Newcastle Symposium on the Goals of Ageing Research
24th-25th April 2001 International Centre for Life Times Square, Newcastle
Session 5. Equality and Diversity: Local and Global Perspectives
Session 5.1
Session 5.2 Discussion Points
Contents of Session 5
Chair: Dr Stephen Louw

Paper 5.1: The need for action in the UK - Astrid Fletcher

Paper 5.2: Equity and diversity: the global perspective - Solomon R Benatar

Points from Discussions
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Session 5. Equality and Diversity: Local and Global Perspectives
Paper 5.1
Health inequalities in older people:
The need for action in the UK
Astrid Fletcher
Evidence for continuing health inequalities in old age
People enter the last decades of the life span with the health disadvantage of earlier experiences
cumulated through the life course. There are clear gradients of ill health in older people
according to their socio-economic position measured in mid-life 1,2or early in retirement,1,3 and
persistent inequalities in old age in the risk of dying, entering institutional care 4 and in life
expectancy 5. For example the life expectancy of 65 year old men from social classes I and II is
nearly 3 years longer than that of men from classes IV and V, and similar differentials are
observed by social class for older women5. In the Whitehall Study, men in the lower civil service
grades in 1965 had the poorest health when re-surveyed some 29 years later, with three fold
increased risks of physical problems and two fold risks of poor mental health 2.
The double disadvantage of poor health in old age and reduced survival results in reduced years
of healthy life (healthy life expectancy) that an older person from a lower socio-economic group
can expect to live6. There are also marked geographical differences in healthy life expectancy
within the UK7 with a strong inverse north-south gradient (e.g. 6.1 years for a 65 year old man in
Sunderland compared to 10.3 years in Surrey) and variation observed even within the same city
(e.g. 8.3 years in the London Borough of Haringey and 9.9 years in neighbouring Barnet).
Not all health inequalities in late life can be attributed solely to earlier experiences. Material and
social circumstances in later life continue to have an influence. Older people who lose favourable
socio-economic indicators during retirement are at similar levels of risk of mortality and
institutional admission to those who have unfavourable indicators throughout4. In the Whitehall
Study, even among high grade civil servants, level of income in retirement was an important
mediator of physical and mental health 1. The benefits of higher incomes in retirement may
operate directly on health risks, for example through healthier lifestyles such as diets,
opportunities for exercise, living in healthier homes and neighbourhoods, or indirectly by being
able to offset the effects of deteriorating health through private health and social care.
Health and social care provision: equality of provision and access?
Health and social services play a potentially important role in improving quality of life and
alleviating health inequalities. The most common disabilities of older people relate to problems
with: hearing, vision, mobility, carrying out basic daily tasks such as washing and dressing, foot
care and incontinence. Crucial services for elderly people include: those which reduce
impairment (low vision aids including spectacles, hearing aids, walking and bathing aids); those
which enable elderly people to live independently in the community (home cleaning, shopping,
bathing and provision of meals); those which provide medical or nursing care to elderly people
(such as community nursing services, incontinence services, chiropody).
It is not known whether disadvantaged elderly people have equitable provision according to
need, and equitable access. In some settings, services are rationed (such as chiropody) or there
are long waiting lists (cataract, hip replacement), which are likely to most disadvantage older
people who cannot afford to pay for these services privately. Where user charges exist, it is likely
that low-income elderly, especially those who fall outside the threshold for free services will be
disadvantaged. For example, evidence suggests that the abolition of free eye sight testing for
older people during 1989-1999 led to a considerably reduced attendance in the low-income
group who did not qualify for a refund8. Older people from ethnic minorities have greater
difficulties in accessing services9. Older people who are economically and socially
disadvantaged are more likely to experience tooth loss, caries and periodontal disease and less
likely to use dental services10.
The future: a more unequal society of older people?
Although incomes of pensioners have increased over the last 20 years, the gaps between the
worst and better off have widened with a 3-fold difference between the top and bottom fifth11.
Nonetheless nearly 40% of pensioners receive means tested help, with the majority being single
women and around 50% of pensioners have savings of less than £3,000.
In the future, older people are expected to show even greater variations in resources and wealth,
reflecting the effect of current employment trends - differences in pension schemes and
coverage, material assets, investments and savings. Based on observations of the past two
decades across a number of countries, we can expect that these variations will result in widening
health inequalities. Improvements in health predicted for future cohorts (less disability, improved
survival) will benefit the better off groups of the older population much more than the poorer.
It is likely that there will be considerable changes in health and social care provision over the
next twenty years. There will be more private/public and voluntary sector partnerships which,
