Aging Populations and Public Health Ethics
Abstract and Keywords
This chapter examines three primary public health goals relating to elderly populations: promoting healthy aging (including aging in place), reducing health inequities, and extending life spans. It then considers the ways in which programs or policies to advance population-wide goals are challenged to meet ethical responsibilities to protect older adults from harm, respect their autonomy and dignity, and treat them fairly or justly when resources are limited. Lastly, by looking at a difficult situation commonly faced in hospitals—the discharge of an elderly patient who may not be able to safely return home—the chapter introduces questions about the relationship between public health ethics, clinical ethics, and social justice, and about the future role of public health as a field of inquiry and action.
(p. 181) Introduction
The world’s population is aging, and it is aging rapidly. Across the globe, in more- and less-developed countries, populations are experiencing lower fertility rates and longer life spans. Between 2010 and 2050, the number of older adults (generally defined as sixty-five years old and older) is expected to triple, and their portion of the population is predicted to grow from 8 percent to 16 percent. Around the time of the publication of this book, for the first time in history, the number of older adults will exceed that of children aged five and younger, and by 2050 older adults should outnumber young children two to one (He, Goodkind, and Kowal, 2015). In many countries, the oldest old are the fastest growing part of the population (WHO and USNIA, 2011); in some, the share of the population aged eighty and older will quadruple by 2050 (He, Goodkind, and Kowal, 2015).
This chapter will explore three primary ethical questions relating to the health of elderly populations in coming decades. First, what are appropriate public health goals for this population? Second, how can programs or policies to advance population-wide goals satisfy ethical responsibilities to older individuals in terms of protection from harm, respect for autonomy and dignity, and treating them fairly or justly? Third, how should public health and public health ethics be understood in relation to the particular concerns of clinical care and clinical ethics, on the one hand, and to broader social justice efforts, such as alleviating poverty or protecting the environment, on the other?
(p. 182) Defining the Elderly Population: Realities and Perceptions
Today, the “older person” is commonly described as someone sixty-five years of age or older, but in the early nineteenth century, people over forty were considered to have entered old age. With current extensions of life expectancy, we can expect a steady rise in the age at which people are considered to have reached old age. Perceptions of “old” or “elderly” can also vary by country or culture. Of course, younger people tend to perceive old age as occurring at a much earlier age than older people. Gender may also play a role—some studies reveal that men think the onset of old age occurs earlier than women do (NCPOP, 2009).
Increasingly older populations pose new public health challenges. Safety net programs to provide for financial security and health care for elderly populations are under strain as more people live longer past their productive work years, even as retirement ages rise. Chronic and degenerative diseases, such as heart disease, cancer, and diabetes, rather than communicable diseases, pose increasingly greater burdens to public health (WHO and USNIA, 2011). Even low-income countries, which may still experience high death rates from infectious disease, are seeing a substantial rise in chronic and degenerative diseases.
It is unclear whether elderly populations will experience more or less disability as life spans increase. Some researchers predict an “expansion of morbidity,” or “an increase in the prevalence of disability as life expectancy increases,” while others posit a decrease in disability prevalence, or a “compression of morbidity” to correspond with healthy aging practices and medical advances (WHO and USNIA, 2011, 12). Alternatively, we may see a decrease in the severity of disability even as chronic illness increases if medical advances are able to mitigate the impacts of chronic conditions. There is some historical evidence for this, although rising obesity rates among the aging may counterbalance these improvements (WHO and USNIA, 2011).
Perceptions of older persons can affect employability, receipt of health care services, social inclusion, and overall well-being. Studies of societal and individual perceptions of older persons do reveal positive perceptions, but negative perceptions predominate. Positive stereotypes include perceptions of warmth, sociability, and dependability. But more commonly, older people as a group are perceived as being unhealthy, asexual, set in their ways, isolated, and in a state of mental decline (NCPOP, 2009). Some symptoms are too readily ascribed to age—for example, people may describe a seventy-five-year-old as “senile” but a thirty-five-year-old as “forgetful” for forgetting to buy an item on a shopping list (Friedan, 1993).
