Explaining rule of rescue obligations in healthcare allocation: allowing the patient to tell the right kind of story about their life

I consider various principles which might explain our intuitive obligation to rescue people from imminent death at great cost, even when the same resources could produce more benefit elsewhere. Our obligation to rescue is commonly explained in terms of the identifiability of the rescuee, but I reject this account. Instead, I offer two considerations which may come into play. Firstly, I explain the seeming importance of identifiability in terms of an intuitive obligation to prioritise life-extending interventions for people who face a high risk of an early death, and I explain this in turn with a fair innings-style principle which prioritises life-extending interventions for people expected to die young. However, this account is incomplete. It does not explain why we would devote the same resources to rescuing miners stuck down a mine even if they are elderly. We are averse to letting people die suddenly, or separated from friends and family. And so, secondly, I give a new account that explains this in terms of narrative considerations. We value life stories that follow certain patterns, classic patterns which are reflected in many popular myths and stories. We are particularly averse to depriving people of the opportunity to follow some such pattern as they approach death. This means allowing them to sort out their affairs, say goodbyes to family and friends, review their life, or come to terms with death itself. Such activities carry a lot of meaning as ways of closing our life story in the right way. So, for someone who has not been given much notice of their death, an extra month is worth much more than for other patients. Finally, I review the UK National Health Service's end of life premium, which gives priority to patients with short life expectancy. I suggest it falls short in terms of such considerations. For example, the NHS defines its timings in terms of how long the patient can expect to live as at the time of the treatment decision, whereas the timings should be specified in terms of time from diagnosis.

Ageism

Chapter 9 explores how ageism and midlife bias find expression in allocating life-saving medical care, selecting subjects for clinical trials, and mandating retirement. Subtle expressions of ageism and midlife bias include epistemic justice, internalized ageism, and elderspeak. Around the globe, ageism is not always directed to older people. We review and rebut the chief arguments for old age-based discrimination, including fair innings, cost-benefit analysis, and complete lives egalitarianism. We raise concerns about using age as a proxy, which can foster ageist attitudes. We show that a common form ageism takes is facially neutral policies that systematically disadvantage older adults. The chapter examines “the puzzle of age discrimination,” which is the tendency to oppose race and sex discrimination more strongly than age discrimination and argues that this tendency is unjustified. We rebut age discrimination by appealing to justice between generations, fair subject selection, and respect for dignity.

Justice between Old and Young

Chapter 5 shifts from asking which values matter for individuals to asking which matter for groups of people at different ages. It addresses age group justice by proposing principles of relational equality, capability sufficiency, and reparations. It defends these principles by appealing to human dignity and central human capabilities. The chapter asks how to deploy justice principles over time; it argues for honoring capability sufficiency at each moment of a person’s life, while permitting inequalities at time slices that even out over the course of a person’s life. The chapter interrogates fair-innings arguments that discount later life and exposes values inherent in viewing life as a rule-governed game. It juxtaposes the metaphors of life as a game with life as a narrative, and argues for a narrative approach.