Ben Davies completed his PhD in Philosophy, on the moral implications of age-related human enhancements, in October 2015 at King’s College London. His interests include inter-generational justice, animal ethics, and death. He is currently an Instructor in Philosophy at Bloomsburg University of Pennsylvania.
Hello, I’m Nigel Warburton. Joining me today is Ben Davies, a researcher affiliated with the Department of Global Health and Social Medicine at King’s College London. The topic we’re going to focus on is a good innings. We’re not talking about cricket; so what is a good innings?
So the idea of a good innings as I understand it is to do with the allocation of resources in health care. I think there’s quite a common strand of thought both in philosophical approaches to health care, and in everyday thought, that says that fairness demands that older people should be a lower priority when it comes to health care allocation, the reason being that they’ve had a good innings, i.e. they’ve lived for some amount of time, whereas younger patients haven’t yet had their chance to have a go.
That doesn’t seem completely unreasonable, does it? There’s a sense in which someone who’s eighty isn’t going to live more than twenty years, probably – maybe twenty-five years if they’re incredibly lucky, or unlucky – so, compared with a teenager, that seems the way to go.
The idea you’ve brought up there seems to be one of efficiency. The idea is that an older person is less likely to have the same level of benefit from an intervention than a younger person. The idea of a fair innings is slightly different – although you can talk about both in connection; it’s more backward looking. The idea is that the older patient has already had their turn. So we’re looking at the amount of time they’ve lived, not the amount of time they have to live, and saying that fairness demands that somebody who has had more should be a lower priority.
So they’ve been lucky enough to live all this time, so they shouldn’t ask for any more. If you’ve had a fair innings, time’s up mate, go back to the pavilion in the sky and have a nice rest.
Exactly. And you might trade that off with the efficiency issue. Generally, older patients probably will get less out of an intervention than younger patients. But you might have a situation where a younger patient unfortunately isn’t going to benefit very much from an intervention. And then you might say, if you were a fan of the fair innings, ‘Well we should prefer the younger patient, but given that they’re going to get so little out of this compared to the older patient, actually, all things considered, the older patient is the higher priority’.
It would be even clearer, maybe, if you had an older patient who is going to have one good quality life-year extension from a treatment, and a younger patient who’s going to have exactly the same quality of life for exactly the same period of time. How do you choose between the two? Obviously, on the fair innings argument, you go for the person who is younger because the older one’s had a fair innings, and the resources should go to the younger one.
Exactly, and a lot of the time when the public is asked about these things, they are asked to compare circumstances where two patients of differing ages will get exactly the same level of benefit. And they very routinely prefer the younger patient.
So it’s a widely held intuition that there is some kind of justice in younger people getting the chance to extend their lifespan whereas older people have had a set of experiences and, perhaps, aren’t as deserving of an extension of life.
Exactly, and I think that’s completely understandable, because there’s a lot of persuasive force behind the intuition. If we’re thinking about what’s fair, normally we think that people who have had more should take a lower priority than those who have had less.
I think we should get this really clear, though: this isn’t about efficient allocation of resources because using the NICE principles of allocation of resources you just assess quality of life years independently of how long somebody’s lived; you just look at precisely the outcome in terms of quality of life years.
That’s right, so at the moment allocations in the UK are purely forward looking; it’s, as you say, about efficiency. So we’re not really interested in how old someone is, in how good their life has been. We’re interested in how good the particular gain that they’re going to get out of an intervention will be.
You’ve suggested that there are widespread intuitions that make us less likely to give life-extending treatment to older people: this good innings. Does that same kind of reasoning apply in other areas, where we take into account the whole lifetime, or is it unique to life extension of older people?
Well I think what’s interesting is that actually we don’t seem to apply this kind of reasoning to many other interventions, both in health care and in terms of other goods. So if you take pain relief as a central example, very few of us would think of asking what someone’s entire lifetime of pain experience has been like when wondering whether to give them pain medication. We tend to assess someone’s claim to pain medication in terms of what their need is at a particular time. I think that’s also got quite a natural intuition behind it, I think it’s the intuition that pain is something you experience in the moment, therefore we should assess your claim to pain relief in terms of what you’re like at the moment.
Why would that be just true of pain but not true of extending one’s life, because it’s in the moment that you want your life to be extended?
Well exactly, and this is why I think that the apparently clear distinction between life-extension and other kinds of intervention is less clear than it might seem. As we’ve said it’s very natural to think of life-extension along this whole life perspective. But as you’ve said, we might also think of life-extension as something that we can call life-saving. So life-saving might be what happens to you in the moment; your life is rescued, you are rescued from the badness that is death. Life-extension would be the whole life approach. It’s also true that we can apply both kinds of perspectives – that’s the lifetime perspective and the in the moment perspective – to things like pain relief. Of course it’s very natural to think of pain relief as something that we care about in the moment. But from a justice point of view it’s not at all clear why we shouldn’t think that it’s unfair that one person has had a life of severe pain, and another person has had a fairly pain-free life.
So, there is that almost Marxist principle that each should get according to their need, not some allocation of resources at birth which, when they’ve used it up, it’s just tough. There is no sense that children only get ten thousand pounds of health care, or a hundred thousand pounds of health care in your entire life, and once they’ve used up that voucher they have to pay for themselves or they don’t get anything.