Societal and cultural influences can affect perceptions of the elderly; these perceptions also vary among households, communities, and subcultures (NCPOP, 2009). In general, North American and Western cultures, which emphasize individuality and independence, have tended to support less positive perceptions of older persons than Eastern and Middle Eastern cultures, which are associated with more collectivist attitudes that expect and (p. 183) value interdependence. Traditional cultures tend to view older persons as repositories of experience and wisdom. These are broad generalizations, however, and where the world becomes modernized, with an increasing emphasis on individualism, attitudes about older persons can be expected to evolve. These attitudes may also be influenced, positively and negatively, by changes in the proportion of the population made up by older persons, the demands on resources from this subset of the population, the contributions older persons may make to society as a result of healthier aging and technological adaptions, and educational or media portrayals of older people.
Stereotypes can lead to both positive and negative “ageist” behaviors. Positive behaviors include taking care to determine that a very old person can adequately hear what is being said, or holding doors open for older persons. But negative, prejudicial attitudes can result in offensive behavior toward older people, such as unfair discrimination, isolation, neglect, and even abuse. Elderly people may be precluded from full access to health care because of assumptions about their physical and mental abilities, such as when older adults are not adequately screened or provided with health services because a reported ailment is dismissed as a natural part of aging (NCPOP, 2009). Elderly patients may be treated in a patronizing manner by health care providers, through the use of infantilizing language or by being excluded entirely from treatment conversations.
The perception that elderly populations are posing unreasonable burdens on society’s resources has been termed “conflictual ageism,” which can lead to resentment of older adults. This contrasts with “compassionate ageism,” which stereotypes older adults as frail, isolated, and vulnerable (Binstock and Post, 1991). Both forms of ageism can be present at the same time.
Identifying Public Health Goals and Benefits for Elderly Populations
Identifying public health goals for elderly populations is itself an ethical challenge. In determining where to spend their efforts and resources, to what degree should societies focus on improving the well-being of older adults, reducing health inequities, or expanding life spans? Even within these broad, sometimes competing goals lie challenges of definition and translation into policy objectives.
“Healthy aging” is frequently cited as an important modern public health goal, but there is much debate about what that term means or whether other terms—suggesting other aims—should predominate, such as “active” or “successful” or “harmonious” aging, each with its own emphasis, such as productivity, independence, or an old age with meaning (p. 184) (Martinson and Berridge, 2015). While we should expect to see continued debate, a few things seem clear. First, there is increasing emphasis on “adding health to years” (WHO, 2015) rather than adding years to life. Second, healthy aging cannot be defined primarily by simply distinguishing between “healthy” and “unhealthy” individuals, as this perspective fails to appreciate that many people can live well with one or more health conditions as long as they are well-controlled (WHO, 2015). Third, there is increasing recognition that objective measurements of well-being in later life are not sufficient; self-reported, subjective meanings are also essential (Fuchs et al., 2013). And fourth, more typically “Western” perspectives that emphasize independence in old age and individual responsibility for achieving and maintaining independence are increasingly viewed as narrow and incomplete.
The World Health Organization defines “healthy aging” as “the process of developing and maintaining the functional ability that enables well-being in older age” (WHO, 2015). Importantly, the definition offered for “functional ability” includes not just intrinsic physical and mental capacities, but also the individual’s interactions with the environment in which he or she lives. The implication is that healthy aging is vitally dependent on an environment—physical, social, relational—that allows people to do the things that are important to them. In emphasizing “well-being,” the WHO definition encourages consideration of how life in old age is actually experienced.
“Aging in place” might contribute to healthy aging or be considered as a separate policy goal (WHO, 2015). Even as older adults experience declines in physical and mental capacity, they may prefer to stay in the homes and communities in which they have lived, where they find comfort in familiar surroundings, have social relationships, and feel connected in terms of personal identity. Aging in place may also hold financial benefits for individuals, families, and societies, but this is only possible given the appropriateness of built environments, social arrangements, and access to adequate care. Advances in technology may help, such as devices to track when prescription medicines have been taken, or robots to provide in-home care, an innovation enthusiastically pursued in Japan, whose aging population faces a shortage of caregivers. Critics of current movements toward aging in place point out that while the goal may be reasonable for some older adults, others are likely to suffer from unmet needs in daily living, social isolation, and deteriorating housing conditions; particularly vulnerable are lower-income and frail elderly homeowners (Golant, 2008).
