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MJM 1998 4: 48-53
Copyright © 1998 by MJM
CROSSROADS: WHERE MEDICINE AND THE HUMANITIES MEET
Should Age Matter?
One Possible Justification for
Age-Influenced Medical Rationing
Shantanu Agrawal*, Sc.B., A.B.
Medicine exists to treat the sick. This statement,
though extremely simple, accurately conveys how most
people intuitively feel that society’s medical resources
should be distributed. Care should be given to those
who require it. But if this was the extent of
consideration, then almost all of society’s social
resources would be spent on health care, leaving little
for anything else. In 1996 alone, total health care costs
in the United States exceeded one trillion dollars, of
which Medicare and Medicaid expenditures accounted
for about $351 billion (1). While this was the lowest
percentage increase from the previous year (about
4.4%) in almost four decades, healthcare costs continue
to be on the rise at about the same rate. There clearly
have to be some justifiable limitations. It has become
increasingly clear, however, that any proposed system
of health care rationing promotes along with it the
unequal treatment of people. While this is not ideal,
unequal treatment which is morally indefensible is, or
should be, carefully avoided. No reasonable health care
system would, for example, promote inequalities
according to gender, religion, or ethnicity. But a gray
area for medical ethics today is age.
Should there be differential treatment between the
young and old? Some differential treatment according
to age is not only socially acceptable, but is considered
sensible and just. Examples of this range from social
security benefits to student and senior citizen discounts
at movie theaters. But should health care become
another example? In a report attempting to quantify the
burden of disease, C.J.L. Murray proposed the use of
the Disability Adjusted Life Years (DALY) curve as a
* To whom correspondence should be addressed: Center for Alcohol
and Addiction Studies, Brown University, Providence, Rhode
Island, USA 02912
way to explain the differential value of life at different
ages— in effect, to establish unequal age weights (2).
He concluded that the most important socially valuable
time is between the ages of about 10 and 60 years.
While unequal age weights may be justifiable, Murray’s
analysis inadvertently produces unequal treatment
along lines which are morally indefensible. The purpose
of the current paper is to first define the problems with
this approach and then provide a new motivation for the
DALY curve based on a philosophy of valuing human
life first suggested by Ronald Dworkin (3) so that it can
be an ethical basis for health care rationing.
ANALYSIS OF ECONOMIC ARGUMENTS
Murray’s approach to the use of the DALY curve (2)
is both centered in economics and is extremely
consequentialist. The age-weighted DALY curve he
used is a function graphed in years versus weighting.
The only ages to have a weighting of greater than 1.0
are between ages 10 and 60. There are two possible
justifications for attributing greater value to the lives of
the people in the middle of the curve. The first line of
reasoning is as follows:
The theory of human capital views individuals as a type of
machine with costs of maintenance and expected output.
The value of time at each age for this human production
machine should be proportionate to productivity (2).
This is basically a cost-utility analysis, which suggests
that the cost of health care spent on a person should be
proportionate to, or dependent on, the benefits that
person will produce for society. Though the term
“productivity” is ambiguous in its use, the assumption is
that people in the middle of the DALY curve will
Vol. 4 No. 1, 1998
Should Age Matter?
generally be more productive than people at the
extremes, no matter the standards used to measure
productivity. This is easily seen if, for example,
productivity is considered to be a direct reflection of
wages earned or even if it is considered to be the
potential to have and raise a family.
Murray’s second line of reasoning in support of the
DALY curve is that “unequal age weights [are] an
attempt to capture different social roles at different
ages” (2). Though not completely clear in its message,
this approach suggests that people on the center of the
curve should be given precedent in health care because
they provide for the people on the ends (either through
social institutions, such as by paying taxes, or by
maintaining families). Because the old and the young
generally have limited social roles, time at these
extremes is less valuable than time spent at middle age.
