Health care rationing in the aged: ethical and clinical perspectives

This article provides an ethical analysis of the question of whether aged patients' access to health care should be less than, the same or greater than, the access younger patients enjoy, when economic resources are limited. This topic is being urgently considered in the US because managed care is becoming more common and brings with it new challenges to traditional medical ethics, and because the prevalence of the aged is increasing as is the number of patients with Alzheimer's disease (AD). It is also critical throughout the world because new findings suggest that the progression of AD may be retarded or even reversed by providing patients with enriched interpersonal environments. If these findings are valid, it would be inhumane to not consider providing these resources to patients with AD, since these gains would be so meaningful and substantial. Deontological and consequential values influencing this question are presented and evaluated. The theories of Veatch, Callahan and Daniels in regard to allocating health care to the aged are discussed. It is argued that 2 subgroups of aged patients, the isolated and demented, are among the patients worst off because the capacity to enjoy meaningful relationships with others supercedes all others and both groups of patients have lost this capacity. We assert that, on the basis of the principle of justice according to need, these 2 groups of patients' exceptional needs should be prioritised. We then raise the question of whether the majority of the population would be willing to provide these isolated and demented aged patients this care if the new findings proved valid. We conclude that, in light of many people's fear of growing old and dying, and some peoples bias against the aged (particularly in the US), willingness to provide the necessary resources is open to debate. Finally, we provide specific examples of the kinds of interventions which might be optimal for each group of patients. For patients who are cognitively unimpaired, this might be providing home care so that they could remain closer to and in contact with their loved ones. For patients who are cognitively impaired, this might be providing interpersonal support when these patients begin to lose control, rather than applying restraints or using psychotropic medication.