The Elderly and the Four Ethical Principles
With more and more people living longer, attributed to various factors including advances in medical treatments, there are more and more elderly now present in the population.
But, first, what is the definition of an older person or the elderly? One definition included in a World Health Organization online document regarding the elderly and old age is by M. Gorman: "The ageing process is of course a biological reality which has its own dynamic, largely beyond human control. However, it is also subject to the constructions by which each society makes sense of old age. In the developed world, chronological time plays a paramount role. The age of 60 or 65, roughly equivalent to retirement ages in most developed countries, is said to be the beginning of old age. In many parts of the developing world, chronological time has little or no importance in the meaning of old age. Other socially constructed meanings of age are more significant such as the roles assigned to older people; in some cases it is the loss of roles accompanying physical decline which is significant in defining old age. Thus, in contrast to the chronological milestones which mark life stages in the developed world, old age in many developing countries is seen to begin at the point when active contribution is no longer possible."
There are the four ethical principles which should be considered and which can apply to the medical care of the elderly. The principles are beneficence, non-maleficence, autonomy and justice. How can they apply? I think that others might give different examples, however the following are the ones that come to my mind presently.
Beneficence is the principle “to do good”. Non-maleficence is the principle “to do no harm”. We, as physicians, are required, as part of our profession, to adhere to these two principles as we proceed in the care of our patients. The question arises as to whether at some point in the life cycle, what these two principles mean in practice is different between the elderly and those who are younger. And then who is to characterize the actions: the doctor, the patient, the profession or society?
For example, is there a point in the care of an elderly patient who has symptomatic cancer where administration of classic or novel cancer chemotherapy with its significant side-effects might no longer be considered a beneficent act but actually a harmful act? Would this point be considered as readily in a patient who is significantly younger? Would the use of a cancer drug in an elderly patient, which by statistics would only prolong the patient’s life by a few months but with continued suffering from the underlying disease be considered a non-beneficent act on the part of the physician? Would the consideration that a new drug might come out during that extra time of life that would be more effective rationalize the current management? Would this issue be the same in a patient who was considerably younger? Should the decision as to whether a treatment represents a “good” or a “not good” be one of the physician based on knowledge and experience or should such decisions be left only to the patient who is the one who has the burdens of the illness, the symptoms, the costs and the effects on the patient’s ways of life and goals?
The third principle, the principle of autonomy, the right of the patients to speak for themselves as to how they want their illnesses to be treated, plays a important role in how beneficence and non-maleficence is judged. As one grows older, some patients may lose their capacity to make their own medical decisions and, without an Advance Directive or legal surrogate to help, the bearing of responsibility for defining the physician’s actions as beneficent and non-maleficent or “wanted” vs “unwanted” in terms of the patient’s own desires may be placed more on the physician’s shoulders or others. Is the principle of autonomy just as valid an ethical principle in the elderly as in the younger patient?
And finally, comes the principle of justice. One reads about the tremendous amount of money spent on disease management within the United States just during the last months of a person’s life. Is that fair? is that spending a fair act to other patients who are sick but have the potential of many more years of life ahead and where the money might be put to use which is more constructive to society? Isn’t the issue of justice most pertinent about the medical care which is given to the elderly? Or is bedside rationing against the elderly an unethical and abhorrent concept?
Many, many questions and mostly about whether the elderly should have the four ethical principles applied differently than to those who are younger . However, I look to my visitors for the answers. ..Maurice.
Graphic: Photograph of the elderly walking in a city park in Southern California by me 11-4-2009.