While this economic approach does justify the shape
of the DALY curve and unequal age weights, it can also
inadvertently produce biases within age groups that are
discriminatory and unacceptable. Take, as an example,
the issue of productivity. From an economic standpoint,
the rich are seen as being more socially productive than
the poor, but does that mean that the “cost of
maintenance” of a rich person can justifiably be
proportionately higher than a poor person’s? In other
words, does a 30 year old rich person deserve more
health care than a 30 year old poor person because of
some assumed difference in the value of their time? For
various social reasons, women and minorities tend on
average to earn less than Caucasian males, but to entitle
these groups to less health care solely because of this is
obviously immoral. As Murray put it,
The logical extension of the human capital approach
would be to weight time by other human attributes that
correlate with productivity such as income, education,
geographical location or even, in some economies,
ethnicity (2).
While this may be logical according to economics, it
cannot be acceptable for a rationing policy.
These problems can also be extended to Murray’s
second line of reasoning. There are different social roles
for people at different ages but, again, doling out health
care according to social role would seem to demand that
a middle aged person paying high taxes or rearing a
large family deserves more benefits than a less affluent
bachelor. Essentially, any person who could not fulfill
his social roles and responsibilities to some undefined
maximum would be discriminated against in this system
of health care rationing.
The basic problem with a strictly economic analysis
of health care rationing is that people do not think
49
merely in terms of economics — a life has more
personal and (hopefully) societal value than reflected by
a person’s productivity or the benefits they will
produce. Life has a worth all its own, and that is why its
loss is felt and mourned even when a person does not
economically improve society. The death of homeless
people or citizens of other countries still stir sympathies
and incite a sense of loss. Rationing decisions will
always be difficult to make, but they should be based on
principles and convictions that reflect the whole value
of a human life.
INTUITIVE NOTIONS
Before going on to describe a new justification for the
DALY curve, there may be some value in exploring
intuitive notions about age-based rationing to really get
at the issue of comparative values of human life. This
paper began with one example of the intuitive notion
that some differential treatment between the young and
old is already socially acceptable, but others have
conducted studies which are by far more scientific and
conclusive. Based on a survey done in Australia to test
the importance of age and length of benefits on the
social evaluation of health care, Erik Nord concluded
that,
Subjects are prepared to discriminate [in favor of the
young] on the basis of age when deciding which health
care projects to fund, and that discrimination increases the
greater the difference in age of the patients under
consideration. This result holds for both life extending and
health improving treatments (4).
While a preference for the young is interesting and
requires explanation, what is perhaps more interesting is
that only about 20% of respondents chose to
discriminate in favor of the young (either for life saving
or life improving treatments) when their views were not
supposed to be from the perspective of a State Health
Board, but were supposed to represent their own
personal beliefs (4). What this disparity seems to
suggest is that people do not see the young as having
intrinsically more valuable lives than the old. The
sanctity of life is held in the same respect regardless of
age, but if forced to make comparative decisions
between age groups when deciding health care policy,
significantly more people are willing to advantage the
young for no other reason than age.
Situational examples confirm this claim but can also
show, based on intuitive feelings, that preferences and
deeply held convictions are not solely a function of
youth. An accident, for example, which leads to the
death of a 70 year-old man is a terrible loss of life and
seems intrinsically bad, but most people would think the
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McGill Journal of Medicine
death somehow worse or more shameful if the man was
30 years-old. This is identical to situations already
considered and does not reveal anything new beyond
the Nord survey (4). Through the same accident,
however, the death of an infant would be bad, but the
death of a young child seems worse to many people.
And even worse still may be the death of a teenager.
This series of comparisons contradicts the pattern
established through the Nord survey and suggests that
instead of holding preferences strictly for youth, people
may just hold preferences for certain age groups.
