Intended for healthcare professionals

Education And Debate

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

BMJ 1997; 314 doi: (Published 15 March 1997) Cite this as: BMJ 1997;314:820
  1. Alan Williams, professora
  1. a Centre for Health Economics University of York YO1 5DD


    As we grow older our recuperative powers diminish. Thus we accumulate a distressing collection of chronic incurable conditions. Some of these are no more than a minor nuisance, and we adapt as best we can; and when adaptation is not possible we learn to tolerate them. Some are more serious, involving severe disability and persistent pain, and may eventually become life threatening.

    We are also at risk of various acute conditions (like influenza or pneumonia) which are more serious threats to the health of elderly people than to younger people. We also have more difficulty recovering from what younger people would regard as minor injuries (such as falls). When you add to all this the increased likelihood that illness (and other disruptions of our normal lifestyle) will leave us rather confused and in need of more rehabilitative and social support than a young person it is hardly surprising that NHS expenditure per person rises sharply after about age 65.

    The vain pursuit of immortality

    People are also living longer, and people aged over 65 now form a much bigger proportion of the population than they used to. From the viewpoint of NHS expenditure this would not matter if the extra years of life were predominantly healthy years but it would if the extra years were ones of disability, pain, and increasing dependence on others.

    The evidence on this is ambiguous. Many people remain fit and independent well into their 80s. Others enter their 60s already afflicted with the aftermath of stroke, heart disease, arthritis, or bronchitis. It is not clear whether things are getting worse at each year of age, or whether expectations are rising and people are now more likely to report disabilities once shrugged off as the inevitable consequence of getting old. That many of these conditions are incurable does not mean they …

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