Education and debate

The rationing debate: Rationing health care by age: The case against

BMJ 1997; 314 doi: 10.1136/bmj.314.7083.822 (Published 15 March 1997)
Cite this as: BMJ 1997;314:822

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  1. J Grimley Evans, professor of clinical geratologya
  1. a Division of Clinical Geratology Nuffield Department of Clinical Medicine Radcliffe Infirmary Oxford OX2 6HE

    Introduction

    Older people are discriminated against in the NHS. This is best documented in substandard treatment of acute myocardial infarction and other forms of heart disease, where it leads to premature deaths and unnecessary disability. The care for older people with cancer is also poorer than that provided for younger patients.

    Age discrimination in the NHS occurs despite explicit statements from the government that withholding treatment on the basis of age is not acceptable. Ageism is mostly instigated by clinicians but condoned by managers. Fundholding general practitioners have a financial incentive to deprive older patients of expensive health care, but there is no ready way to find out whether they do so. Whatever its full extent, the documented instances of age discrimination, together with the occasional published apologia for ageism, show that the morality of age based rationing should be a matter of public concern.

    Need to assess individual risk

    It is important to be clear what we are talking about. It is proper for a doctor to withhold treatment or investigation that is likely to do more harm than good to a patient. In an individual case actual outcome depends on the patient's physiological condition. The prevalence of impairments that shift the risk:benefit ratio adversely increases with age, so where individual physiological condition is used as the basis for allocating treatment older people are more likely on average to be excluded than are younger people. Nevertheless, wide individual variation exists in aging, and many people in later life function physiologically within the normal range for people much younger. The key issue, therefore, is that each decision should be made on a competent assessment of individual risk.

    What I am objecting to is the exclusion from treatment on the basis of a patient's age without reference to his or her physiological condition. The patient is being …

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