Newcastle Symposium on the Goals of Ageing Research
24th-25th April 2001 International Centre for Life Times Square, Newcastle
Session 3. Priorities and Quality of Life
Session 3.1
Session 3.2 Discussion Points
Contents of Session 3
Chair: Professor Jan Reed

Paper 3.1: Priorities - Mary Midgley

Paper 3.2: Priorities and quality of life - Harry A. Lesser
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Points from Discussions
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Session 3. Priorities and Quality of Life
Paper 3.1
Priorities
Mary Midgley
The questions we are trying to deal with in this Symposium really are difficult, because most of
them are not yes-or-no black-or-white questions but questions about priorities. Is this at all
surprising? Ought the matter to look simpler?
I think not, and I think it is worthwhile to see why they take this form. Most of the moral
questions that are important in our lives are about priorities rather than about absolute right and
wrong. They are about choices of evils. They concern situations where no outcome is going to be
satisfactory – genuine conflicts between ideals. For instance, we don’t doubt that is absolutely
wrong to torture people and we don’t doubt that it is right to save their lives. The occasions
where we doubt are those where saving their lives begins to look like torturing them. And again,
we know that the law must aim both at justice and at mercy. But there are times when we don’t
see how it can achieve both. And again over public spending, we recognise many different sorts
of claims, and we often cannot find a simple principle on which we can judge between them.
Over conflicts like this, compromise really is necessary. I think it is important to grasp this, and
to see that this does not mean that we must give up in despair and stop thinking. Compromise as
such is not copping out. It is itself a necessary form of thought. Complicated situations always
involve many ideals and many values, so we necessarily have to think about the relations
between them. In order to do that, we have to place these conflicting ideals and values in a much
wider context. We have to consider more generally what kind of society we would prefer to live
in - what kind of priority we want to see given to these various elements in life.
The point where compromise goes wrong is when this thinking is badly done. When that
happens, one ideal is simply allowed to override another. These are the occasions when people
supporting the suppressed ideal begin to march with banners that say ‘No betrayal! No
Compromise!’ What they are objecting to is not really compromise itself but a bad compromise.
Bad compromises, however, are often defended by bad philosophy - thus bringing people like me
into these discussions. The trouble is that, in dealing with these painful clashes, we naturally long
for simple guidelines, and that wish for simplicity is, of course, one of the main things that drive
people to do philosophy in the first place. Philosophic work is the attempt to find a general
structure behind the muddle of experience, to simplify life by detecting order in it. But in order
to do this properly one has also to be honest about the complications. There is always a tension
between the need to simplify and the need to be realistic about existing complexity. Hasty, onesided solutions can’t be used just because they are simple.
In every age, however, people do tend to accept some kinds of simplification which accords with
the spirit of the times, even though it doesn’t arbitrate the relevant conflicts properly. In our time,
there is tremendous pressure to find a system that solves these conflicts by reducing the
conflicting aims to a single currency - to treat them as quantities of a standard unit in which they
can both be valued. Two centuries back, Jeremy Bentham proposed to do this in terms of
standard quantities of pleasure and pain (the `felicific calculus’). Though this did not work very
well, ever since his time people have become increasingly attracted to this economic model in
the hope of somehow finding a simple guideline in an increasingly confusing world. They have
therefore proposed various other units for the job, the most recent being QUALYs.
These patterns are seductive because our life is now organised on such a large a scale that we
seem to find some such impersonal approach necessary. Increasingly, we are indeed dealing with
economic problems – problems about where to put the money. These problems obviously cannot
be solved merely by personal taste and preference, so we look for something more objective.
And the enormous successes of physical science in our time make it seem as though we should
take it for our model. The fact that formulas for calculation, such as QUALYs, are abstract and
quantitative can seem most impressive. Their abstractness overawes us and makes us feel that we
are doing something reliable, something prestigious like physics.
Unfortunately, however, this likeness is superficial. The work of the natural sciences is actually
quite different from the sort of problems that we have here. These sciences are always concerned
with establishing facts. No natural science ever has to resolve priorities – choices of evils,
clashes between ideals. No natural science is ever asked how we ought to act, how we should
live, what sort of society we should favour. And there really is nothing scientific about using a
pattern of reasoning that does not suit your subject-matter and obscures its complexities.
Each of the formulas that has been proposed as a way of simplifying these life-choices – from
Bentham’s on - has actually been a piece of propaganda, an inducement to favour a particular
view of the conflicting values involved. None of them has the sort of impersonal, objective
standing that is required of the units used in physics. The simplest, most purely quantitative unit
of all is, of course, money, but using it as our sole calculus has never proved very satisfactory.
We may value each of these suggestions for some light that they incidentally cast on the
situation, but we must absolutely refuse to be bullied into treating any one of them as the whole
solution. The insistence on one-sided simplification is not scientific, neither is it philosophical,
though both science and philosophy have been raided to justify it. Life really is quite
complicated, and we shall deal with it best if we admit this sad fact.
