NICE says that patients' age should affect treatment
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7500.1102-a (Published 12 May 2005) Cite this as: BMJ 2005;330:1102All rapid responses
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Whilst the National Service Framework for Old People (2001) advised
that "NHS services will be provided, regardless of age, on the basis of
clinical need alone" (standard 1), NICE guidelines on Social Value
Judgements suggest that "where age is an indicator of benefit or risk, age
discrimination is appropriate" (Recommendation 6, point 3). These are
compatible if we assume that age CAN be used as a genuine indicator of
benefit or risk. We, as many doctors also do (paper in preparation), would
argue that age is an indicator for benefit because it is a proxy for some
other measure that is logically and causally connected to benefit and
risk. Age is a vicarious indicator of years left until death, it is a
vicarious indicator of frailty, and of comorbidity. Some might also take
it as a vicarious indicator of a patient's wishes, desires and
expectations.
Each of these factors might reasonably be taken into account when making
decisions, but are less obvious than age. This week NICE has encouraged
the use of age as a proxy. Why not encourage the direct use of these
reasonable
cues and discourage discriminatory practice.
Competing interests:
None declared
Competing interests: No competing interests
Why not ?
Clare makes an entirely reasonable analysis that AGE ( and sex or
race etc. ) are vicarious pointers to health risk ( or benefit). It should
be noted that any shift towards more accurate pointers would result in
even greater 'discrimination' - in the best sense of the word. And the
treated population would show major 'imbalances' in age, sex, etc.
She asks "Why not encourage the direct use of these reasonable cues
and discourage discriminatory practice." to which my answer is " because
the chosen parameters ( Age, sex, Race, or any other ) must be easy to
ascertain, and directly relevant discriminators of risk or benefit.".
It is misguided Political Correctness to avoid '..... discrimination
on grounds of Age, sex, race, gender, sexual orientation', unless it is
'unreasonable'.
The examples that sprang to my mind where:
1: The current practice of targetting WOMEN, aged 20-65 , for
cervical screening. Previously, GPs were paid to screen tri-parous women,
and those over 35. But parity and sexual-years were themselves proxies
for number of heterosexual partners, itself a proxy for 'viral exposure',
perhaps. A recall programme based on a questionnaire of sexual careers
would still be a proxy (albeit closer to the putative cause), and much
less likely to succeed.
2: Coronary Risk screening. The Framingham studies identified the
vicarious risks - Age, Sex, Smoking, Blood Pressure, Cholesterol, Diabetes
and LVH. When I set out to 'target' my patients, I began with the 'Age-
Sex Register'... which quickly halved my potential workload measuring the
other parameters, maximising cost-effectiveness.
To avoid age, sex, race discrimination, would we :-
- include men in a cervical screening programme ?
- screen children for coronary risk ?
- pursue Eskimos for sickle-cell trait ?
Surely not !
Sam Lewis, GP
Competing interests:
I am a 55 year old male of mixed race. My sexual history is private.
Competing interests: No competing interests