Western society has described the phenomenon of population ageing as a "problem" and a "burden" since the beginning of the twentieth century. There is evidence that industrialised, Western countries are inherently ageist. Studies have shown that older people are perceived as stereotypically rigid in thought and old fashioned in morality and values.

Concurrently, older people have been found to frequently hold negative ideas about themselves. The older people included in one study reflected the narratives frequently seen in the popular media describing the ageing population in terms of a burden on available resources. A significant number of the participants of the study reported fear of becoming a burden on their families and wider society. This less than benign social context for older people is important to recognise and incorporate into any consideration of the ethical issues of old age.1,2,3,4

There are four widely accepted general ethical principles: autonomy, beneficence, non-maleficence and justice. This framework developed by Beauchamp and Childress will be used in the remainder of this paper to attempt to illustrate and critically reflect on some of the ethical considerations relevant to older age both on an individual and population level.5

Autonomy

The principle of autonomy, or self-determination, requires a respect for the choices and wishes of people who possess decisional capacity, along with protecting those who lack this capacity.6

The issue of autonomy can be more poignant among older people, primarily because we live in a society where older people can lose dignity, along with personal self-determination and respect. Later life is frequently where the incidence of neurodegenerative and cerebrovascular disease becomes more common, along with the frequent attendant issues of preserving autonomy in situations where the capacity to make decisions is impaired or lost. In the context of health and social care, decisions for those who lack capacity are made in their best interests, however this is difficult to define and can facilitate a paternalistic approach.7

The approach to decisions taken in a non competent person's best interests directed by the England and Wales Mental Health Act 2005 demands that consideration is to be given to the person concerned and their past and present wishes, including anything relevant to the decision outlined in an advance directive and including any person who may hold power of attorney for healthcare decisions (these are recognised mechanisms in which people with decisional capacity can maintain an input into healthcare decisions should they later lose competence to participate). It is also considered best practice to include people who are close to the person to gain information regarding the person's current and previously held values and beliefs.6,7

This approach is not without difficulties. Most people have not made advance directives, and there is evidence that even when they do exist they can be ignored.8,9

Although advance directives are useful to some people, they commonly fail to be effective in improving the quality of care received at the end of a person's life or the communication of patients' wishes regarding their care.9

The problems encountered with advance decision making are due to individuals being unable to predict what they might want in a future hypothetical situation where their medical and psychosocial context may be very different to their current one. A person's values and preferences regarding medical treatment have been seen to change with altering health status, at the end of life and during periods of stable health.10-12

A possible explanation of people changing their preferences about future medical care is connected to a human being's ability to adapt to new situations. Often, people can't imagine how they will have the emotional resources to endure a situation where they are seriously physically incapacitated or obliged to undergo burdensome treatments for uncertain benefit.13,14

In spite of this, there is evidence that people will often accept invasive and significantly burdensome treatments with the prospect of limited benefit once they find themselves in the previously imagined state of ill health they believed would deliver them a quality of life that would no longer be worth living. Alternatively, some patients who may have previously have chosen to accept any life sustaining treatment offered in order to "live at all costs" may change their priorities to palliation and good quality of life at the onset of serious or incurable illness.11

Most people feel that they can rely on close family members or even their doctors to make decisions for them. However, there is some evidence suggesting that, when presented with hypothetical decisions about life sustaining treatment family members and physicians do not consistently predict patient's preferences at levels of accuracy better than that expected to be achieved by chance alone. It has been noted that family members commonly overestimate the frequency with which patients would like to receive treatment. When an intervention is initiated or continued largely for the benefit of a person's family, the patient is being used to serve the interest of others and their autonomy is consequently violated.12,15,16

It should also be considered that by respecting an older person's autonomy, we may create a situation where we compromise the autonomy of another person. For example, an elderly man who is prone to frequent falls may decide to go home with a maximal social care package of four visits a day, however this leaves a large part of the day where he is alone. His daughter who is still of working age and looking forward to retirement within the next few years feels obligated to care for him, and leaves her job in order to facilitate this. Consequently, her autonomy is impinged as her lifestyle has been greatly changed, she now no longer able to work and is likely to lose out on crucial savings and pension contributions needed for her own retirement and her ability to live autonomously in the future. Further themes of responsibility and intergenerational justice are addressed again later in this paper.11