while they may offer additional opportunities, may also lead to substantial variations in the range
and quality of services available to older people. There are dangers of poorer older people being
excluded from the benefits of new technologies, such as proteomics, regeneration medicine, high
tech aids and equipment, based on what is affordable in a universal health care system.
Developments in design and technology (such as smart homes) will be more accessible to those
in the older population who can afford to take advantage of innovation either because of their
greater spending power or because their previous life experiences (work, education, social
position) have equipped them with the necessary skills to use such technologies.
Although greater flexibility in age at retirement and working opportunities in later life are being
advocated, this may have adverse health and social effects on the more disadvantaged sections of
the older population where choices may be governed by necessity, and opportunities for good
quality employment restricted by redundant or minimum work skills. The rosy picture of an
older person continuing to participate in the work force and lead an active and creatively fulfilled
life is in stark contrast to the situation of monotonous, low paid work in poor conditions for some
older people.
Should we care?
A laissez faire approach stresses the "natural" variation between individuals over the life course,
which inevitably leads to differences in social position, wealth and opportunities in late life with
commensurate effects on health. Such a posture is incompatible with the ethics of public health
and untenable for advocates for a better deal for older people. The moral imperatives for
addressing health inequalities relate both to their intrinsic "unfairness", to the quality of the
society we wish to live in and to a recognition that health inequalities can be tackled 12.
What can be done?
Health inequalities among older people need a higher profile on the agenda of government and
agencies. The "Ageing" debate of the last decade, stimulated primarily by demographic trends,
has done much to raise awareness of the needs and opportunities created by a growing older
population. The size of the older population has given this movement its voice and strength but
the experience of old age is not uniform. We need to focus on the segment of the older
population where "ageism" has most impact- those with little influence, resource or
representation.
It is understandable that government initiatives to tackle poverty and social exclusion prioritise
children. There is at least some awareness of the problems of low-income pensioners; for
example, fuel poverty and housing improvement are receiving some action. But far more needs
to be done. Uprating of pensions and benefits – a key recommendation from the Acheson report13
- still lags behind. Defining the minimum income required for health is critical in older people.
Older people need adequate incomes to enable healthy living environments, lifestyle choices and
access to health and social care.
Health and social care departments have a key role to play. Disappointingly, the newly
announced National Service Frameworks for Older people14 include many laudable initiatives
but do little to address health inequalities. It is remarkable how little attention is given to the
importance of monitoring equity and use of services, although social class gradients in some
target areas (such as strokes) are well documented. The recommendations for diet, physical
activity and oral health take no account of the barriers to their adoption in older people with
lower incomes and reduced opportunities.
Older people have been relatively neglected in debates about health inequalities although they
have the greatest need for health care and an economic position that is the least favourable in the
population. We need better understanding of the ways in which social and personal environments
interact in late life to modify or augment health inequalities. We need to be proactive in the
development and evaluation of strategies to ensure that disadvantaged older people have equality
of access to services and initiatives to improve health and can benefit from scientific and
technical innovation. The brave new world for older people we are building now must be
inclusive. It may be the "End of Age" for some, but unfortunately it is not the end of inequality.
References
1. Breeze E, Sloggett A, Fletcher A. Socioeconomic status and transition in old age in
relation to limiting long-term illness measured at the 1991 Census. Results of the
Longitudinal Study. European Journal of Public Health. 1999; 9:265-270
2. Breeze E, Fletcher AE, Leon DA, Marmot MG, Clarke R, Shipley MJ. Do socioeconomic
disadvantages persist into old age? Self-reported morbidity in a 29 year follow-up of the
Whitehall Study. Am J Public Health 2001; 91:277-83
3. Grundy E, Glaser K. Socio-demographic differences in the onset and progression of
disability in early old age: a longitudinal study. Age Ageing 2000; 29:149-157
4. Breeze E, Sloggett A, Fletcher A.. Socioeconomic and demographic predictors of
mortality and institutional residence among middle-aged and older people: results from
the Longitudinal Study. J Epidemiol Community Health 1999;53:765-774
5. Hattersly L.Expectation of life by social class In; Drever F, Whitehead M eds. Health
Inequalities: decennial supplement. London. The Stationary Office. 1997
6. Melzer D, McWilliams B, Brayne C, Johnson T, Bond J. Socioeconomic status and the
expectation of disability in old age: estimates for England. J Epidemiol Community
Health 2000; 54: 286-292
7. Bone MR, Bebbington AC, Jagger C, Morgan K, Nicolaas G. Health Expectancy and its
uses. Department of Health 1995
8. Van der Pols JC, Thompson JR, Bates CJ, Prentice A, Finch S. Is he frequency of having
an eye test associated with socio-economic factors? A national cross sectional study in