That’s right, and I think even when people are advocating something like the fair innings view for life-extending interventions, they are often quick to point out that they’re not advocating it for other forms of health care such as palliative care. So very often you get the position that we should restrict life-extending interventions for older patients, but not at the expense of making their deaths or declines painful or uncomfortable.
So again, that’s quite intuitively plausible, that we could have a view about a fair innings in terms of extension of life, but not have that same way of thinking when it comes to minimising suffering because suffering is in the moment. We want to stop people suffering, ideally we want to stop everybody suffering; that seems a good way of behaving. So there must be something different between the two cases.
That’s right, there’s a natural way of thinking which is that, as you say, suffering is in a particular moment so we should focus on people’s needs at that moment; life-extending interventions on the other hand are, as the name suggests, focused on someone’s lifetime, on how good and how long it’s been. So again, it seems quite natural to think that we should assess someone’s claims from, as it were, an entire lifetime perspective.
Are you suggesting that there’s maybe something flawed in the good innings principle?
It’s slightly more complicated than that. It’s more that I’m not certain that the clean cut between, on the one hand, the fair innings principle as applied to life-extending interventions, and on the other hand this need at a particular time principle applied to things like pain relief, is justifiable. I’m not sure a clear justification can be given, and although we’ve just spoken about a fairly persuasive pair of intuitions that might justify each of those approaches, I’m not sure that the opposite approach can’t be applied in either case. I suppose the idea that I have in mind is that we’ve said, ‘Look, it’s very natural to think about life-extension from a whole lifetime view, it’s very natural to think about pain from an ‘at the moment’ view’. What I’m suggesting is that we can think about life extension from an ‘at the moment view’, and pain relief from a lifetime view as well. If we can think about both of those kinds of interventions from both perspectives, it becomes much less clear that we should have such a strict dichotomy in our approach.
Could it be that people who seem to be advocating the good innings principle are really just closet efficiency supporters? It’s just a short hand for saying ‘People who are elderly, we know, aren’t going to extend their lives thirty or forty years, whereas a teenager could easily live fifty or sixty years’.
It certainly could be in some cases, but there have been quite a few studies into people’s attitudes when it comes to this issue. Usually when people conduct these studies, people are asked to compare people of different ages, but who will get similar benefits out of an intervention. In those cases people almost routinely prefer the younger patient. But when you start to introduce a difference in the amount of benefit that favours the older patient, things start to change a bit. People will still often prefer the younger patient – say if the younger patient’s going to get another five years, the older patient a slightly better improvement such as seven years – but for almost everyone there comes a point where the difference in efficiency if it benefits the older patient is sufficient to overrule a preference for the younger patient.
So are you suggesting then, look, you have a very sick child who could get five years extension of life through a treatment which would give twenty years extension of life to an older person, at that point people stop thinking about a good innings and start to take the number of years as a deciding factor?
Exactly, and the fact that that only happens at a certain point, and doesn’t happen as soon as the benefit is greater for the older patient suggests that it’s not just efficiency that people are concerned with.
Couldn’t it just be that we’re all mixed up here, that we have conflicting intuitions and are quite irrational in the way we think about this sort of question?
I suppose it could be. I suppose my approach is that there can be multiple considerations that conflict with one another, and that good health policy will take those multiple considerations into account. If there’s something intuitive behind the fair innings principle – and I think there might well be – we maybe should try to introduce it into health policy. At the moment we’re just relying on the idea of efficiency, and it’s not clear that that matches up with very common intuitions on justice.
I can imagine the fair innings principle will appeal to a younger person, but as you get older you might feel quite aggrieved at the thought that you’ve had your fair innings and so you’re not quite as eligible for treatment as these younger people coming up behind you.
Well, interestingly, I don’t have any empirical data on this but a lot of the people advocating a fair innings principle in the philosophical literature are older, and a lot of older people when you speak to them do seem to believe in something like the fair innings principle. I’m a younger person, and I’m rather less convinced by the fair innings principle.
Basically what we’ve been discussing is a philosophical question about justice and the allocation of scarce health resources. You’ve already talked about the potential impact on policy, but do you plan to do empirical research on how people behave, and how, for instance, doctors implement policies here?
I think that would be a very important avenue of research to go down, yes. As much as we have a lot of data on what the general public think about these things, at the moment – in the UK at least – we don’t implement a fair innings principle in an official capacity, but it may well be the case that if this intuition is very common amongst the public that it’s also common amongst doctors, and that it thereby affects their decisions, whether or not they are aware that it’s affecting their decisions. So I think it would be very interesting to look at doctors’ behaviour, and also to canvas their opinions aside from being members of the general public.
In all this discussion we’ve been assuming that the best thing to do is to be rational about allocating health resources. But what about the idea that what we just need here is compassion: we need some people who are emotionally in the moment of a particular case and can just respond to the particularities of an individual patient in front of them?
I think there’s a lot to be said for that kind of approach. I think the problem with that is that we don’t seem to have a willingness to spend unlimited resources on health care. Perhaps that would be the best approach, I’m not sure. But given that we’re in the context of limited resources, what you end up with if you take an approach that purely focuses on the moment is an unfair situation where people who come later, or have less compassionate health care practitioners, are unfairly put to a lower priority, and I don’t think that’s the right approach. My view is that thinking about the principles that underlie justice isn’t just a theoretical matter. If we go forward with health care allocation without thinking about the principles we’re applying, that’s arbitrary and unfair. So I think that clarifying our views and making them more rational is actually a fundamental component of justice.
Ben Davies, thank you very much.