question of filial obligations and various other issues, such as issues of gender justice, the extent of institutionalization of eldercare, and social conventions regarding filial responsibility. Therefore, I integrate what I think we should keep from the aforementioned models into a contextual, pluralist model, which places filial obligations in a broader social and cultural context and relates them to issues of social justice. The model also highlights the difference between general and specific filial obligations, and the factors that determine their nature and extent, thus enabling a deeper and more comprehensive understanding of filial obligations. (shrink)

This paper responds to discussion and criticism contained in a mini-symposium on Just health: meeting health needs fairly. The replies clarify existing positions and modify or develop others, specifically in response to the following: Thomas Schramme criticises the claim that health is of special importance because of its impact on opportunity, and James Wilson argues that healthcare is not of special importance if social determinants of health have a major causal impact on population health. Annette Rid is concerned that the (...) relevance condition in accountability for reasonableness is unclear and does little work. Harald Schmidt aims to flesh out where an account of responsibility for health should go since one is under-developed in Just health. Michael Schefczyk and Susanne Brauer challenge aspects of the prudential lifespan account. Samia Hurst asks what impact a population view should have on clinician obligations. (shrink)

Some empirical findings seem to show that people value health benefits differently depending on the age of the beneficiary. Health economists and philosophers have offered justifications for these preferences on grounds of both efficiency and equity. In this paper, I examine the most prominent examples of both sorts of justification: the defence of age-weighting in the WHO's global burden of disease studies and the fair innings argument. I argue that neither sort of justification has been worked out in satisfactory form: (...) age should not be taken into account in the framework of the burden of disease measure, and on the most promising formulations of the fair innings argument, it turns out to be merely an indicator of some other factor. I conclude by describing the role of age in theories of justice of healthcare resource allocation. (shrink)

Justice Across Ages offers an attractive account of justice between the young and the old that brings together three notable principles of age-group justice: complete-lives equality, relational equality, and prudence. Yet, the book says little about the fact that many of us live longer than others, and the little it does say casts doubt on whether lifespan inequality threatens justice as construed by the three principles. This essay argues, instead, that theories of justice between the young and the old should (...) not dispense with a conception of justice between different longevity groups. It concludes that we must be sensitive to lifespan variations when designing policies to promote justice across age groups. (shrink)

A society is said to age when its number of older members increases in relation to its number of younger members. The societies in most of the world’s industrialized nations have been aging since at least 1800. In 1800 the demographic makeup of developed countries was similar to that of many Third World countries in the early 1990s with roughly half the population under the age of 16 and very few people living beyond age of 60. Since that time, increases (...) in life expectancy, combined with declines in fertility rates, have dramatically increased the proportion of older persons in developed nations. The rapid increase in the number of older persons relative to younger ones carries important societal implications. In the domain of healthcare, societal aging will increase costs and exert greater pressure to ration services. It will, thus, bring to the fore questions, regarding a just distribution of healthcare between young and old age groups. This paper considers some of the most influential arguments to date for age-based rationing of health care. I show that these arguments fall short, and that the theoretical assumptions underlying them do not withstand careful scrutiny. (shrink)

A continuing need for care for elderly, combined with looser family structures prompt the question what filial obligations are. Do adult children of elderly have a duty to care? Several theories of filial obligation are reviewed. The reciprocity argument is not sensitive to the parent–child relationship after childhood. A theory of friendship does not offer a correct parallel for the relationship between adult child and elderly parent. Arguments based on need or vulnerability run the risk of being unjust to those (...) on whom a needs-based claim is laid. To compare filial obligations with promises makes too much of parents’ expectations, however reasonable they may be. The good of being in an unchosen relationship seems the best basis for filial obligations, with an according duty to maintain the relationship when possible. We suggest this relationship should be maintained even if one of the parties is no longer capable of consciously contributing to it. We argue that this entails a duty to care about one’s parents, not for one’s parents. This implies that care for the elderly is not in the first place a task for adult children. (shrink)

This paper argues that we can see our lives as a snapshot happening now or as a moving picture extending across time. These dual ways of seeing our lives inform how we conceive of the problem of age group justice. A snapshot view sees age group justice as an interpersonal problem between distinct age groups. A moving picture view sees age group justice as a first-person problem of prudential choice. This paper explores these different ways of thinking about age group (...) justice and illustrates them using a principle of respect for human dignity, understood in terms of reasonable support for floor level central human capabilities at each stage of life. I argue that different frames are suitable for different kinds of decisions, and each provides a true, but partial, picture of aging and age group justice. (shrink)

