Three cardinal questions
Towards the end of his first ground-breaking work―the Critique of Pure Reason, the German philosopher Immanuel Kant stated that the substantive kernel of any philosophical endeavour, whether speculative or practical, boils down to resolving either of the following three fundamental questions: “what can I know?”, “what ought I to do?”, and “what may I hope for?”. The first question is principally epistemic, in the sense that it examines the nature, scope and justification of knowledge under which can operate any particular field of inquiry. Answers to the question “what ought I to do?” settles practical considerations that pertain to the nature and the proper motive for a course of action that one is either permitted, obligated, or for that matter forbidden, to do.
That is precisely where thin concepts such as ‘right and wrong’, ‘good and bad’, ‘permissible and impermissible’, and ‘respect and violation’, or substantively thick concepts such as fairness, justice, kindness, generosity, selfishness, and impartiality find their proper reflective platform. And thirdly, Kant reasoned that “what ought I to do?” engenders a deeper question of meaning and significance of acting as one ought―a philosophical investigation that is both speculative and practical all at once.
Most philosophical problems are composite in nature for they include a mix of each of the three questions, their difference is mainly in emphasis. Similarly, we must recognise that the aforementioned WHO documents on
Healthy Ageing cut across the three Kantian lines of philosophical questioning. However, for the sake of simplicity, we can describe what each document principally seeks to investigate in terms of one of the three philosophical questions that each document predominantly seeks to answer. The
World report on ageing and health systematically captures
what we can and do know about ‘ageing and health’, and in so doing further articulates the challenges presented by the rapidity with which the world’s population is ageing. Drawing from a body of knowledge emanating from multidisciplinary research on ageing and health, the report identifies key areas of immediate concern “and builds a strategic framework for taking public-health action, with a menu of practical next steps that can be adopted for use in countries at all levels of economic development.” [
14]
The
Global Strategy and action plan on ageing and health, on the other hand, makes explicit the principles that underpin an adequate national strategy and plan of action necessary for fostering
Healthy Ageing. To fulfil its vision for realising a world in which everyone can live a long and healthy life (‘what may we hope for’), and focusing on five strategic objectives, the
Strategy seeks to implement 5 years plan of action (2016–2020) for ensuring a Decade of Healthy Ageing from 2020 to 2030 at which point “functional ability is fostered across the life course and where older people experience equal rights and opportunities and can live lives free from age-based discrimination.” [
15] The underlying principles are: human rights, equity, equality and non-discrimination on the basis of age, gender equality, and inter-generational solidarity. Whereas the key areas for national actions that the
Strategy sets out to accomplish include establishing national frameworks towards
Healthy Ageing, strengthening national capacities to formulate evidence-based policy, and combating ageism.
In a nutshell, what may we hope to achieve is the highest achievable health for all through the scheme of Universal Health Coverage and optimize healthy ageing. What ought we to do? A generic reply could be, ensuring a fair and equitable path to UHC that is inclusive of older persons. And that is precisely what the third WHO document ― the final Report of the WHO Consultative Group on Equity and Universal Health Coverage ― seeks to establish. It recognises that critical choices are to be made as to which services to prioritise, whom to include first, and how to shift from out-of-pocket payments towards a system of prepayment that does not render getting needed and effective services conditional upon the person’s ability to pay. Consequently, the report identifies three areas of strategic action: (1) categorising services into priority classes―guided by principles of cost-effectiveness, priority to the worse off and financial risk protection; (2) expanding coverage for high-priority services to everyone while devising fair and equitable ways of eliminating out-of-pocket payments; and (3) ensuring that disadvantaged groups are not left behind.
The path to UHC is an arduous journey that involves continuous improvement, since each country experiences some form of resource or structural constraint, requiring prioritisation and trade-offs at every step of the way. In moving towards a progressive realisation, some trade-offs are therefore unavoidable. With that in mind, the Report on Equity and UHC identifies five particular scenarios in which trade-offs are generally unacceptable. The first three unacceptable trade-offs correlate to the first strategic action and its attendant principles, whereas the other two correspond to each of the remaining two strategic actions.
In contrast to the first two WHO documents, the final Report on Equity and UHC is construed in general terms and thus makes no specific reference to older adults. But substantively the latter hits the right notes for it concerns itself with the topic of fairness and trade-offs on the path to UHC. In addition, the Report identified five generic impermissible trade-offs that national policies should dispense with on the path to UHC. Since our specific concern is identifying which of the legitimate concerns for the health and well-being of older adults are impermissible for trade-offs, that poses some methodological problems. In settling our specific concern for older adults, two possible analytic approaches can be taken.
One approach may be to identify unacceptable trade-offs attendant upon the health of older persons on the grounds of fairness (and the overlapping concern for equity), and then fine-tune the list so that it aligns with the ethical reasoning that underpins the five specific trade-offs that the Report on Equity and UHC declared unacceptable. Even though the report on Equity and UHC addresses health policy issues affecting societies across the board, one may argue that we can identify those issues and concerns that uniquely affect older persons on similar, equity-based, grounds. Such analytic route runs the risk of being procrustean, in the sense that it might compel us to stretch the normative scope of fairness under which are to be nested all fundamental moral concerns relating to the health and well-being of older persons. And, on the flip side, this approach appears to neglect some impermissible trade-offs that are grounded on moral principles that do not in the first instance reflect equity or fairness.
Or we could proceed in the other direction: begin by independently formulating valid ethical and moral standards that warrant stringent normative constraints against trade-offs on the health and well-being of older persons, then look to see if we find compelling the concrete convictions about unacceptable trade-offs itemised in the report on equity and UHC. This potentially permits the deployment of basic ethical and moral judgments, that are nested on principles other than the requirement of fairness, in defence of the claim that some of the specific rights to health and well-being of older persons are impermissible for trade-offs. This appears to be a promising approach for discovering some compelling moral reasons for protecting the claims of older persons, claims that do not figure in existing policy documents; but the judgements thus established need to be oriented towards policy making.
The required moral framework should therefore pursue an integrated approach that allows for examining the specific concern for fairness within the broader moral reasoning about what we owe to older persons.