If all life has the same intrinsic value, then from
where does this preference for any age group stem? It
could be argued that the surveyed people were thinking
along economic lines when making comparative
decisions, leading them to prefer the potential social
productivity of youth. But to ensure that people really
thought about the questions being asked in an ethically
relevant sense, Nord presented them with two
philosophical arguments — one advocating equal rights
to treatment and the other prioritizing according to age
— before they had made their decision (4). This
encouraged them to think along principles of equal
entitlement to medical attention rather than along their
own personal biases. The fact that most of the people
surveyed read these arguments and then made decisions
favoring the young suggests there may be a principle at
work which entitles the young to life saving or life
improving care over the old. It may be possible to tease
out what this principle is and show that it does not really
extend to all young people, but only to those within a
certain age group, as suggested by the situational
example made above.
NATURAL INVESTMENT
One plausible statement of this principle is a
philosophy of valuing human life first suggested by
Ronald Dworkin (3). Though it speaks of investments,
this philosophy avoids the problems and
discriminations of the current DALY curve by being
less consequentialist than Murray’s approach (2) and
taking more than economics into account when
answering the question of what qualities really give
value to a human life. Dworkin’s basic claim is that he
does not want to focus “only on future possibilities, on
what will or will not happen in the future,” since,
“[That] ignores the crucial truth that waste of life is
often greater and more tragic because of what has
already happened in the past” (3). Instead, he considers
the value of a human life to be the product of two kinds
of investment — what he terms “morally significant
modes of creative investment” — the natural and the
human (3). Since he purposely defines these
investments rather ambiguously, both will have to be
Vol. 4 No. 1, 1998
considered separately, more carefully defined, and then
shown to fit together in a coherent justification for the
DALY curve.
In every human life, there are certain biological
stages of development, often termed the natural course
of life. Everyone is born after the random mating of
genetic material. All people grow and change, first as
infants, then children, then adolescents, and finally as
adults. Eventually, at the end of this natural course of
life, all people die. It is the very existence of these
stages that Dworkin is referring to with his notion of
natural investment (3). From the first moment of
conception, parents and nature have made an
investment in lives, and the investment continues to
grow with each completed life stage.
This is as far as Dworkin took the idea, but in order to
aid the DALY curve, it needs to be extended somewhat
further. With the first investment made in a life, a whole
series of events is set in motion and expected to go to
completion. Nobody creates life with the express
purpose of ending it prematurely. In fact, the loss of life
that has not yet reached its own natural endpoint is
considered to be frustrating and bad. The general
feeling, then, is that once the initial natural investment
has been made, any disruption in the process it initiates
is upsetting and fundamentally affects intuitions.
This concept is important for the DALY curve. The
death of any person is terrible, but premature death is
worse for two reasons. Objectively, premature death
wastes whatever initial natural investment was made in
that life, and (natural investment in) life has a worth
quite independent of the benefits it may produce, either
for society or for any individual. This is the hallmark of
Dworkinian theory: a greater regard for past efforts over
future possibilities and benefits (3). On a more personal
level, premature death is terrible because it denies a
person of the natural process of living. This statement
may seem trite but it is echoed in sentiments of
incompleteness and a desire for more time to
accomplish certain goals that people facing premature
death will often express. There is the notion that given
an initial natural investment in life, people make plans
that depend on having a full and complete life — the
“normal opportunity range,” as Norman Daniels would
put it (5). Termination of the process before it reaches
its natural conclusion is abrupt, cannot be planned for,
and denies a person the chance to utilize the natural
investment made in him as much as he desires.
A claim could be made, in opposition to the natural
investment line of reasoning, that it discriminates
against people born with some sort of disability. It could
be argued that these people have had a smaller natural
investment made in them than people who are fully
abled and, so as long as natural investment is considered
Vol. 4 No. 1, 1998
Should Age Matter?
as a basis for prioritizing health care, the disabled could
receive lower priority than fully abled people of
equivalent age. The response to this is that every human
being, fully abled or not, has a natural course of life.
