In the course of caring for elderly patients, legal and ethical concerns frequently arise, posing special challenges. Some common challenges involve determining competence, resolving conflicts among decision makers, determining the available treatment options (including with¬holding or withdrawing treatment), and anticipating future decisions and death. Various factors, including individual and societal determina¬tions of benefits, burdens, resource allocation, and cost containment, influence these ethical issues.
When weighing an ethical issue, the physician should think carefully before relying on age as a rationale for choosing a specific course of action. Generally, the approach to resolving ethical problems is the same for older people as it is for younger people because the two groups are more alike than different. However, differences in physiologic, psy¬chologic, and social reserves may place older people at greater risk of adverse outcomes.
In certain circumstances, age may be an adequate justification for a course of action—for instance, providing Medicare insurance to those over age 65 because they have a substantial need and few resources and because setting age as the criterion for enrollment was administratively easy. In other circumstances, age is merely a substitute for the real ra¬tionale for a decision. For example, a line of reasoning may be as fol¬lows: People over age 80 are often multiply handicapped; multiply handicapped people are usually poor surgical candidates; therefore, surgery for those over age 80 should be severely restricted. Clearly, the reason for restricting surgery is not age but physical condition. A ro¬bust 80-yr-old with strong physiologic, psychologic, and social reserves who could benefit from surgery should not be denied it because of age alone. In contrast, valid reasons may exist for advising a less healthy 80-yr-old not to undergo a potentially beneficial surgical procedure. These reasons should be clearly identified, then explained to the pa¬tient, who should understand and agree with them.