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A New Fair Innings Argument On Rationing Healthcare by Age

One of the highly disputed issues concerning modern healthcare services is the validity of rationing healthcare by the criterion of age. This issue has been at the heart of public discussions and scholarly debates about the question of how to distribute limited healthcare resources in a fair and cost-effective manner. As witnessed in many western countries where the aging population has surfaced as a major social concern, the topic of healthcare distribution is projected to draw accelerating attention owing to the swift transition of the demographic structure.

Rationing healthcare on the criterion of age is subject to criticism that it is based on a biased point of view against the elderly. Even so, many empirical studies have shown that a substantial number of those surveyed prefer to weight age over the other criteria. Efforts to justify the notion of age as a prominent distinguishing marker regarding healthcare rationing have been reflected and conceptualized into some recognized theoretical frameworks: outcome-benefit approach, fair innings argument, and prudential life-span account, for example. This paper examines these approaches and then suggests a new fair innings argument to advance current methodologies.

Both outcome-benefit approach and prudential life-span account are inherently flawed as a theoretical and moral basis for justifying healthcare rationing by age. Outcome-benefit approach takes the utilitarian philosophy that concerns the overall well-being of society and thus defends prioritization of choices in allocating scarce resources between competing individuals. Hypothetically, it is assumed that age is an independent variable for healthcare rationing regardless of other factors at play such as a patient’s socioeconomic status, the severity of the disease, the cost and effect analysis of care options.

However, outcome-benefit approach contradicts this assumption when it adheres to the presupposition that the resultant benefit of a given medical service is greater when it is administered to younger people than to the older. This absolute scale of benefit is too inflexible and erroneous to support healthcare rationing by age.

Prudential life-span account by Norman Daniels, on the other hand, seeks to reverberate John Rawls’s theory of justice in the healthcare context. This approach rests on a universal fact that all of us become old eventually, and so it is far more rational to focus on how to allocate healthcare resources along different phases of an individual’s whole life span, rather than to compare partial lists of available healthcare resources between age groups. The transition from an interpersonal point of view into an intrapersonal reasoning scheme brings out meaningful implications but does not yet explain the discrepancy between the commitment and benefits given to an individual throughout the span of his or her life.

This is mainly true in a society where fast population aging takes place. It is likely that young people are disproportionately burdened with the healthcare cost while older people take advantage of the system with more benefits allowed than they have paid for up to date. Another leading theoretical framework to justify healthcare rationing by age is the fair innings argument (FIA), which is based on egalitarianism. ‘Fairness’ in this sense means fair share of resources – that is, the younger are entitled to scarce resources in preference to the older because they have not completed the average duration of life yet.

By contrast, if a person has lived a major part of life through typical activities and events such as birth, education, marriage, and career, he or she has already had the ‘fair innings’ and reached the threshold. This notion of ‘threshold age’ (age of 70, by common understanding) appears to acknowledge only a limited form of life and is criticized since it relates the completeness of life only to the length of time. Relativism has a potential to overcome the drawback by declining the idea of ‘threshold age’ and, instead, adopting the following argument:

Those patients who have lived longer should be given less privileges, in order to direct restricted resources to the younger who will miss out relatively more if they are deprived of the priority.

This approach, however, is not competent enough to justify the rationing by age when confronting the question of whether it is deemed just and right to place a younger patient higher on the list than an older patient even if the latter is expected to show more promising effects of treatment. There have been more efforts to extend the concept of a ‘fair innings’ to incorporate the notion of quality-adjusted life years (QALYs). This view supports the judgment that those who are worse off with poor health conditions such as disability and long-term diseases should be given more consideration, to compensate for the apparently lower quality of life they are prone to. This branch of the FIA is not without limitations: it does not account for other disadvantageous conditions of life, including social isolation and financial distress.

To corroborate the FIA in a practical decision-making process, two issues ought to be addressed: 1) How to justify rationing by age between patients who are equal in all conditions other than age, in a manner that does not defy intuitive ethics and sense of justice among the members of a society; 2) How to substantiate the FIA in a case where the effects of life-sustaining treatments are estimated to be more hopeful when they are given to the older patient.

A new fair innings argument is proposed to tackle these issues, in light of the concept of equal opportunity as advocated in Daniels’s principle of ‘Equity for Opportunity.’ Age can be thought to be a more reasonable criterion when scoped through the filter of opportunity. Rationing healthcare resources by age can be justifiable if we agree that the younger patients deserve priority since the sum of opportunities they have had is likely to be less compared to that of the older patients.

Nonetheless, it should be noted that older patients have the right to health all the same; also, it is far from guaranteeing social justice if we withhold even cost-efficient, helpful treatment options for the elderly in support of expensive yet ineffective treatments for younger patients. The new fair innings argument proposed here puts more value on the new, unachieved opportunities than already seized opportunities. The amount of new opportunities generated by life-extending treatments can be quantified by the following formula: (extended lifetime) x (rate of total desired opportunities per unit of time) x (the ratio of new opportunities to the total opportunities).

If we assign the same value across all lives, ‘rate of total desired opportunities per unit of time’ is a constant. On the other hand, ‘the ratio of new opportunities to the total opportunities’ will diminish as one grows older. Accordingly, if there is a medicine to extend the life of a young person (agey years old) by X years while the same medicine can extend an old patient’s life by Y years who has lived ageo years long, the equal opportunity can be achieved at the time of (X/agey=Y/ageo). This formula offers a more balanced perspective by considering some important variables affecting the effectiveness of age as a rationing criterion. Therefore, the proposed fair innings argument has a potential to advance the current FIA and justify rationing by age more plausibly.


Jisu Lee is a medical student at Seoul National University School of Medicine (2014-Present) and a graduate of Kyung Hee University’s College of Korean Medicine (KMD, 2014)