The two concepts - 'ageism' and 'rationing' - are widely believed to exist in the health care systems of industrialised countries. Do they exist? And if they do, are they separate phenomena, or are they tied together? In other words, does ageism play a part in health care rationing and, conversely, does rationing intensify ageism?

The implication is that, had Alice C been 45 - or for that matter 25 - the question would not have been asked, because the answer would have been self-evident.

The interesting sequel was that Alice C recovered, went home after 10 days and "resumed her independent lifestyle". The author lost touch with her 3 years later when "she was still alert and enjoying life at the age of 91".

A Lancet correspondent subsequently attacked Levinsky's choice of Alice C as an argument against age-based rationing and posed the intriguing question: how would this argument have looked if Alice C, instead of enjoying life at 91, had "_been discharged back to an unsatisfactory long-care facility to endure a lingering death?" [Neville W. Goodman, "Alice C is poor evidence against age-based rationing", Lancet, 353, February 20, 1999, 677-8] He concluded: "Rationing of health care_is neither uniformly logical nor uniformly just. But rationing is more just at the end of a natural life than before its end."

Ageism, rationing and justice
The concept of 'just' forms of rationing at the end of life seems to have economic appeal to advocates of rationing. At the same time, it raises factual problems, because 'the end of life' can be a moveable feast, as in the case of Alice C. In the first decade of the Twentieth Century, average life expectancy at birth in England was about 50 years (48.5 for men and 52.4 years for women). Are we to conclude that medical 'justice' would have been done around 1905 by deliberately rationing or withholding access to the over-50s at their statistical 'end of life'?

'THE END OF LIFE' - a convenient argument for rationing expenditure
The cost of technological advance can be restrained by rationing its application to those who can often derive the greatest benefit from it, namely elderly sufferers from chronic diseases. To apply calendar age as the measuring rod of 'the end of life' is logically indefensible and morally repugnant.

However, ethical considerations are also complex. Demographic ageing and economic prosperity have created conditions in which high technology is increasingly being used to set up or create conditions for 'a lingering death'. At the same time, euthanasia remains unacceptable and illegal in most industrialised countries. Here, the point at issue is not primarily cost (though cost comes into it) but a blend of medical judgment, ethics and law.

Torture by high technology When an individual has reached his or her biological end of life, the application of high technology can be a well-meaning form of torture. Avoiding high technology under such circumstances cannot be regarded as 'ageism' in health care. Indeed, the contrary could be argued, namely that high-tech prolongation of 'a lingering death' is in effect an inverted form of 'ageism'.

There is an essential difference between the biological and the statistical, and between the individual and the bureaucratically decreed 'end of life'. Ageism tends to rely on statistics and bureaucracy as instruments of health care rationing whilst regarding the biological situation of the individual as an inconvenient obstruction. In this context, ageism discriminates against the individual on the grounds of calendar age: in other words, were the patient younger, rationing would either not be applied or applied less stringently.

The difference between rationing and cost containment
The two are not the same. All health care systems are obliged to make strenuous efforts to control and contain expenditure. This can be done with or without rationing. The elimination of wasteful procedures; more appropriate prescribing or intervention; improvements in patients' compliance; defining guidelines and monitoring their observance; and (in the public sector) shifts between public expenditure and private insurance or patients' copay are examples of budgetary control that do not necessarily involve health care rationing.

Health care rationing involves conflict between medicine and money. 'Rationing' means the denial or delay of treatment as a result of a state of conflict between what the physician considers to be medically and ethically the best treatment for the patient in question and the treatment that the system actually permits him or her to give.

The motivation of rationing in health care is primarily financial. Although the intention of such rationing is to be fair in allocating priorities and selecting patients, the ethics of 'fairness' in health care are a minefield of error and subjective judgment on the part of decision makers. When 'age' is also introduced as a rationing criterion, the concept of 'fairness' is effectively abandoned unless one assumes that 'being old' can be equated with 'being moribund'.

That demographic ageing will present difficult financial problems to health care is undeniable. That new technology and the expectations of new generations of older patients (demanding it!) will rise dramatically, too, is predictable. Moreover, the ethical quicksand between what is medically justifiable and what merely prolongs life without content or quality will become ever more treacherous with demographic ageing. None of this, however, seems to justify health care rationing by age.

Where do we go from here?

There is real need for the accumulation and dissemination of a body of evidence demonstrating that methods other than 'age rationing' can be medically more appropriate and more effective, and presumably as cost-effective or more so than simplistic assumptions about calendar age.