Epilogue: confronting the age of aging.

INTRODUCTION The planning sciences, by definition, bring a coherent, systematic framework for identifying potential problems at various levels of aggregation and specifying the implications of alternative actions responsive to emerging issues. Most often planning proceeds sequentially by first describing the current state of affairs, that is, specifying the relevant factors and their interrelationships; second, drawing out the shortand long-range implications of the status quo, often with the use of static-component or other mathematical projection models; third, isolating the nature of the emerging issue area in terms of its endogeneous and exogeneous components, as well as of the timing and magnitude of impact; fourth, evaluating alternative actions intended to remedy the problem altogether or distribute its impact over a longer time frame or additional sectors; fifth, considering strategies of implementation for the chosen course of action. Thus, the planning sciences encompass both decision-making and managerial concerns. Notably absent from this typology, however, is a stage in which planners and policy makers explicitly consider what should be done in response to a specific problem. This last assessment will surely be interpreted by some as the naive understanding of nonplanners, since alternative actions are typically evaluated against some sorts of cost-benefit criteria. Yet this calculus can easily mask value considerations that are implicit in the assignment of an impact to the “cost” or “benefit” column. In evaluating the feasibility of expanded home care benefits under Medicare or Medicaid, “service substitution” may be counted either as an unwelcome consequence of this policy change, hence a “cost”, or as a desirable outcome, that is, a “benefit” to the extent that service substitution delays institutional placement [ 1, 21. Perhaps in no other policy area is the need for an explicit reckoning of the value basis of decision making more urgent than in anticipating the historically unique and dramatic aging of our population. Several emerging societal trends intersect to support this judgment. The first is the sheer force of the demographic imperative, that is, rapid growth in the population 65 years of age and over, peaking in about 2020, and the even more dramatic growth of the 85 and over segment beginning in 2040. Second, these demographic changes would be of little more than academic interest were it not for the fact that nearly all production and consumption functions are highly age related, especially the consumption of health care services. Those 65 and over disproportionately consume nearly all kinds of such services [3]. Although this age group accounts for but 11% of the total population, the elderly account for at least 30% of all hospital bed days per year, over 80% of all nursing home residents and 25% of all prescriptions written annually [4, 51. Thus, accommodating a rapidly aging population inevitably raises issues of allocating increasing shares of our collective resources to a subgroup that is a decided numerical minority. Such issues are further complicated by the third relevant social trend: the dwindling number of nonelderly adults who have traditionally supported both young and old dependents through a variety of intergenerational transfer mechanisms. Shortly after the turn of the century changes in the relative size of the middle-aged and elderly segments of our population will require working-age adults to increase their aggregate service and/or financial contributions to the elderly. Underlying most of the issues associated with an aging population, then, is not simply how to provide for the elderly (in particular, their financial and health service needs), but how to do so in a manner that is “just” and “equitable” for all generations. In short, the overarching issue of resource allocation invariably subsumes, albeit implicitly, concerns for notions of distributive justice. Before attempting to explore these concerns for justice and equity, we begin by clarifying the policyvalue-ethics nexus alluded to above. In subsequent sections we present a framework for systematically identifying ethical components of policy decisions and for integrating such considerations into decision making. We illustrate the application of this framework with respect to a specific allocation issue. Finally, we propose mechanisms for ethical decision making compatible with the pluralistic nature of contemporary society.