Age-Based Rationing in the Allocation of Health Care

Objectives: This article seeks to review debates about age-based rationing in health care. Methods: The article identifies four different levels (or types) of decision-making in health resource allocation—societal, strategic, programmatic, and clinical— and assesses how the issues of rationing vary in relation to each level. Results: The article concludes that rationing is least defensible at the clinical level, where it is also most covert. The role of rationing at other levels is more defensible when based on grounds of cost-effectiveness rather than equity. The article emphasizes the impor-tance of fairness in health allocation and suggests that efficiency criteria need to be considered in that context. Discussion: The article suggests that rationing is most problematic where it is least overt. This raises further questions about how rationing can be made more explicit at different levels of decision making. Should age be taken into account as a criterion for allocating resources in health care? This question has acquired increasing salience, espe-cially in the United Kingdom and the United States, as resource limits in health care have become more stringent. Callahan (1987) has called for a shift in resource allocation away from the elderly in favor of the younger generation. This has stimulated a lively debate about the ethi-cal arguments for and against age-based rationing in health services. In this changing climate, clinicians and health managers are increas-ingly encouraged to make explicit judgements about how services should be distributed