The Ethics of Life Expectancy

Review of Economic Design, 2022

We analyze the implications of axioms formalizing entitlements to continued life for the evaluation of population health, when combined with basic structural axioms. A straightforward implication of our analysis is that if the scope of equal entitlements to continued life is not limited, concerns for morbidity are dismissed in the evaluation of population health. Nevertheless, with axioms formalizing a more limited scope of equal entitlement to continued life, we provide several characterization results of focal population health evaluation functions, ranging from lifetime utilitarianism to generalized healthy years equivalent utilitarianism.

Journal of Medical Ethics, 2023

The technical possibilities of biomedicine open up the opportunity to intervene in ageing itself with the aim of mitigating, reducing, or eliminating it. However, before undertaking these changes or rejecting them outright, it is necessary to ask ourselves if what would be lost by doing so really has much value. This article will analyse the desirability of ageing from an individual point of view, without circumscribing this question to the desirability or undesirability of death. First, we will present the three most widely used arguments to reject biomedical interventions against ageing. We will argue that only the last of these arguments provides a consistent answer to the question of the desirability of ageing. Second, we will show that the third argument falls prey to a conceptual confusion that we will call the paradox of ageing: although ageing entails negative health effects, it leads to a life stage with valuable goods. Both valuations, one positive and the other negative, refer to two different dimensions of ageing: the chronological and the biological. We will defend that, by not adequately distinguishing these two types of ageing, it does not become apparent that all the valuable goods exclusive to ageing derive only from its chronological dimension. Third, we will argue that, if we just conceive ageing biologically, it is undesirable. We will elaborate on the two kinds of undesirable effects biological ageing has: direct and indirect. Finally, we will respond to potential objections by adducing that these are insufficient to weaken our argument.

Background: The state of the world is one with scarce medical resources where longevity is not equally distributed. Given such facts, setting priorities in health entails making difficult yet unavoidable decisions about which lives to save. The business of saving lives works on the assumption that longevity is valuable and that an early death is worse than a late death. There is a vast literature on health priorities and badness of death, separately. Surprisingly, there has been little cross-fertilisation between the academic fields of priority setting and badness of death. Our aim is to connect philosophical discussions on the badness of death to contemporary debates in health priorities. Discussion: Two questions regarding death are especially relevant to health priorities. The first question is why death is bad. Death is clearly bad for others, such as family, friends and society. Many philosophers also argue that death can be bad for those who die. This distinction is important for health priorities, because it concerns our fundamental reasons for saving lives. The second question is, ‘When is the worst time to die?’ A premature death is commonly considered worse than a late death. Thus, the number of good life years lost seems to matter to the badness of death. Concerning young individuals, some think the death of infants is worse than the death of adolescents, while others have contrary intuitions. Our claim is that to prioritise between age groups, we must consider the question of when it is worst to die. Conclusions: Deprivationism provides a more plausible approach to health priorities than Epicureanism. If Deprivationism is accepted, we will have a firmer basis for claiming that individuals, in addition to having a health loss caused by morbidity, will have a loss of good life years due to mortality. Additionally, Deprivationism highlights the importance of age and values for health priorities. Regarding age, both variants of Deprivationism imply that stillbirths are included in the Global Burden of Disease. Finally, we suggest that the Time-Relative Interest Account may serve as an alternative to the discounting and age weighting previously applied in the Global Burden of Disease. Keywords: Age weighting, Badness of death, Welfare loss, Discounting, Deprivation account, Epicureanism, Global burden of disease, Health priorities, Morbidity, Time-relative interest account

Cuadernos de bioetica: revista oficial de la Asociacion Espanola de Bioetica y Etica Medica

If the prediction of some scientists comes true, then we are only few years away from the appearance of the first generation of human beings who will be able to add one year to each remaining year of life expectancy. Faced with this possibility, it seems appropriate to give thought to the public policies that should be adopted. It is better to anticipate the various future scenarios than react to a reality which is a fait accompli. To date, the debate has mainly focused on the ethical question: is it good or bad for us humans to achieve immortal life? Until now, neither legal guidelines at State level nor those of international organisations which deal with bioethical issues have concerned themselves with this matter.