In this paper, I offer a solution to the Capacity/Equality Puzzle. The puzzle holds that an account of the franchise may adequately capture at most two of the following: (1) a political equality-based account of the franchise, (2) a capacity-based account of disenfranchising children, and (3) universal adult enfranchisement. To resolve the puzzle, I provide a complex liberal egalitarian justification of a moral requirement to disenfranchise children. I show that disenfranchising children is permitted by both the proper political liberal and (...) the proper political egalitarian understandings of the relationship between cognitive capacity and the franchise. Further, I argue, disenfranchising children is required by a minimalistic, procedural principle of collective competence in political decision-making. At the same time, I show that political equality requires the enfranchisement of all adults, regardless of cognitive capacities, and that the collective competence principle does not ground adult disenfranchisement. This justifies the progressive legal trend that holds the capacity-based disenfranchisement of adults to be incompatible with liberal democratic principles. (shrink)

The British National Health Service (BNHS) was founded, to quote Minister of Health Aneurin Bevan, to ‘universalise the best’. Over time, however, financial constraints forced the BNHS to turn to incrementalist budgeting, to rationalise care and to ask its practitioners to act as gatekeepers. Seeking a way to ration scarce tertiary care resources, BNHS gatekeepers began to use chronological age as a rationing criterion. Age-rationing became the ‘done thing’ without explicit policy directives and in a manner largely invisible to patients, (...) to Parliament, and to the public. The invisibility of the practice, however, violates the publicity principle that John Rawls and other philosophers believe essential to fairness. BNHS invisible age-rationing practices are thus a test case of the principle that fairness presupposes publicity; they raise the question: is it possible to preserve equitability in a system that uses non-public criteria to allocate scarce resources? To seek an answer, published data on access to end-stage renal disease (ESRD) treatment in Britain and the European Community (EC) are analysed. Among the findings are: that BNHS age-rationing acts as an excuse for denying care to those most likely to need ESRD treatment; and is, moreover, arbitrary and inequitable. It is further argued that no age-rationing policy can sustain visibility, and that, if the BNHS is to be fair to its patients, it must reform its present age-rationing practices, replacing them by a publicly visible, outcome-based rationing policy that rations either in terms of QALYs or triage categories. (shrink)

An aging population is often taken to require a profound reorganization of the prevailing health care system. In particular, a more cost-effective care system is warranted and ICT-based home care is often considered a promising alternative. Modern health care devices admit a transfer of patients with rather complex care needs from institutions to the home care setting. With care recipients set up with health monitoring technologies at home, spouses and children are likely to become involved in the caring process and (...) informal caregivers may have to assist kin-persons with advanced care needs by means of sophisticated technology. This paper investigates some of the ethical implications of a near-future shift from institutional care to technology-assisted home care and the subsequent impact on the care recipient and formal- and informal care providers. (shrink)

Multiple self approaches purport that to have equal concern about all stages of one’s life is not a requirement of rationality. This poses a challenge to the prudential lifespan account which Norman Daniels advocates in Just health: meeting health needs fairly. Daniels has criticised the multiple self approach in earlier works, most extensively in Am I my parents keeper? In Just health, he only takes up the issue except in one footnote, presumably because he is convinced that his preceding discussions (...) settled the matter. This article argues that Daniels underestimates the force of the multiple self objection to prudential lifespan account. (shrink)

One of the societal problems in a new influenza pandemic will be how to use the scarce medical resources that are available for prevention and treatment, and what medical, epidemiological and ethical justifications can be given for the choices that have to be made. Many things may become scarce: personal protective equipment, antiviral drugs, hospital beds, mechanical ventilation, vaccination, etc. In this paper I discuss two general ethical principles for priority setting (utility and equity) and explain how these principles will (...) often point in diverging directions. Moreover, each of these principles can be understood in different, again often competing, ways. Notwithstanding these controversies and conflicts, in the context of pandemic response there are at least some points of convergence: several policies can be justified by appeal to different ethical principles and theories. Convergence may be found with respect to a focus on saving the most lives (instead of other aggregative accounts); giving priority antiviral prophylaxis and therapy for life-saving pandemic responders; and, partly depending on epidemiology of the pandemic, to prioritise vaccination of children. Although decision-making about access to intensive care will involve choices with immediate tragic implications, the ethical complexity of these choices is relatively modest (although decisions will not be easy): there are persuasive moral reasons for giving priority to patients who are expected to benefit most within the shortest time. Finally, in the last section I tentatively argue that constraints on people’s freedom, as necessary for an effective public health approach, may support giving somewhat more weight to saving the most lives, than to concerns of equity. (shrink)