British elderly. J Epidemiol Community Health 1999;53: 737-8
9. Social Services Inspectorate 1998. They look after their own don’t they? Inspection of
Community Care Services for Black and Ethnic Minority Older People.
10. O’Mullane D, Whelton H. Oral health of Irish adults. Dublin: Stationary Office 1992
11. Foresight Ageing Population Panel. Finance Task Force. Department of Trade & Industry
2000
12. Woodward A, Kawachi I. Why reduce health inequalities? J Epidemiol Community
Health 2000; 54:923-929
13. Acheson D Chairman: Independent Inquiry into Inequalities in Health. London: The
Stationary Office 1998
14. National Service Frameworks for Older People: www.doh.gov.uk/nsf/olderpeople.htm .
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Session 5. Equality and Diversity: Local and Global Perspectives
Paper 5.2
Equity and diversity: the global perspective
Solomon R Benatar
Introduction
We live in world characterised by major inequalities in wealth and therefore in health and
longevity.1,2 It is also a world in which economic, religious, cultural and ideological differences
are potential causes of conflict and violence. Life in a modern pluralistic world requires greater
tolerance of diversity and respect for different ways of life, but this is most difficult to achieve
when vast differences between people are the result of social injustice. The fact that we live in an
increasingly unjust world, in which some consider their lives to be of infinite value while
simultaneously according little value to the lives of billions of others, threatens us all. In an era
in which greater control of nature and prolongation of life could be achieved through advances in
biotechnology, social justice could either be enhanced or further eroded depending on how new
knowledge is used.
Equity and inequality
Equity is a concept that could transcend national borders and cultures. At least some inequalities
in wealth, health, longevity and disease are inevitable aspects of life and eliminating all
inequalities would not be possible. However, not all inequality is inequitable. The provision of
equal shares for equal needs is equitable - and so is the allocation of unequal shares for unequal
needs as long as proportionality is maintained. However, proportionality is difficult to assess
because of incommensurability. Inequity refers to inequalities considered to arise from
unfairness. In recent years appropriate attention has been focused on inequitable disparities in
health.3
Longevity has improved dramatically worldwide during this century. However, in recent years
this trend has been reversed in the poorest countries. For example, life expectancy in Canada is
80 years and rising, but in some countries in Africa it is 40 years and dropping. To a considerable
extent this is due to the recrudescence of infectious diseases that could have been controlled (for
example tuberculosis) but even more so as a result of emerging diseases including HIV/AIDS. A
number of adverse historical, political and economic forces have helped create the milieu
contributing to the rise and spread of these diseases. 4,5
The deteriorating state of health in many countries is further aggravated by widening economic
disparities in a globalising world driven by neo-liberal economic policies, increasing
consumption of mass-produced/highly-processed, western foods, the relentless promotion of
tobacco, and the spread of violence associated with trade in small arms and illicit drugs.6 With
regard to health care two facts illustrate inequity. First, that 87% of annual global health
expenditure is spent on the 16% of the world's population who bear 7% of the global burden of
disease (expressed in DALYs).7 Second, that of the US$56 billion spent on medical research
annually 90% is spent on diseases causing 10% of the global burden of disease.8 This is the
background against which to consider the ethics of focusing intense research on prolonging the
lives of some while neglecting the premature deaths of others.
How can inequity be reduced?
Inequalities could be reduced directly through changes in the health sector. For example the
Rockefeller Foundation has funded the Global Health Equity Initiative (GHEI) 9 based on the
idea that advocacy, capacity building and focus on specific product initiatives could effectively
harness the new sciences to counter health-product market failures. The project's goal is to
develop a robust new framework for health equity and a global network in which new leaders
can give a voice to the poor in a system striving to translate evidence of growing inequalities in
health into action to redress inequities.
In recent years the discourse on international health policy debates (promoted by the World
Health Organisation, the World Bank, other international institutions and individual researchers)
has shifted away from considerations of equity to a market driven efficiency perspective.10 This
is however, inappropriate and is being countered by an indirect approach to reducing inequity
that draws attention to the neo-liberal economic forces driving and perpetuating economic
inequity.5,6, 9,11,12, An approach that views the pursuit of health as a concept embedded in the
broader pursuit of social justice allows the "politics of need" to be to be addressed and promotes
use of health indicators as markers of the extent to which social justice has been achieved.12
Diversity
Many religious and cultural differences influence the way people live and may impact on health,
longevity and on how health care is perceived. However, it is necessary to recognise that much
of what is described as diversity or cultural variation is actually the result of poverty. As Paul
Farmer, a Boston physician, has noted in his courageous work in Haiti… "We saw oppression –
it looked…different from our comfortable lives; and so we called it ‘culture’. We came, we saw,