The specific stages of development may be different in
some way for a person with a disability (though clearly
not very different), but they will be personally
equivalent in every way as the development a fully
abled person undergoes. The same sort of cascade of
events has been set in motion with the initial natural
investment, so the same frustration would be produced
with a premature ending of this life. As long as this is
true, and as long as there is potential which has gone
unrealized, a disabled person will be on equal footing
and will be considered as fully abled.
It is easy to see how a line of reasoning utilizing
natural investment allows the prioritization of the young
over the old for life improving or life saving health care.
Above a certain age, the normal human life is in its last
stages and it would be unreasonable for a person to
make as many life goals at this point as during his
youth. By this age, death is expected as a part of the
natural process of living — it is no longer an abrupt or
sudden occurrence that cannot be planned for. A person
at this stage may still desire a longer time to live and
utilize the natural investment made in him, but his death
will not be as frustrating or terrible, either personally or
objectively, as the death of a 30-year-old. In a sense, the
older person has gained all that he can from his life and
the initial investment made in it. Any additional gains
will be small in comparison to the gains possible for the
younger person.
PERSONAL INVESTMENT
If natural investment was the only motivation behind
the DALY curve, then it would demand that everyone
below a certain old age would be given equal
prioritization for life improving or life saving medical
care. But that would ignore the intuitive priorities
assigned earlier that somehow made it seem worse or
more shameful for a teenager to die over a young child
or infant. To find a justification for this prioritization,
the second kind of investment defined by Dworkin (3),
human investment, must be considered. In the simplest
sense, human investment is the combination of deeds
and emotional attachments that improve a person’s life.
It is the love given to a child by his parents, the money
made by the parents to finance their child’s education,
and the time spent taking the child to soccer practices
and malls. Almost anything which makes a person
happier, more successful, or better able to function in
society can be considered a human investment, but for
the purposes of the DALY curve, this definition must be
more specific.
51
The socioeconomic position a person is born into is
decided completely by chance. What this means is that
two children who are completely alike in every way
may have different levels of human investment made in
them simply because one is born to an affluent family
while the other is not. The child who gets a pony on his
birthday will have a higher investment — since money
is considered one form of human investment — than the
child who just gets building blocks. But if human
investment is to be an integral part of health care
rationing, then it must be more limited in scope to keep
such random products of chance from affecting health
care policy. The child with the pony should be treated
the same as the child with building blocks in a morally
defensible system. So for the purposes of the DALY
curve, a better motivation than general human
investment may be personal investment, which will be
defined as all the work done by a person towards the
accomplishment of his goals and aspirations. This
concept briefly arose during the discussion of natural
investment when it was argued that premature death is
terrible because it does not allow a person to accomplish
all that he has reasonably planned in the normal
opportunity range offered by the natural stages of
biological development.
This definition, however, does not require that a
person’s goals be highly specific or well defined. In
fact, most people must have only broad, general
concepts of what their ultimate desires are, such as
wanting to raise a family or being successful in a certain
profession. The key to the definition is not that the goals
be exact, but that the person is actively pursuing their
fulfillment through whatever means are available. At
certain young ages, for example, pursuing a goal is a
matter of realizing the importance of school work or
understanding how school fits into whatever broad
future plans are being made. At other times, pursuing a
goal is a matter of working harder in order to save the
money needed to raise a family.
Personal investment is important and relevant for the
DALY curve because of the way in which natural
investment motivates the curve. If premature death is
terrible because it disrupts the plans a person makes
assuming a natural course of life, then it must be asked
when these plans are first formulated because, in some
sense, they are a part of the driving force which
encourages people to value their lives. The moment
these plans and goals become an integral part of an
individual’s conception of the future and the way in
which they choose to use their natural investment, a
personal investment in their lives has been made which
will only be frustrated by premature death. Death before
this point would not be as terrible (from an objective
standpoint) because of the lack of a personal
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McGill Journal of Medicine
investment. Instead of merely being the formulation of
a goal, however, personal investment is defined to be
the actions leading to the fulfillment of that goal in
order to introduce an element of practicality into this
kind of investment. Consider the following example:
children often have fantasies of being fire fighters,
astronauts, or doctors when they grow up. But it can be
questioned whether they truly have any idea what it
means to be a fire fighter, astronaut, or doctor. Do they
really imagine themselves in one of those professions,
or is it something said just because it sounds neat? To
say that at that age children have made a personal
investment in life would be inaccurate, because they
really have no conception of the future or their part in it.