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Session 3. Priorities and Quality of Life
Paper 3.2
Priorities and quality of life
Harry A. Lesser
I find myself very much in agreement with Mary Midgley. I agree with her view that the difficult
moral decisions—difficult in the sense that it is hard to know what to do, rather than in the sense
that it is hard to carry them out—are often those about priorities, about deciding what is best or
what is least bad. I also agree that these problems cannot be solved by appealing to any kind of
quantification, such as that proposed by Bentham or by the advocates of QALYs. This is not just
because any attempt at quantifying good and harm will be very crude and to some extent
arbitrary. If this were the only problem, the Benthamite or the advocate of QALYs could defend
what they were doing on the ground that, however imperfectly, it offered a more systematic and
efficient way of carrying out the sort of cost-benefit analysis that we are already stuck with. The
problem is rather that many of the choices we have to make are between different kinds of goods,
so that we have to decide which is the most important without being able to compare them on
any quantitative scale. We can compare two ways of tackling the same problem, and find that
one will probably be better, because, for example, more people can be cured with the same use of
resources. But in deciding priorities between radically different options this will not work—how
could one compare the relief of physical and mental suffering on the same quantitative scale?
One may be able to order them, sometimes, but not to quantify them against each other.
Moreover, if one believes in human rights, one must believe that, even when measurement is
possible, it is not always justified, so that even if one could show that much good would result
from sacrificing the lives or liberty of some innocent people, one would still have no justification
for doing it.
I want now to suggest that problems arise in medical ethics in particular because medicine has
three aims which cannot always coincide—to preserve life, to preserve or create efficient bodily
and mental functioning, and to relieve suffering. Very often, treatment or research will achieve
all three ends; it is when it does not that decisions become hard—for example, on the mercifully
rare occasions when only death can relieve the suffering. In the light of this, I want to raise the
question whether in research in geriatric medicine the first priority should be to try to find ways
of extending the life span or ways of improving the quality of life of the elderly. It seems to me
that quantification cannot help us here, but that one can give rational arguments for prioritising
one or the other, while accepting that there should probably be some research into both. In what
follows, I put the case for prioritising the quality of life, and suggest that the pursuit of
immortality or of a vastly increased length of life is a misplaced concern.
First of all, we should realise that nothing can alter the fact that we are mortal. In one sense it is
true that "we are not programmed to die"—there is always something that kills us and we do not
simply wear out at a pre-programmed moment. Nevertheless in the end we do all die and always
will even if we were able in principle to heal any disease or injury and replace any organ, it is
clear that eventually for each person some day something would go fatally wrong: perhaps we
might reach a stage where in theory it need not, but in practice it would. Moreover, so far the
human life-span has not altered very much. The Psalmist gave the days of humanity as "seventy
years, or through strength eighty years": the big change has been in the numbers reaching this,
and the change in the length of life itself relatively small. AISO, though it is natural to fear one's
own death, and sad to lose relatives and friends, it is no bad thing that we die --- it sets a limit to
suffering, forces us to make way for those coming after us, and pressurises us to do something
with our lives before it is too late.
It might be objected that even if this is true, there are benefits in extending the lifespan. This is
true, but they are likely to be benefits for a small number of people, wealthy enough to afford
them, who may not have any very good quality of life, unless research goes into this as well, and
who as a result may not be able to do much to help others. From this, three arguments for
prioritising research into improving the quality of life over research into extending it can be
derived. First, it is more just to do research into what will benefit many more people, given that
for neither group is the research vitally necessary. Secondly, a longer life is of no value, unless
its quality is good, which makes quality of life the first priority. Thirdly, improving the quality of
life for the elderly has benefits for other people and society as a whole-- it reduces the resources,
human and material, needed to look after them, and it enables them to do more for other people,
in all kinds of ways. To these three arguments we may add the two from the preceding
paragraph, that it is not clear that a great deal can be done, given human history so far, and that it
might not be overall desirable, even if it benefited some individuals.
So I offer for consideration five arguments for giving priority to improving the quality of life of
the elderly over trying to extend the human life-span. Essentially, these are arguments for setting
as our ideal—which admittedly cannot be ever fully realised— what has been called "squaring
off": the replacement of the slow decline at the end of life by the maintenance of reasonable
health and ability of body and mind for nearly all one's life followed by a rapid decline and
death. ("Squaring off" refers to the fact that a graph of the end of life would look like half of a
square or rectangle, rather than like a sloping line). I suggest that physical immortality is a false
ideal—we are not concerned here with the religious concept of life after death—and that our
attitudes to ageing and to care of the elderly will be better served by an ideal of worthwhile life
for all. Finally, it should be emphasised that these arguments relate to priority in research, and
not to priority in treatment, which may well involve different considerations.
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Session 3. Priorities and Quality of Life
Discussion Points from Session 3