Health Equity in Aging
Advancing health equity in aging is also recognized as an important public health goal. Many of the health differences observed among older people are the result of “social determinants,” such as socioeconomic conditions, living and working conditions, education, and the like. The conditions into which one is conceived, born, reared, and educated, and where one eats, sleeps, lives, works, and receives health and social care, have a lifetime cumulative effect on the well-being of a person entering old age. The best way to reduce (p. 185) health inequities—“differences in health that are judged ‘unnecessary, avoidable, unfair, and unjust’” (Sadana et al., 2016, S179)—within an elderly population may be to adopt measures or support social changes that affect people at a younger age. But what does this say about how priorities should be established between public health measures to benefit current versus future populations of older people? Directing public health initiatives to benefit existing younger populations may be a final indignity to those who have reached old age despite experiencing health inequities throughout their lives.
Although the focus of recent public health efforts for older populations has moved to healthy aging, aging in place, and reducing health inequities, the goal of longer life expectancy cannot be forgotten. Indeed, public health statistics commonly focus on achievements in extending life expectancy, and part of the more recent focus on well-being in later life is the result of such achievements. But should we continue efforts to expand what we have taken to be a natural life span? If medical care is funded by public monies—and in much of the world, much of medical care is—then the question appears appropriate for public policy analysis. For some, like the philosopher Daniel Callahan, the answer is clear: resources are better, and more fairly, spent on allowing younger people to live out a natural life span. Callahan (2008) writes that “a good society ought to help young people become old people, but is under no obligation to help the old become indefinitely older. The latter is a fiscal black hole, abetted by endless new and costly technologies.” But the question of whether to devote resources toward extending the natural life span is not generally posed as a policy question to society at large. Instead, medical advances are offered to individual patients in clinical settings, leading incrementally to population-wide life extension. A public policy that denies medical interventions to individuals on account of age suggests age-based discrimination, a controversial proposition.
Ethical Challenges in Pursuing Public Health Goals
Protection from Harm and Promotion of Well-Being
The moral norm of avoiding or preventing harm is seen in efforts to protect older people from falls, isolation, neglect, or abuse. But avoiding and preventing harm through protective measures may come at a cost of reducing autonomy and well-being. The balance is not easy to find. Consider the case of mandatory reporting laws for elder abuse and neglect.
(p. 186) All states in the United States have laws mandating reporting of elder abuse by certain professionals, such as physicians, nurses, attorneys, and clergy. Like mandatory reporting laws for child abuse, these laws appear based on the central assumption that those being “protected” are vulnerable and cannot care for themselves. This assumption is often inappropriate. Laws that include a requirement to report older adults’ “self-neglect”—i.e., not just neglect by caregivers—suggest a significant limitation on other important moral norms, such as respecting older people’s privacy and their choices and actions in matters such as food, clothing, medication, and health care (Dolgin and Shepherd, 2013). Young and middle-aged adults are—for better or worse—allowed to make all kinds of daily living choices without governmental oversight or intrusion.
Respecting Autonomous Choices
A policy more singularly focused on promoting autonomy might appear to be an easier case, but not always. Take the case of efforts in the United States to promote advance directives for elderly populations. An advance directive is a written statement of a person’s wishes regarding medical treatment, should the person later be unable to make decisions for him or herself. A health care agent may be appointed to make decisions and/or provide instructions about what treatments the patient would or would not want in certain conditions, such as terminal illness or permanent unconsciousness (Shepherd, 2014).
Increasing the use of advance directives is clearly an explicitly recognized public health effort in the United States. Most states provide an approved advance directive form, although other forms may also be used. The federal government requires health care facilities to ask all patients upon admission whether they have advance directives and to document their existence. Medicare, the national social insurance program covering older Americans, has recently begun to reimburse health care providers for engaging in advance care planning with patients, including explanation and discussion of advance directives. A few states require physicians to inform patients with a terminal condition of their end-of-life options, including advance directives. The Centers for Disease Control and Prevention (CDC) provides online resources that encourage advance care planning.