At older ages, however, youths have a much clearer idea
of what they want to be when they grow up and have
actually taken steps toward that goal by taking certain
classes or committing to certain activities; now it can be
said that they have made a personal investment which
would be frustrated with premature death.
It could be argued that this line of reasoning, if
instituted in health care rationing, would discriminate
against people who are simply not as ambitious as
others or who meander through life without any specific
notions of what they want to do. A reasonable response
to this would be that there are few people in the world,
if any, who have absolutely no goals for their life. What
may seem less ambitious or meandering from one point
of view may simply be the more humble goal that these
people aspire to. But as with natural investment,
personal investment is not intended as a system of
comparing life goals between people — one person’s
goals will not be pitted against another’s to see who
made the greater personal investment. All that is
required is that some basic investment is made that
indicates planning and concern for the future, even if
the future is a broad, abstract notion.
What the issue of personal investment means for the
DALY curve is that there is some young age below
which children do not really have even the broadest
notion of their future. Below this age, no real personal
investment is being made because they are basically just
following (to a point) the directions of their parents.
Children go to school because they are told to and may
look forward to it, but they do not see it as a stepping
stone to anything else. School, as with many other
activities, is something they do because everyone else
does it. Above a certain age, however, children acquire
a sense of the importance of what they are doing and
how it relates to their future, even if that future is only
broadly defined. This is the beginning of personal
investment because plans have begun to be made that
assume and require a natural biological life span, and
because the child is now actively working to fulfill
Vol. 4 No. 1, 1998
those plans (instead of merely going through the
motions). Premature death at this age would be worse or
more shameful than before this age because of the
personal investment being made on the basis of the
natural investment. It is this interplay that produces the
intuitive notions comparing the death of a teenager to
that of a child or that of an infant, mentioned earlier.
EFFECTS OF THIS NEW MOTIVATION ON
THE DALY CURVE
The basic shape of the DALY curve produced by this
new motivation is essentially similar to Murray’s (2).
Ages receiving weights greater than 1.0 are between 12and 60- years because they seem to best exemplify the
notions of natural and personal investment. At roughly
the age of twelve, a child is entering adolescence and is
beginning to take a real interest in his future. School is
no longer just a socially-organized requirement, but is a
springboard to the accomplishments he desires. At the
other extreme, a person at sixty is entering the last stage
of biological life and is setting goals much simpler and
more short-term than in his youth. While not set in
stone, these two ages are seemingly good guidelines for
natural and personal investments to justifiably favor the
age group in the middle of the curve.
There is one point of difference between Murray’s
DALY curve and the one being suggested. Murray’s
curve starts at zero, suggesting that absolutely no
weighting is given to the life of a newborn, and
asymptotes at a value greater than zero for ages over
90-years (2). What this means is that a 100-year-old
person is given a higher priority for life saving or life
improving medical care than an infant, which seems
somewhat counter-intuitive. If the arguments of natural
and personal investment are extended to the extremes of
the DALY curve, then it can be seen that while an infant
has made no personal investment is his own life, there
is an enormous natural investment that is just at its
beginning and has gone unfulfilled. A 100-year-old
man, on the other hand, has made a personal investment
in his own life, but that investment has now gone to
fruition and will provide for little else in the future. In
the same way, he is in the last stage of natural life, so the
natural investment made in him has also gone to fruition
and can be relied on for little else. Having made such a
comparison, it would seem that the infant’s natural
investment outweighs the spent personal and natural
investments of the 100-year-old man, suggesting that
the infant ought to receive a higher age weighting. Since
this also fits intuitive notions, the re-defined DALY
curve currently suggested starts at an undefined
weighting for a newborn and asymptotes below this
value at extremely high ages nearing or surpassing the
average life span.