Ageism can be taken to mean discrimination based solely on a person’s age. This seems
wrong in comparison to weighting decisions depending on the person’s state. The notion
of discrimination is sometimes used as if using the particular concept, whether it be age
or sex, to make any practical difference must be always wrong. This might be the case for
racism, which seems unlike other discriminations because race is a criterion, which is not
significant for any moral purpose. But there are other grounds on which it seems
reasonable to base decisions. Speciesism would be discrimination merely on the grounds
of species. However, there do seem to be reasons for making some decisions on the
ground of species. For instance, a chimpanzee should not be subjected to education
merely on the grounds of species and there may be circumstances under which it is
morally acceptable to sacrifice an animal (e.g. in a sinking boat) merely on the grounds of
its species. For some purposes the difference is important. Similarly, returning to age,
there may be grounds for saying that someone has already had the chance to experience
certain goods in life and, therefore, if decisions have to be made between people of
different ages, age will come into account. But it should not just be that the youngest are
treated first without further details about the quality and actual life expectancy of a
particular person.

In discussing QALYs, whilst enhanced life sounds great, a question is raised about who
makes decisions concerning what sort of life is enhanced. Studies with people with
disabilities have shown that they rate their lives higher than some professionals and some
professionals regard some states as worse than death, although this appears not to be the
subjective experience in such states. These sort of concerns were shown in the recent
NICE guidelines concerning the anti-dementia drugs. The drugs were only seen as
desirable if they did not prolong life. This raises questions about how much value is
placed on this sort of life. How do we rate the subjective experience of people with
dementia? Hence, we need to encourage people to participate in decisions about what
would or would not enhance their lives. Having said this, there is clearly a lot that is
obviously lacking in the lives of some older people with some sorts of disability.
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In choosing between, say, a child and an older person, one might take the view that
children have a future, but we need to bear in mind that the older person has a past. The
past might give the older person some sort of entitlement, but we have to recognise that
judging entitlement brings into play all sorts of complicated psychological and social
factors. It can be argued that the future is a very different sort of thing from the past.
There is a sense in which some people can say that they have done what they were meant
to do with their life and the quality of life is not necessarily affected by age, disease or
disability.

Views on the quality of life change and given that after QALYs we now have DALYs we
can see that prejudice creeps in over disability. Having a disability can be viewed
differently subjectively, even if some people say that disabled people are wrong in their
judgement about their lives still being valuable.

We have to bear in mind that the pendulum can swing to the other extreme. That is, there
is a danger of power being associated with the reaction to various-isms. We could have
older people ending up with rights that allow them to suppress younger people. There
have been gerontocracies in the past and currently in particular societies. Democracy has
to allow shifts in power, but must attempt to temper those shifts. Older people having
power can be in some circles and circumstances stultifying, but social respect for older
people is deeply ingrained in certain cultures.

When we set up a debate between giving priority to the old versus giving priority to the
young, we are instantly in danger of being too simple because this choice is actually only
required to be made in rare situations when the choice might in fact be made easily on the
grounds of the person’s state at the time. On the other hand, if we wish to pursue this
debate we have to take into account enormously complicated political and economic
realities. These are the realities, not only of age, but also of limited resources, the fact that
there are interventions which can be made, that there are advocates for one group over
against another, that individuals have particular intentions, as does the wider society. And
we have to be aware that we are dealing with particularities and stereotypes, assuming
that we know whom the old and the young are.

This is linked to the ways in which we speak of older people as, for instance, "the
elderly". Language can constrain our thinking and talk of "the elderly" persists in
academic, health and political circles, whereas in social care there is a greater awareness
of the need for participation in which older people are seen more as citizens. Medical
people continue to talk about "consultation" rather than "participation with". Older
people, on the other hand, need to be thought of as consumers and citizens. The language
reflects our relations with people.

Nevertheless, we need to consider general structures in addition to the particularities
when we are considering, for instance, priorities in research or treatment and the general
structures might be different in the two cases.

It might be that Social Service departments have had to divert resources towards child
abuse work, as a result of societal and political pressures, to the detriment of older
people. It is difficult to judge whether this is or is not the case, but certainly those who
work with the elderly tend to do so in multidisciplinary teams and this team approach
reflects the realisation that health care is not the only thing that brings about health. It
reflects the holistic view of people who are not simply regarded as machines that take
tablets.

Philosophy can be regarded as critical description that allows us to understand the
realities of the human situation. Such description might bring out human goods - what is
important in life - and it might be that ageing research is only relevant in so far as it aims
at human goods. This description of human goods, of what it is that research and health
care aim at, might be a unifying factor. However, it has to be recognised that, although
we might agree in our list of goods, it might also be that we disagree concerning the
priority given to various different goods. The notion of philosophy as description is
problematic, but it is true that philosophy can come into play when things have not been
clearly noticed. For instance, there has been a recent trend to emphasise autonomy and
freedom, but these notions can come into conflict with notions of the public good. In fact,
any descriptions bring into play values.

One of the factors that determines the quality of our lives is our ability to take risks.
Professional carers sometimes or often have to take steps to protect people, but it has to
be recognised that this can adversely affect their quality of life.
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Ageing pages constructed by Andrew J. Palmer Jan 2002