Promoting the autonomy of patients to make end-of-life decisions seems like a relatively simple idea, free from the complications of competing ethical considerations—such as balancing this autonomy interest against the individual’s welfare interests or the interests of others—but efforts to promote autonomy are ethically complex. This is especially so when those efforts are not individualized but are targeted toward broad swaths of the population. The available instruments are blunt. A standardized form, completed well in advance of an actual treatment decision, may not offer the options desired or later provide the guidance intended by the person who has signed it. When forms do provide more adequate options for individualized choice, they become increasingly legalistic, lengthy, and difficult to understand. Sometimes, advance directives misalign (p. 187) with the current best interests of patients, and it is not clear which should prevail (Dresser, 2003).
Even with the best of forms, advance directives may or may not promote patient autonomy. Because only three in ten Americans have an advance directive, advocates often point to the need for better education, access, and counseling. But skeptics reply that people may avoid them for good reasons: they may not anticipate the medical condition they will later have, or they may not know what they would want done in that situation (Fagerlin and Schneider, 2004). They may prefer to trust family members to make decisions for them when the time arrives. Respecting patients, critics argue, includes respecting the choice not to specify medical treatment preferences in advance.
These population-wide efforts may also be biased to encourage individuals to make a socially preferred choice. Early versions of advance directives (“living wills”) provided patients only with the option to forgo life-sustaining measures, not to accept them; these forms are still in use in some places. This restricted choice was not necessarily ideologically driven; the assumption at the time was that a living will was not needed if someone wanted treatment. On the other hand, some restrictions reflect government-chosen values. In some states, artificial nutrition and hydration will be provided unless specifically refused in an advance directive. Choices have thus been restricted rather than enhanced; only patients with an advance directive have the full panoply of medical choices available to them. The bias most feared, however, is that at some time older people or others with chronic disease or disability will be encouraged to forgo life-prolonging measures (or even hasten their deaths with physician aid, where permitted) in order to reduce governmental health care spending.
Distributive justice—the fair distribution of benefits and burdens—is a core moral principle of public health ethics (Childress, 2013). But what is fair? Is it just or fair to support more or less access to health care resources on the basis of old age?
At the societal level we make decisions about the allocation of public monies (Dey and Fraser, 2000). In the United States, older adults might be considered to be advantageously positioned vis-à-vis other age groups because of their eligibility for Medicare. Medicare was adopted in 1966 to aid a population that at the time had disproportionately low incomes and was vulnerable to exclusion from private insurance plans. It covers many of the health care needs of older adults, but not all. It does not cover long-term nursing care, for example. Working Americans make income-based contributions to the program through payroll taxes. But some of those receiving Medicare benefits, while they have paid into the program, are not financially needy, and concerns have existed for many years about the financial sustainability of the program through decades of rising medical costs.
We can expect that questions about the extent of health coverage for older adults—e.g., what preventive measures, forms of treatment, and so on, should be paid for with public monies—will be asked with increasing intensity as nations respond to aging (p. 188) populations. How should resources be allocated between the young and the old? Between the poor and the old? Or, within the elderly population, between those who are financially needy and those who are financially secure? Between those with chronic illness or disabilities and those who are aging “well”? In both the United Kingdom and the United States, aging populations are sometimes viewed as posing a heavy burden on public coffers, although some would argue these budgets are unnecessarily and artificially restricted (Dey and Fraser, 2000). Other countries are more accepting of large public expenditures toward health.
Much is made of the frequently cited statistic that a quarter to a third of US government spending on Medicare goes toward medical care in the last year of life. Since the patient dies regardless, these expenditures are often seen as ineffective or wasteful. But many of the most expensive treatments are not known to be ineffective in advance—in other words, “[s]ince there are no reliable ways to identify the patients who will die, it is not possible to say accurately months, weeks, or even days before death which patients will benefit from intensive interventions and which ones will receive ‘wasted’ care” (Emanuel and Emanuel, 1994, 543). With respect to savings to be achieved by limiting care to the elderly, it is important to note that the oldest old (eighty-five years old and older) already receive less intensive, less hospital-based care when they are near the end of life. Their medical treatment expenses in the last year of life are actually half that of individuals who die between the ages of sixty-five and seventy-five.
