Flaws in agist arguments

BMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7007.752a (Published 16 September 1995) Cite this as: BMJ 1995;311:752
  1. Richard J Lilford, Chairman
  1. Research School of Medicine, Institute of Epidemiology and Health Services Research, University of Leeds, Leeds LS2 9LN

    Doctors need pragmatic strategies

    EDITOR,--In his article on agism Michael M Rivlin points out that old people differ greatly in their wishes and prognoses.1 Any argument concerning agism should, however, take account of the consideration “other things being equal.” Thus Rivlin is right to point out that old people often have a good medical prognosis, that treatment might produce substantial benefit, and that many old people seem more “deserving” than some of the younger people he describes in his article. The philosophical question, however, is not whether treatment of certain old people has a greater claim on expensive resources than the treatment of certain young people. The question is: other things being equal, do we allocate indivisible resources preferentially to younger people? Is age an acceptable criterion, other things being equal? To give a stylised example, what should our policy be if two people arrive in an emergency department with the same prognosis for recovery and the only distinguishing feature is that one is 30 and the other is 80? To whom should we allocate the only remaining ventilator, intensive care bed, artificial lung machine, etc?

    The argument that “it is not incumbent on the critics of the policy of agism to propose an alternative” and that it is acceptable “to show the flaws in an argument without having to suggest what to do in its place” might be all very well for an academic philosopher. There is, however, no method of allocation of scarce resources that cannot be shown to have flaws. If a philosopher really wants to help decision makers then it would be more useful for him or her to compare different arguments so that the extent to which opposing policies violate various fundamental principles can be compared. This should enable us to come up with the “least bad” solution. So, what would Rivlin do with my two injured patients in the accident and emergency department: would he allocate treatment by randomisation, withhold treatment from both, allocate the scarce resources to the younger person, or simply go back to his department of philosophy and leave the doctor on the spot to decide?


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