we misdiagnosed." 13 True diversity that enriches human life must be distinguished from
differences arising from social class or economic deprivation. There should be tolerance of
religious, cultural and ideological diversity but not of economic diversity when this has arisen
through social injustice.
How will new biological power be used?
The ‘language’ commonly used to promote hope that inequity could be diminished includes the
popular rhetoric of human rights, faith in scientific progress and confidence in the beneficial
effects of the invisible hand of the market. However, when speaking of these it is necessary to
consider whether we are speaking merely about the rights of the 1 billion people in the world
who, like those of us who attended this seminar, live well and will continue to benefit from
scientific progress, or whether we include the 4 billion people who live under wretched
conditions and for whom scientific progress, neo-liberal economic forces and the concept of
human rights have brought little advantage.14
It is necessary to ask this question for several reasons. Firstly, because the disparities between
lives within and between nations have been constantly widening over the past 30 years and there
is little evidence that this pattern will be reversed. Secondly, because the abuse of power has
been a significant force in contributing to wide disparities in human lives and to gross violations
of human rights. Thirdly, because there is little to suggest that the new power that will be
available in the biotechnology era will be used more wisely than other forms of power have been
used in the past.
While the Universal Declaration on the Human Genome (UDHG), the first universal instrument
in the field of biology, sets out to safeguard human rights, fundamental freedoms and the
freedom of research, it is clear that there are many obstacles to achieving the high ideals
expressed in this document. For example despite the statement in Article 4 that "the human
genome in its natural state shall not give rise to financial gains," and in Article 6 that "no one
shall be subjected to discrimination based on genetic characteristics..." there is already evidence
to suggest that these requirements will be ignored. Considerations of "who will offer what to
whom and at whose expense in health care in the USA" have been explored in detail and concern
expressed that genetic information will be used adversely to influence access to health care in a
nation with "a long and disturbing history of drawing sharp distinctions among [its] citizens on
the basis of race and ethnicity" as well as "a long tradition of belief in biological determinism." 15
Generation of massive amounts of genomics data is also driving megamergers by companies
seeking patents. The US patent and trademark office receives thousands of requests for patents
on nucleic acid sequences, and major biotechnology, chemical, pharmaceutical and agribusiness
companies are investing in molecular technologies.16 Techniques that are paving the way to
controlling farming and world food production by giant agrochemical companies may threaten
subsistence farmers in poor countries.
At least three key risks are associated with the new life science industry: the excessively high
valuation of some life science conglomerates could substantially influence the international stock
market; genetically engineered products may be widely used before they have been rigorously
tested; and developments in biotechnology are outstripping public understanding – thus eroding
both the trust and confidence of the public.16
During the Truth and Reconciliation Commission's investigations into biological warfare in
South Africa it was revealed that there had been programmes designed to investigate methods of
interfering with the ability of Africans to reproduce.17 This gives some credibility to more
widespread fear among the marginalised and oppressed of the world that knowledge gained from
the Human Genome Project and the Human Genome Diversity Project may be used for genocidal
purposes.
Shortcomings in the Human Rights approach
How will individual human rights be protected under these circumstances? More declarations
will not be sufficient. Against the background of power abuse in this century, it can be justifiably
concluded that human rights declarations, despite their best intentions, have not achieved as
much as desired to guarantee widespread access to even the most basic requirements for a decent
human existence. It therefore becomes necessary to ask whether in the era of biotechnology the
language of "Human Rights" alone can enable achievement of the respect we desire for all
individuals. In defence of the Human Rights approach as the single most powerful means of
promoting human well-being, it can be argued that failure to achieve human rights more widely
is not the result of an inadequate concept of human rights, but rather that the full potential of the
human rights approach has not been achieved because of simplistic or insincere use of the term,
and a lack of commitment by powerful nations to what a more wholesome concept of human
rights means and implies for them as well as for others. A coherent and comprehensive approach
to morality requires full consideration of the conceptual logic of rights language and co-relative
duties as an essential aspect of its moral grip.18
New perspectives on capitalism and democracy
Democracy, coupled to the free-market system, has been a widely recognised feature of progress
during the 20th century. Less widely recognised are the tensions between democracy and
capitalism. Modern democracy embraces demands for equal rights to a reasonable income,
access to education for children and adequate medical facilities at levels that cannot be met
without a radically different system of resource distribution from the one operative under the