Questions also arise about the proper allocation of programmatic efforts across ages, such as whether it is appropriate to target prevention, screening, and treatment efforts more intensively toward younger populations. When risk declines with age, then such differential treatment may be justified in terms of limited resources. But such questions become more difficult when risk is not associated with age. Cancer screening programs that have upper age limits even when risks increase with age may be justified if treatment will not be effective; otherwise, such age limits seem based on the notion that the extra years of life for an older person are of less value (Daniels, 2008).
Limiting health resources for older adults has been justified by two primary approaches: cost-effectiveness (often discussed in terms of quality-adjusted life years [QALYs]), and the “fair innings” argument. The concern of cost-effectiveness is utilitarian—to maximize the greatest health outcomes (measured in terms of QALYs) relative to cost. QALYs, explicitly adopted in the United Kingdom as a tool in making strategic decisions in public health investments, “are based on life years saved adjusted to take account of impairment of quality, measured in terms of dimensions like ability to function and degree of distress” (Dey and Fraser, 2000, 522). As such, the use of QALYs may mean that public health choices are made that discriminate against older people because “they have fewer life-years ahead of them to be saved” (Childress, 2013, 24). Depending upon how one defines “quality-adjusted,” persons with disabilities are also susceptible to discrimination by QALY analysis. Older people who are disabled due to frailty or chronic disease—for which increasing age is a risk factor—can suffer doubly (Brock, 2004).
The “fair innings” argument for limiting resources is based on equity rather than utility or cost-effectiveness, and its effect on older adults is more explicit and unapologetic. Most (p. 189) simply, it posits that if choices about resources have to be made, younger people should have the same opportunity to live a full life that older people have already enjoyed. This will promote equality in “lifetime experiences of health” (Williams, 1997, 822).
Future Directions for Public Health Efforts: The Clinical and the Social
Policy debates about ethics and public health sometimes appear abstract, or removed from the lives of actual persons. Conversely, clinical ethics cases often appear particularized, or removed from public health policies. Any ethically troubling situation relating to health is likely to have both a clinical and a public health component, and to have been borne of hundreds of decisions, made over time by many different actors and made for the intended benefit of various individuals or groups.
Consider the case of a frail man in his late seventies, a lifelong smoker, who has suffered a fall at his rural home, where he lives alone on a small government old-age pension. Hospitalized, he is now ready to be discharged. The hospital social worker and his daughter believe he cannot safely return to his home, but he does not want to move to an assisted-living or nursing facility. He does not want to leave his home, yet his government-provided health insurance will cover only limited home health care assistance.
Situations like this confront hospitals, social workers, families, and older adults every day. This man’s story presents a classic example of a conflict in clinical ethics between respecting his autonomy (by discharging him to home as he prefers) and protecting him and perhaps others from harm or burden (by persuading or coercing him to move into an assisted-living facility). But this is also a public health ethics story. Even with this “thin” presentation of facts, we can identify areas of concern that have population-based application: What transportation, social, health care, and other resources are available that make aging in place more or less possible? What public policies might influence whether an assisted-living or nursing facility is more or less of an attractive option? What effect have past and present public health policies had on this man’s current condition? What are societal expectations about family members’ involvement?
Looking at particular cases, with particular individuals, can reveal much about the ethics of public policies that affect older populations. Have those policies been, or can those policies in the future, be just? Can they be health-promoting? Can they be respectful of individual dignity and autonomy? An important strategy for advancing public health for older populations is to recognize patterns of ethical conflict in clinical settings—such as at the point of discharge—that may have been influenced by past public policy decisions and which population-based strategies may now help reduce or resolve.
But this case example also raises questions about the social determinants of health, in terms of both their past and future influence on this man’s health. Factors far (p. 190) removed from health systems and traditional health sectors—factors like education and transportation—are increasingly understood to play prominent roles in population health. What does this understanding signal for the future role of public health as a field of inquiry and action, especially as it relates to elderly populations? Growing appreciation of the social determinants of health might suggest that greater efforts should be focused on people’s needs early in life, in order to achieve the largest reductions in health inequities across populations and time. But it might also lead to a greater sense of responsibility to those current older adults whose health and other needs are linked to a lifetime of social inequities.
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