Vol. 4 No. 1, 1998
Should Age Matter?
CONCLUSION
There are two additional points worthy of emphasis.
The first concerns the universal significance of the
philosophical arguments and motivations underlying
this analysis, and whether they are really cross-cultural.
On the surface at least, cultural differences concerning
values as basic as those being discussed seem to differ
greatly. While research into such values is difficult and
rarely entirely conclusive, some studies have indicated
that cultural differences may be smaller than they
appear (6). Perhaps common foundations produce
vastly dissimilar social behavior or thought. It is not
clear that cultures truly vary so greatly that these
arguments would not apply at all. Even in more
community-based societies, for example, some relevant
variation of natural and personal investment may still
produce similar outcomes for age-influenced rationing
schemes. Clearly, though, more social research must be
done to test this notion.
The author would also like to reiterate a point made
earlier, but which cannot be stressed enough. Age-based
health care rationing is an unfortunate but potentially
justifiable outcome in the present environment of finite
medical resources. While an analysis using natural and
personal investments as its basis is designed to justify
the mentality and purpose of the DALY curve, it was
designed to do so without any of the additional biases
imposed by Murray’s approach (2). In utilizing
Dworkin’s theory as the basis of a new motivation for
Murray’s DALY curve, and then extending it into fields
beyond his original intent, the author has tried to stay
true to basic Dworkinian tenants and beliefs. The most
essential of these would seem to be that no one life is
intrinsically less valuable than another. The DALY
53
curve can and should only be used in issues of
comparison, not as a direct measure of the intrinsic
value of life. Hopefully now the DALY curve, and the
comparisons made with it, can be based on intuitive
convictions and principles that are truly believable, and
though the solution is not perfect, it may at least be
morally justifiable and simply fair.
ACKNOWLEDGMENTS
The author would like to express gratitude to
Professor Dan Brock of the Department of Philosophy
at Brown University (Providence, Rhode Island, USA)
for support and guidance as a research advisor and
teacher. Professor Brock’s willingness to make time for
students and discussions helped to inspire the author’s
interest in, and commitment to, this field. The author
would also like to thank Professor John Tomasi of the
Department of Political Science for his amazing classes
and strong encouragement.
REFERENCES
1.
2.
3.
4.
5.
6.
Sweeney R, Rose V. Health care spending increased slightly in
1996. American Family Physician 57: 1752; 1998.
Murray CJL. Quantifying the burden of disease: the technical
basis for disability adjusted life years. Bulletin of the World
Health Organization 72: 429-445; 1994.
Dworkin, R. Life’s Dominion. New York, NY: Alfred A. Knopf;
1993.
Nord E, Street A, Richardson J, et al. The significance of age
and duration of effect in social evaluation of health care. Health
Care Analysis 4: 103-111; 1996.
Daniels, N. Just Health Care. Cambridge: Cambridge University
Press; 1985.
Super D, Sverko B, eds. International Findings of the Work
Importance Study. San Francisco, CA: Jossey-Bass Inc.; 1995.
Shantanu Agrawal graduated magna cum laude from Brown University (Providence, Rhode Island, USA) in May, 1998,
earning a Sc.B. in Chemistry (with honors) and an A.B. in Biomedical Ethics. He is now a Research Assistant at the Brown
University Center for Alcohol and Addiction Studies, a research and policy institute promoting the identification, prevention,
and effective treatment of problems associated with drug use. In the future, he plans to pursue a career in medicine, with a
focus on health policy and medical ethics.