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Age rationing and prudential lifespan account in Norman Daniels’ Just health
  1. S Brauer
  1. Dr S Brauer, University of Zurich, Institute of Biomedical Ethics, Zollikerstrasse 115, 8008 Zurich, Switzerland; brauer{at}


Could age be a valid criterion for rationing? In Just health, Norman Daniels argues that under certain circumstances age rationing is prudent, and therefore a morally permissible strategy to tackle the problem of resource scarcity. Crucial to his argument is the distinction between two problem-settings of intergenerational equity: equity among age groups and equity among birth cohorts. While fairness between age groups can involve unequal benefit treatment in different life stages, fairness between birth cohorts implies enjoying approximate equality in benefit ratios. Although both questions of fairness are distinct, the resolution of the one depends on resolution of the other. In this paper, I investigate whether Daniels’ account of age rationing could be defended as a fair way of setting limits to healthcare entitlements. I will focus on two main points. First, I will consider whether the age group problem could be resolved without appealing to a conception of the good. Second, I will demonstrate that the connection between the age group problem and the birth cohort problem runs deeper than Daniels initially thought—and that it ultimately suggests a method for prioritisation in problem solving strategies.

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  • Competing interests: None declared.

  • i After the USA, Switzerland has the second- and Germany the third-most expansive healthcare system worldwide with approximately 11% of gross domestic product spent on healthcare in 2003. Cf1 2

  • ii Cf4 (p21) and the report of the Swiss Academy of Medical Sciences.5

  • iii What is prudent is also morally permissible for,7 (p276) although not necessarily a sufficient reason for an accordant policy.

  • iv Georg Marckmann forcefully argues that there is no direct empirical link between age and healthcare costs but rather one between approximation to death and costs. Demographic aging burdens the healthcare system because the non-working population increases disproportionately.2 Various policy remedies could approach this issue, for instance raising retirement age or incentives for child bearing.

  • v In critic of Daniels, McKerlie demands that justice has to say something about synchronic distribution between different ages as well.11 I agree with McKerlie that if we are concerned with the real world situation in which healthcare reductions have to be justified, we do this not to ourselves undergoing a prudential lifespan thought experiment, but to other affected people.

  • vi Cf6 (p178ff) “Pure age rationing” means providing differential treatment to persons of different ages not because of different healthcare needs, but simply and only because they belong to different age groups.

  • vii On Daniels’ concept of disease cf also Jecker.14

  • viii Daniels mentions the possibility of trading away total quality of life years as well (p175 footnote 9).6

  • ix In Just health Daniels discusses this problem with the example of Italy and China.

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