Nordicum-Mediterraneum, 2012

The ethical desirability of considerable life extension by medical technology has become an increasingly discussed topic in bioethics during recent years. Immortality can be seen as a maximum of life extension. Because of this, many authors use the term ‘immortality’ for referring to a lifespan that is considerably longer than our current one. However, being literally immortal would be very different from living for hundreds, or even thousands, of years. The arguments that have been made about the metaphysical questions about immortality need to be clearly distinguished from the bioethical discussion on life extension. What is true of immortality is not necessarily true of a considerably extended human life. In this paper it is argued that immortality in its literal sense should be separated from the discussion on the ethical desirability of considerable life extension more explicitly than is done at the moment. Referring to immortality not only causes conceptual confusion but somet...

The questions we address are the following: Are we entitled to access life extension therapies? Must we draw the line at some point (say 120 years, the maximum life span so far, or maybe even earlier) and decide that that’s that and now we must die? Are there considerations that might make either living or making it possible to live after a certain ages immoral? Does justice require foregoing life extension therapies or does it require the development and application of these therapies?

My essay explores the reasons why we try to prolong life in our highly technological age. Prolongation of life is symptomatic of our unease with death as a positive event. I have drawn on remarks made by ancient philosophers and Chinese sages to alert us to what is remarkable about death. We hear from Socrates, Boethius, and others such as Walter Benjamin and Simone Weil in their attempt to alert us to the 'value' of death. The essay is seen through the eyes of my own experience with the passing of an old Aborigine that I once knew, and how his death figured as a positive event for all concerned, including himself. The re-disovery of an ethics of dying is paramount if we are to arrest our reliance on overburdened health budgets and the technologization of death. Hopefully this essay will provoke some debate.

International library of ethics, law, and the new medicine, 2001

Reflection on aging in bioethics has been influenced by a single paradigm of what growing old involves, namely, the so-called life span model. This model involves a set of normative beliefs that conceive aging as a conventional process of development through distinct stages or phases, each composed of a set of characteristic features or tasks. In this chapter, I discuss the way this model operates in mainstream bioethical discussion of the impact upon society of an enlarged population of dependant elders whose needs for heaIthcare services raise concerns about the fair allocation of resources among generations. I argue that treatment of this problem relies on background assumptions associated with the life span model that are largely unanalyzed. An historical analysis or an analysis attentive to the autonomy-enhancing aspects of aging research shows that these assumptions are problematic. AGING IN BIOETHICS Primarily focused on the issues of allocation of medical resources and decisionmaking at the end of life, the treatment of aging in bioethics has generally relied on a life span approach to aging and old age. The fIrst issue involves a concern for social justice in the allocation of medical and other societal resources to an aging population. The increasing life expectancy of the population is creating a cohort of elders that pose intergenerational issues of justice in the allocation of scarce resources. The majority of bioethicists concur in the judgment that some solution to the resource problem needs to be found as our population ages (

I aim to defend a form of age-based discrimination. Actually I consider two new principles in succession. First I consider a fair innings principle according to which anyone who, without treatment, is expected to die younger than society's average life expectancy merits priority for life-extending treatment in order to help bring them up to society's average. Then I defend a generalisation of this principle, concluding that anyone with a quality-adjusted life expectancy lower than society's average merits priority for any treatment to help bring them up to society's average quality-adjusted life expectancy. I start by clarifying some of the claims which fair proponents of age-based discrimination need not be committed to. For example, they need not be committed to discriminating directly by the patient's current age, as has traditionally been assumed. This could be seen as wrongfully ageist (and presumably for this reason would be illegal in many jurisdictions). But I will argue that, given the justifications that have been offered for age-based discrimination, the morally relevant consideration is not the patient's current age, but the age at which they are expected to die (which is why the principle I defend is articulated in terms of when people are expected to die, not how long they have lived already). So the fair innings principles that have been defended miss the point, in that they talk in terms of the patient's current age rather than the age at which the patient is expected to die. I then consider a counterexample to age-based discrimination raised by John Harris. Addressing this case requires us to distinguish two types of principle: "straight line" principles according to which the strength of your claim to life-extending treatments declines at a steady rate according to your expected age at death, and threshold or "stepped" principles according to which your entitlement declines faster as your expected age at death rises past a certain age, such as 70. I adopt a threshold principle (a "fair innings" principle) which largely avoids the counterintuitive implications in Harris's case. Specifically, I defend a view according to which the fair innings in a given society is equal to that society's average life expectancy. However the real work is not characterising the principle, but defending it, so as to avoid being ad hoc. I do this with an innovative set of cases in which society's average life expectancy is varied to show its importance for intuitions. I also offer a new set of egalitarian arguments to defend the same principle. Finally, I consider whether a similar principle can be applied to QALYs or their equivalent, and not just life years. I consider a QALY-based proposal from Alan Williams, noticing that it has some counterintuitive consequences. However, I find that if Williams accepts some relatively painless constraints on his weighting factors, he can dodge the counterintuitive consequences. I therefore conclude by endorsing his proposal.