Societal aging raises challenging ethical questions regarding the just distribution of health care between young and old. This article considers a proposal for age-based rationing of health care, which is based on the prudential life span account of justice between age groups. While important objections have been raised against the prudential life span account, it continues to dominate scholarly debates. This article introduces a new objection, one that develops out of the well-established disability critique of social contract theories. I show (...) the implications of this critique for the prudential life span account and for the special case of age-group justice. The result is that age-based rationing based on the prudential life span approach is not supported, and that the prudential life span approach itself is not the best way to think about allocating health care between age groups. I propose an alternative approach that avoids the disability objection, and consider its implications for specific proposals for age-based rationing of health care. (shrink)

Both arguments are based on the breakdown of normal criteria of identity in certain science-fictional circumstances. In one case, normal criteria would support the identity of person A with each of two other persons, B and C; and it is argued that, in the imagined circumstances, A=B and A=C have no truth value. In the other, a series or spectrum of cases is tailored to a sorites argument. At one end of the spectrum, persons A and B are such that (...) A=B is clearly true; at the other end, A and B are such that the identity is clearly false. In between, normal criteria of identity leave the truth or falsehood of A=B undecided, and it is argued that in these circumstances A=B has no truth value.These arguments are to be understood counterfactually. My claim is that, so understood, neither establishes its conclusion. The first involves a pair of counterfactual situations that are equally possible or tied. If A=B and A=C have no truth value, a counterfactual conditional with one of them as consequent and an antecedent that is true in circumstances in which either is true should have no truth value. Intuitively, however, any such counterfactual is false. The second argument can be seen to invite an analogous response. If this is right, however, there is an important disanalogy between this and the classical paradox of the heap. If the disanalogy is only apparent, the argument shows at most that the existence of persons can be indeterminate. (shrink)

The paper begins by drawing a distinction between “allocation” — the distribution of resources between different categories, and “rationing” — the distribution of scarce resources within a single category. I argue that the current allocation of funds to health care makes some form of rationing unavoidable. The paper next considers proposals by Daniel Callahan and Norman Daniels supporting age rationing publicly-financed life-extending medical care. I provide reasons for doubting that either argument succeeds. The final section of the paper sets forth (...) an alternative approach which holds that if people have any rights to health care, then they have a right to a decent minimum. (shrink)

The issues are familiar to most in bioethics by now, through professional or personal experiences (or both). The rapidly expanding population of elderly persons who require care is raising critical...

In recent literature, there has been much debate about whether and how luck egalitarianism, given its focus on personal responsibility, can justify universal health care. In this paper we argue that, whether or not this is so, and in fact whether or not egalitarianism should be sensitive to responsibility at all, the question of personal responsibilization for health is not settled. This is the case because whether or not individuals are responsible for their own health condition is not all that (...) is relevant when considering whether we should somehow hold them responsible for their own health condition, e.g. cost-wise. There may also be efficiency-based reasons to hold them responsible, and there may even be egalitarian reasons. Defining universal health care as an insurance system where everyone’s deductible and premium is 0, we will argue that efficiency-based reasons for cost-responsibilization are not convincing, but that there are egalitarian reasons for cost-responsibilization. Luck egalitarianism, therefore, cannot, at least not on its own term, justify universal health care. (shrink)

In this paper, I assess Peter Dabrock's “Drawing distinctions responsibly and concretely: A European Protestant perspective on foundational theological bioethics.” I explore the ways in which Dabrock announces nontraditional Christian assumptions to guide Christian bioethics, engages the secular bioethical agenda on the very terms set by and congenial to the field of secular bioethics, and searches for insights from philosophy and science through which to recast Christian moral judgments. For example, he cites approvingly, as if they were expressive of Christian (...) moral concerns: human rights, democracy, and state-based social redistribution of resources to satisfy welfare entitlements. In this short essay, I argue that Dabrock has unduly limited the role of Traditional Christian theology to guide bioethics and, consequently, has also wrongly characterized the Christian moral life and Christian social/political obligations. (shrink)