current capitalist system. Such democratisation at the global level is not in the interest of
capitalists and democracy faces many crises in the modern world. 19
While it is now being cogently argued that the forces of economic globalisation are eroding
democracy, four reasons have been advanced for in support of a future democratic global
community: keeping under control dangers threatening a globalised world requires co-operation
and commitment of a maximum number of states and other institutions; the process of
globalisation is in need of control and orientation notably in its financial and economic facets –
more freedom does not mean more equity or equality; peace and co-operation will only prevail
over conflict and wars through shared values of greater scope and depth; and a set of reasons can
be advanced justifying the search for a global democratic community as the only morally and
politically acceptable form of social organization.20
As democratic market regimes have varied enormously geographically and historically four
criteria have also been offered for assessing the quality of a democracy: economic participation
of all in a wide range of productive activities; economic justice (fair rewards for activities);
economic morality (addressing the behaviour of all actors in the market economy - including
public authorities); and economic moderation – one of the most difficult virtues to achieve in a
market economy. Achieving better quality democracies is a challenge for all countries including
those with the hubris to consider themselves to be developed.20 These considerations reveal the
need to understand democracy as more than either mere procedural democracy (‘free and fair
elections’), or constitutional democracy (with its focus on legislated rights) and illustrate the
complexity of achieving the goals of a more comprehensive democracy (for example a
participatory democracy) even in developed nations.
Conclusions
Privileged people live within what J K Galbraith has called a "Culture of contentment and
entitlement," in which the lives of billions are marginalised and neglected.21 So, we must ask:
what will happen in the era of biotechnology to improve the lives of the poor? Will advances in
plant, animal or human genetic engineering and ageing research be of any benefit to them? Will
the sentiments expressed in the UDHR and the UDHG be respected? Is it possible that genetic
data from some groups of people will be exploited for economic benefit, or even more
horrifyingly, to develop genocidal weapons? Will major agrochemical companies enable cheaper
food to be produced or will the insistence on intellectual property rights and reduction in the
biological diversity of agricultural products disrupt the economies of poor nations and ensure
that food prices continue to rise and malnutrition be aggravated? If drugs for malaria and
tuberculosis have not been made available in poor countries is it likely that the poor will benefit
from advances in biotechnology? Honest answers are essential if we claim to be rational and
humane.
References
1. Wilkinson R. Unequal societies. Routledge, London 1996
2. Hobsbawn E. The age of extremes: a history of the world 1914-1991. Pantheon Books.
New York 1994.
3. Ethics, Equity and Health for all. Z Bankowski, J H Bryant, J Gallagher (eds) CIOMS
Geneva, 1997.
4. Garrett L. Return of the plague: new emerging diseases in a world out of balance. Fara,
Straus and Giroux. New York 1994.
5. Lee K, Zwi A B. A global political economy approach to AIDS: ideology, interests and
implications. New Political Economy 1996; 1 (3) 355-721
6. Benatar SR. Global disparities in health and human rights: a critical commentary. Amer J
Public Health 1998; 88: 295-300.
7. Iglehart J, American health services: expenditures. N Engl JMed.1999; 340:70-76.
8. Commission on Health Research for Development. "Health Research: Essential link to
equity in development." Oxford, Oxford University Press, 1990.
9. Challenging Inequities in Health: from ethics to action. Eds Evans T, Whitehead M,
Diderichsen F, Bhuiya A, Wirth M. Oxford University Press, Oxford, 2001.
10. Gilson L. In defence and pursuit of equity. Soc Sci Med 1999; 47: 1891-1896
11. Peter F, Evans T. Ethical dimensions of global health equity. In: Challenging Inequities
in Health: from ethics to action. Eds Evans T, Whitehead M, Diderichsen F, Bhuiya A,
Wirth M. Oxford University Press, Oxford, 2001.pp 24-32.
12. Robertson A. Critical reflections on the politics of need: implications for public health.
Soc Sci Med. 1998; 47: 1419-30.
13. Farmer P. Infections and inequalities: the modern plagues. University of California Press
1999.
14. Benatar S R. Human rights in the biotechnology era: a story of two lives and two worlds.
In: Peace, Justice and Freedom: human rights challenges in the new millennium. Bhatia
G S, O’Neil, J S, Gall G L, Bendin P O (Eds) University of Alberta Press, Edmonton,
2000.
15. Murray T H, Rothstein M A, Murray R F (Eds) The Human Genome Project and the
future of health care. University of Indiana Press. Bloomington 1996.
16. Enriquez J. Genomics and the world economy. Science, 1998; 281: 925-26.
17. Gould C, Folb P I. The South African chemical and biological warfare programme: an
overview. The Non-proliferation Review. Fall-Winter 2000. 10-23
18. Benatar S R. A perspective from Africa on human rights and genetic engineering. In: The
genetic revolution and human rights Burley J (Ed). Oxford University Press, 1999.
19. Gray J. False Dawn: the delusion of global capitalism. Granta, London,1998.
20. Building a world community: globalisation and the common good. Royal Danish
Ministry of Foreign Affairs. Copenhagen 2000.
21. Galbraith J K. The culture of contentment. Houghton Mifflin, Boston 1992.
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Session 5. Equality and Diversity: Local and Global Perspectives
Discussion Points from Session 5:

We need to be clear in our definitions of ageing and health in order to make statements
that can be measured. To take pragmatic steps forward big changes are needed. There is a
need for intervention studies and we must determine the factors that govern inequality.

Some information is known, for instance concerning healthy diets. Community cafes are
an example of an initiative that has produced good diets and community functioning, but
studies are very difficult to perform in these complex areas. For instance, advocacy can
be used to combat age discrimination, but outcomes are difficult to measure. Age
Concern has performed useful work on benefits and pensions and pension reform is
critical to health inequalities.

There are a number of associations to be worked out. For instance, a person’s skills used
at work might be associated with longer-term health and financial resources. It is true that
the playing field for older people is not level because so much depends on earlier life,
from the time of birth, but including education. There is a moral argument concerning
whether or not this imbalance should be redressed in old age.

Other societies are more equal and less disparate than in the UK. There is a danger in
professionalised advocacy, which might cause older people themselves to be
marginalised.

Ageing is even more important in Africa. There is a rising proportion of people over the
age of 65. The AIDS epidemic is killing people in their productive years. Grandparents
are needed to bring up children. The South African Government is spending 20% of its
wealth on debt repayment and only 10% on health care. Therefore, there is no hope of
addressing health care in this part of the world without dealing with the global problems
of inequality. But where is the forum for dealing with these global issues? Is it possible to
work co-operatively for change? Or does there need to be global regulation of
corporations? There is a need for co-operation given that about 50% of all the money
spent in the world on health is spent on only about 5% of the population. Guidelines are
needed for research and there are multiple routes for change. The recent case in South
Africa in which the pharmaceutical companies were beaten in the courts showed what is
possible.