Society, 2013

Two sorts of motions, each natural in its own way, determine our lives. In one sort, our bodies metabolize food, heal wounds, regulate body temperature, maintain salt balance, distribute oxygen, remove toxins, and so on. These remarkable processes occur quite independently of our individual and collective abilities to understand them. Most of us, most of the time, remain blissfully inattentive to the rather automatic biological substructure on which our conscious activities depend. And yet these vital operations, in their complexity, coordination, and durability, compel our wonder whether we take them to be caused by nature's unmindful teleology (as Aristotle did), God's creative generosity (as Augustine did), or indifferent chemical mechanism (as any number of our contemporaries do). In the other sort of motions, our metabolism slows, eyesight weakens, bone density lessens, muscles slacken, skin loses elasticity, and, generally, our vital powers and processes become increasingly vulnerable to

Sociology of Health and Illness, 2006

With increasing frequency, the oldest members of US society are undergoing medical interventions aimed at prolonging life. Using cardiac care as a case study, this paper explores how a discourse of risk infuses and legitimates high-tech clinical treatments in late life. In particular, we examine how the diminishing risks associated with biomedical procedures produce a sense of medical possibility regarding life extension, and push the definition of 'old age' into a receding future. Simultaneously, physicians, patients and families come to understand the management and reduction of future cardiac risks to be germane for individuals even near the end of life. Driven by the logic and language of risk, decisions to intervene are experienced as incremental and largely unremarkable, and the pursuit of an open-ended future via biomedical means is perceived as an ethical imperative, trumping deliberation or discussion of the utility of intervention and the ultimate ends being pursued. For practitioners and patients alike, the engagement of risk, the preservation of hope it facilitates and the routinisation of intervention it produces all contribute to the emerging mandate to treat at ever-older ages.

An aging U.S. society, a growing array of life-extending medical interventions, Medicare policy and an ethic of individual decision-making together contribute to the deepening societal tension between controlling health care costs and enabling health consumer use of life-sustaining technologies. The activities that constitute longevity making, like so many other socio-medical practices, constitute a site for the governing of life and the emergence of new forms of ethical comportment and social participation. Those activities-including the necessity of treating risk, the difficulty of saying 'no' to evidence-based interventions and the responsibility of choosing among clinical options-also lie at the heart of debates about health care rationing and reform. Cardiac procedures, organ transplantation and cancer treatments are three examples of medicine's success in extending life and are emblematic of the existential and societal quandaries that result. A perspective from medical anthropology shows the ways in which the making of life is linked to health care spending and the ongoing debates about age-based rationing. Keywords health care reform; age rationing; privatized ethics; self-care With health care reform and especially Medicare reform on the front pages and at the forefront of the Obama administration agenda, a perspective from medical anthropology can highlight some of the socio-cultural sources of emergent and recalcitrant obstacles to cost containment efforts and can show, too, why the topic of age rationing continues to be a significant point of ongoing tension and lack of resolution. An explosion in the varieties of life-extending interventions for older persons is changing the face of many medical specialties in the U.S. Routine and innovative treatments are prolonging more lives at older ages than ever before, and the average age of persons who receive surgery or other non-primary care interventions that extend life is rising. Indeed, octogenarians comprise the most rapidly growing group of surgical patients and there is a growing medical literature on the justification and benefits for performing many kinds of procedures on persons over the age of 80. These practices are reshaping medical knowledge and societal expectations about 'normal' old age, ordinary medical treatment and the time for death. For example, medicine's successes have promoted the widespread assumption that its techniques can almost always restore health; practitioners and patients alike consider the office phone:

Chapter in THE POWER OF DEATH: Contemporary Reflections on Death in Western Society Edited by Maria-José Blanco and Ricarda Vidal. New York and Oxford: Berghahn Books. October 2014. ISBN 978-1-78238-433-5

EMBO reports, 2005

Law and Biomedicine, 2022

From a critical human rights-based approach, Law and Biomedicine addresses available international legal answers to various questions about human life and health affecting highly appreciated individual and social values—namely, autonomy, life, dignity, and moral status, among others. Papers of each lesson are available under request.