Beneficence

There is evidence that older people have been denied potentially useful healthcare interventions in the past on the grounds of age. Increasingly, it has been demonstrated in the literature, and in clinical practice that older people benefit from many medical interventions they may have been previously denied.4,17

A doctor is obliged to promote the welfare of his patient-this is described by the concept of beneficence. Maintaining this ethical principle in practice usually entails decision making by considering and weighing up the risks and benefits of any given intervention leading to implementation of the considered treatment if it is considered to be of likely overall benefit to the patient.

This is particularly difficult in the area of elderly care medicine, as there are complex relationships between individual combinations of often multiple comorbidities making the prediction of potential outcomes more difficult.18

This is compounded by the lack of strong research evidence in this age group who are often excluded from medical research studies. This has led to the assumption that older people may have less to benefit from aggressive treatments, and are recognised to be more likely to suffer harmful complications from medical therapies than younger patientss. A beneficent choice in this situation is arguably one where the patient is not offered the treatment in consideration of the possible harms to the patient.18,6

Non maleficence

The principle of autonomy has been discussed previously and is usually understood to occupy primacy over the other three principles of the ethical framework.6 Consequently, it can be argued that if we respect this ethical principle a person who decides to die should have their opinion respected.

It can be conceived that it is beneficent to end the life of a person who is significantly suffering psychologically or physically and where there is no available medical intervention to fully relieve that suffering. However, the legal system, society and most religions hold taking the life of another human being as universally morally wrong.6

The issues that attend the issue of euthanasia are particularly relevant to old age. It has been observed that with the compression of morbidity seen in later life, people are more likely to suffer chronic disease for a number of years before their natural death. During these years they may exert a financial and emotional burden on their family or on society at large for a number of years.19,20

We live in a society in which it is conceivable that pressure will be perceived by older people to proceed voluntarily with euthanasia to prevent being such a burden.

This forms the basis of the slippery slope argument which envisions such an expansion from the intended use of euthanasia to relieve a few people out of intractable suffering, to include cases of people volunteering to be euthanized in order to not be a burden on society, or their family and friends. There is some evidence that this has occurred in countries where euthanasia is practiced legally. It has been argued from the perspective of resource allocation that nothing further should be done to preserve the life of older people once the end of their "natural" life is reached, defined as reaching approximately 80 years of age. This argument advocates passive euthanasia and it is possible that from this position the "fair innings argument" of resource allocation could lead to a policy of active euthanasia at a certain age or health status.6,21,22

Justice

The population profile of many industrialised countries is ageing. In 1971, 12.4% of the population of the UK were aged 65 years and older; this number is expected to increase to 18% by 2030 along with a particular expansion in the numbers of the very elderly, with a consequent increase in the dependent population economically supported by those of working age.

The debate regarding how much should be spent on pensions and health and social care for older people is a major and contentious ethical issue within our society where resources to spend on welfare costs are not infinite and some prioritisation is necessary.

The phenomenon of population ageing may bring with it some cost reductions, such as the saving seen with the widespread provision of informal childcare by older family members. Older members of society often provide care for friends and family members. There is also evidence that the effect of a smaller child population has brought savings in education that has offset the effects of an ageing population on healthcare and social services spending. Furthermore, older people cannot be considered as economically inactive as they are significant consumers of goods and services.

However, older people are undeniably higher users of health services than younger members of the population. Health expenditure on those over 65 is four times higher than that spent on people under 65, and can be up to nine times higher for those aged 85 and over.22,23 In the UK, the allocation of resources according to need was a founding principle of the NHS, it is considered in tandem with a defined population's ability to benefit from treatment or funds. This is ethically based on the model of utilitarianism, which can be broadly described as providing the greatest good for the greatest number.

A cost-benefit analysis has been increasingly applied to various medical interventions, and the Department of Health has indicated that resources should increasingly be channelled towards those interventions which are known to be effective. This has led to a number of effective medications not being recommended by national guidance, high profile examples include treatments for wet macular degeneration and medication for Alzheimer's disease.