We are perhaps overcome by waves of health. There is an extraordinary medicalisation in
society. There is an epidemic of dismay at the state of our bodies. People are anxious
about their fates. There is evermore public dread concerning ill-health.

We need to consider the abuse of older people. This need not be medicalised, but it is a
feature of those whose voices who are not heard and research is required into the extent
of abuse. At present it seems that elder abuse is not on the social policy agenda. The
concept is amorphous, involving as it might do financial, emotional or physical abuse.
But there is also the possibility that older people themselves abuse carers. There are
boundary issues, just as there are in child abuse, with distinctions needing to be made
between smacking and battering. Abuse also occurs in hospitals. Being left on a
commode is a form of abuse concerning which there can be a conspiracy of silence.

There is a limit to what we can do because resources are finite and shortage is natural. So
inevitably there is a question of prioritisation. But needs are also socially constructed.
Nowadays we tend to talk in terms of economic resources, but we might previously have
spoken about public goods and moral content. The change is political and we need
philosophical input into these debates.

We should note that not all hospital care is hi-tech. In stroke care, for instance, many
interventions are low-tech.

The perspective of the wider political economy can make us as individuals seem like
pawns, with a devaluation of human life and human worth. Consider, for instance, the
international flow of finance, in which 95% of the daily exchange of money is
speculation and only 5% is actually productive.

We need to engage with the voices of older people.

We have the previous experience of attempts to standardise biological work, which never
took off internationally, despite the World Health Organisation, until the U.S. adopted the
standards. People are anxious about exercises that just seem to be hot air and do not
produce change.

The idea that "might is right" seems to be diminishing possibly in favour of the moral
approach that "right is might". Some leading Americans are dissatisfied with America’s
international role and there are influential bodies that are currently discussing research in
developing countries. The role of trans-national corporations remains a concern.
Democracy is threatened by the global political economy with its lack of accountability.
We need globalisation from below, but there is always the danger of social unrest.

The recent guidance from the General Medical Council in the U.K. on patient
confidentiality might undermine some epidemiological research. Bioethics, as spawned
by the U.S.A., has pushed the notion of autonomy and neglected the notion of justice. We
need a balance between individual rights and the public good. Information for
epidemiological research can be anonymised. There is a need for a public approach but
there is also a need to distinguish between confidentiality and privacy. Confidentiality
should not be a problem. But privacy implies that there is a need for permission to gain
information and this will undermine research. The idea of privacy when pushed to its
extreme harms everybody. There is a good deal of rhetoric around the notion of
confidentiality. But many organisations and agencies have a right of access to
information and often this seems quite legitimate.

There is much talk about human rights, but there are limits to what can and should be
protected.

Informed consent, for instance, can be difficult to obtain from older people with
dementia. When we cannot gain valid consent we might have to settle for assent and
often carers are used as proxies, although strictly this does not have a basis in law.

In carrying out research with vulnerable groups who cannot consent, as in the case of
people with dementia, there are four things to bear in mind: 1) the research should be the
only way to get the information; 2) the research should be of value to the individual or to
the cohort; 3) there should be minimal harm; 4) there should be legitimate proxy consent.
We should note that the language of ethics tends to be inter-personal, with less emphasis
being placed on the societal. But there is also a need for public health ethics.

The media have a role to play in communicating to the public. Often the media love
confrontation and things that are newsworthy, but this does not help the understanding of
grey areas. We seem to have a hunger for titillation in the media. There are cultural
differences, with research seeming easier to perform in the U.S.A. than it is in the United
Kingdom. Ethics review boards are seen as an obstacle to be overcome and ethics is
sometimes not taken seriously in America. There is also poor training in research ethics
and there are attempts to dilute the regulation of research internationally. Generally
speaking ethics is less well developed than science, as seen in the vast disparity in
spending by the Wellcome Trust, for instance, on science over against ethics.
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Ageing pages constructed by Andrew J. Palmer Jan 2002