This article examines two questions pertaining to the extension of infertility treatment to postmenopausal women. First, what concepts and principles of infertility practice apply to assisted reproduction for the postmenopausal patient? Second, what role should these concepts play in the development of an ethical justification for extending women's reproductive lives past the menopausal boundary? The argument offered here supports their claim to infertility services on the basis of the formal principle of justice, which requires that similar cases be treated similarly. (...) The cases of many postmenopausal patients are argued to be relevantly similar to classes of patients who already receive assistance in reproduction. (shrink)

Nancy Jecker (2013) makes a compelling argument for using a capabilities approach to resolve the issue of the fair allocation of health care resources across various age groups. This question has b...

This paper considers the place of children within liberal-democratic society and its related political morality. The genesis of the paper is two considerations which are in tension with one another. First, that there must be some point at which children are divided from adults, with children denied the rights which go along with full membership of the liberal community. The justification for the difference in the statue between these two groups must be rooted in some notion of capacities, since these (...) are the only relevant differences between adults and children. Second, that linking an individual's capacities to her status undermines the central liberal commitment of political equality. This dilemma explains what I term the threshold view, which holds that children become adult citizens upon reaching an age of competence and that above this level differences in abilities cease to matter to an individual's status. While this view has attractions, this paper argues that this view must eventually be rejected because of its inability to deal with the actual process of human development. In its place, the paper proposes a modification to this view which sees the threshold constrained by moral demands and applied indirectly to age groups rather than individuals. These constraints preserve the commitment to equality in a way consistent with a plausible view of children's place in society. (shrink)

The allocation of scarce health care resources such as flu treatment or organs for transplant presents stark problems of distributive justice. Persad, Wertheimer, and Emanuel have recently proposed a novel system for such allocation. Their “complete lives system” incorporates several principles, including ones that prescribe saving the most lives, preserving the most life-years, and giving priority to persons between 15 and 40 years old. This paper argues that the system lacks adequate moral foundations. Persad and colleagues' defense of giving priority (...) to those between 15 and 40 leaves them open to the charge that they discriminate unfairly against children. Second, the paper contends that the complete lives system fails to provide meaningful practical guidance in central cases, since it contains no method for balancing its principles when they conflict. Finally, the paper proposes a new method for balancing principles of saving the most lives and maximizing life-years. (shrink)

Rather than base social welfare policies on contractual bargaining, policies should focus on the duties the strong members of society have toward the weak: the poor should clearly receive more, and the rich pay more, than either group has bargained for.

What should maximin egalitarians think about seniority privileges? We contrast a good-specific and an all-things-considered perspective. As to the former, inertia and erasing effects of a seniority-based allocation of benefits from employment are identified, allowing us to spot the categories of workers and job-seekers made involuntarily worse off by such a practice. What matters however is to find out whether abolishing seniority privileges will bring about a society in which the all-things-considered worst off people are better off than in the (...) seniority rule's presence. An assessment of the latter's cost-reduction potential is thus needed, enabling us to bridge a practice taking place within a firm with its impact on who the least well off members of society are likely to be. Three accounts of the profitability of seniority privileges are discussed: the “(firm specific) human capital”, the “deferred compensation” and the “knowledge transfer” ones. The respective relevance of “good-specific” and “all-things-considered” analysis is discussed. It turns out that under certain circumstances, a maximin egalitarian case for seniority privileges could be made. Senior: Do you know that they are planning layoffs? Of course, it is only fair that they lay-off the newcomers first! After all, I have been loyal to the company for many years. Junior: Did I choose to be a newcomer? Footnotes1 Many thanks to two anonymous referees, to P.-M. Boulanger, B. Cockx, C. Fabre, L. Jacquet, E. Lazear, I. Robeyns, G. Vallée, Y. Vanderborght, Ph. Van Parijs, V. Vansteenberghe and J. de Wispelaere for their help and critical comments. Earlier versions of this paper were presented in Louvain-la-Neuve, Ghent, Montevideo and London. I am very grateful to these audiences. Special thanks to G. Brennan for his extensive and extremely valuable comments on earlier drafts of this paper. The usual disclaimers apply. (shrink)