The cost-analysis has been estimated and expressed in Quality Adjusted Life Years (QALYS). The elderly are disadvantaged in this system, as by definition they have fewer years to live than a younger person. As mentioned earlier in this paper, the treatment offered to older people may have a less robust evidence base for benefit in their age group as they are often excluded from clinical trials, and often benefit from multi -interventional management that is difficult to evaluate and for which there is little evidence base to draw an estimate of benefit from. This utilitarian mechanism of distributing resources throughout the population is unable to respond to individual patients who want to achieve the best possible combination of quantity and quality of life attainable for them.

It may be valid to use outcome measures when choosing between rival therapies, but it is arguably not ethical to use this system in distributing resources between groups of patients, especially where there is such a general paucity of research based evidence.

Conversely, without better and wider evidence on the benefits of innovative patterns of care for elderly people, more resources being allocated for older peoples services may not necessarily mean enhanced quality care.6

The decisions regarding rationing of resources are dependent on the value of an older person's life in society. If no value is placed on life once economic productivity ceases, then an argument to not waste resources on health services, and an ageist pattern of rationing will continue. If quality of life in older age is seen to have its own value, then there is strong motivation for allocating resources for this section of the population.

As briefly touched upon earlier, health economists can use the 'fair innings' concept to argue for resources to be directed from the older members of society toward the young rather than vice versa.24

The flaws in this argument are as follows. The longevity that has brought about the phenomenon of the ageing population is largely the result of surviving the risks of infective illnesses and early childhood disease earlier in the life course, and not as a result of expensive medical intervention applied later in life. A large proportion of the costs of caring for an older population is ensuring proper nursing and social care.

Older people have contributed to society throughout their lives, and with the observed trend of compression of ill health and dependency toward the end of life will be denied support from society by a system that utilises the "fair innings" argument at the only time they require it. Additionally, the fair innings argument fails to consider a person's potential to benefit from treatment, only age attained.

Intergenerational tensions also exist around the issue of retirement and public pensions. Retirement is a relatively recent social phenomenon becoming ubiquitous during the post-war period in European countries. In the UK, the introduction of the old age pension in the post-war period came at a time where there was full employment, and were primarily introduced as a means of ensuring continuing rejuvenation of the workforce along with sharing out the costs of retirement. Retirement in now considered a normal part of the life course, and there has been trend towards ever earlier retirement over recent decades. Many people who retire early do not do so out of personal choice, but find themselves unable to gain new employment after being made redundant. Many people who are retiring at the present will expect to spend up to a third of their healthy adult life living in retirement. This is a well publicised cause for political concern. Possible partial solutions have already started to appear in Europe. Germany has responded by raising retirement limits and introducing reductions in the level of pensions in cases of early retirement. Ethically this approach is problematic as this would be expected to exacerbate social inequalities from earlier in the life course and compound them in old age to significant disadvantage (for example the person who suffers ill health, loses earnings, potential savings and receives a reduced pension). An alternate scheme has been set up in Austria where people are rewarded for staying in work longer with a small pension increase per extra year worked.

Some of the economic effects of a large potentially retired population could be offset if early retirement was avoided. This could be brought about if the demand for older workers in the workplace increased, this is related to how much investment a society puts in to retraining and educating its adult populace.

Intergenerational tensions can be viewed alternatively. Children in modern times face a longer transition to adulthood; parents across all social strata are providing more support to their children and for longer. It is conceivable that this may bring consequences later in life when parents will not have the financial resources in retirement that they may have accrued if they had not been financially committed to providing for their offspring.

The ethical issues that are relevant to an ageing individual, or an ageing society are multifaceted and complex, and require consideration of how all people are connected in society and across the life span. However, it is likely that the older people of the future will have a stronger sense of entitlement, will be better educated, are likely to be healthier until later in life and will inevitably occupy differing roles in society than previous cohorts. The ethical issues that concern older people as a population will evolve with them.24,25

Conflict of interest: none declared

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