1. New interventions into human ageing and social justice Dr. phil. Hans-Joerg Ehni Institute for Ethics and History of Medicine, University of Tuebingen CWIPP Seminar, University of Sheffield, Jan 27 th 2010

2. Overview I. Biology of aging and new medical interventions II. A justice framework III. Predicted access IV. Application of the justice framework V. Ethical and legal Recommendations 2

3. Overview I. Why is there a promise of new interventions into aging? II. How can access to interventions into the aging process be evaluated in general from a perspective of justice? III. What would this access and its consequences look like if such interventions become available in the near future? IV. How can this predicted access be evaluated from the justice framework developed before? V. What shall be done? 3

4. Overview I. Why is there a promise of new interventions into aging? II. How can access to interventions into the aging process be evaluated in general from a perspective of justice? III. What would this access and its consequences look like if such interventions become available in the near future? IV. How can this predicted access be evaluated from the justice framework developed before? V. What shall be done? 4

5. Biology / Medicine Biology of Ageing: The ageing process is flexible and manipulable.

6. Biology / Medicine Possible new interventions into aging: - Personal genome, life style interventions and dietary/medical recommendations - Caloric restriction mimetics - Anti-Oxidants - Stem cell treatments - Gene therapy / Activated Gene expression - Telomerase - Hormone treatments 6

7. Overview I. Why is there a promise of new interventions into aging? II. How can access to interventions into the aging process be evaluated in general from a perspective of justice? III. What would this access and its consequences look like if such interventions become available in the near future? IV. How can this predicted access be evaluated from the justice framework developed before? V. What shall be done? 7

8. A justice framework Possible Approaches: 1.Foundations of Human rights / Social rights (Right to Health) 2.Analysis of relevant concepts in philosophical theories of justice (goods, distribution principles; John Rawls) 3.Normative relevance generally given to health / life expectancy / access to health care (Norman Daniels) 8

9. A justice framework Analysis of justice (according to Thomas Pogge): W is just, if X guarantees for Y the good Z according to the principle P. W: entity with „just“ or „unjust“ quality, e.g. health care system. X: who has an obligation (society, community of the insured). Y: towards whom (every member of society) Z: to provide what (goods relevant for justice). P: following a certain principle of distribution, e.g. equality. 9

10. A justice framework Relevant in the context of the evaluation of new medical interventions into aging: Which goods are generated and how is their relation to the concept of goods relevant for justice? According to which principles shall these goods be distributed? 10

11. A justice framework Relevant Goods: Goods which are all purpose means to realize individual freedom (Rawls, Dworkin, Sen, Nussbaum). E.g. John Rawls, Primary goods Preconditions of life-plans 1. Rights. 2. Freedom of movement and the choice of occupation 3. Powers and prerogatives of offices and positions of responsibility 4. Income and wealth 5. Social basis of self-respect 11

12. A justice framework Principles as the result of a fair process of agreement among the people concerned by a distribution of goods. E.g. John Rawls, Second Principle of Justice / Difference Principle. 12

13. A justice framework The Difference Principle: Social and economic inequalities are to be arranged so that: - offices and positions are open to everyone under conditions of free equality of opportunity. - they are of the greatest benefit to the least advantaged members of society. 13

14. A justice framework Establishing a relation between the different types of goods: Four levels of goods: 1. Goods relevant for justice 2. Goods relevant for just health care 3. Categories of goods created by age-related interventions. 4. Age-related interventions as goods. 14

15. A justice framework Four levels of goods: 15 Goods relevant for justice Goods relevant for just health care

16. A Justice framework Categories of goods possibly generated by medical interventions into the aging process: 1)Prevention or therapy of age-related diseases. 2)Improvement of well-being in relation to age- related changes. 3)Improvement of non-functional changes related to the aging process (wrinkled skin, grey hair) 4) Improvement of functional changes affected by age-related decline (cognition, sensual perception, mobility etc.). 5)Life time. 16

17. A Justice framework Establishing a relation: Several of these categories of goods are relevant for the realization of freedom (equality of opportunity, acquisition of primary goods). E.g. Category 4, Improvement of functional changes affected by age-related decline (cognition, sensual perception, mobility etc.): More opportunities for jobs and positions, positive correlation with income and wealth, higher self- respect. 17

18. Overview I. Why is there a promise of new interventions into aging? II. How can access to interventions into the aging process be evaluated in general from a perspective of justice? III. What would this access and its consequences look like if such interventions become available in the near future? IV. How can this predicted access be evaluated from the justice framework developed before? V. What shall be done? 18

19. Predicted access There will be limited access to this new type of medicine (according to the social distribution of wealth and income). 19

20. Predicted access Structural limits to access: 1. Not financed by public health insurance (inclusion criteria, further rationing due to scarce resources). 2. Economic reasons. Personal limits to access (contributing to capabilities) 1.Life styles and personal outcomes (obesity, smoking, unhealthy diets). 2.Not seeking access. 3.Lack of resources for longer life spans. 20

21. Overview I. Why is there a promise of new interventions into aging? II. How can access to interventions into the aging process be evaluated in general from a perspective of justice? III. What would this access and its consequences look like if such interventions become available in the near future? IV. How can this predicted access be evaluated from the justice framework developed before? V. What shall be done? 21

22. Evaluating the predicted access 1.Already existing inequalities in healthy life expectancy will further rise. 2.Equality of opportunity will decrease. 3.The situation of the worst off will deteriorate. 22

23. Evaluating the predicted access The goods generated by interventions into the ageing process are relevant for social justice (from a Rawlsian and a capability- perspective). A fair process regarding the principles of their distribution would presumably opt for principles leading to a prioritarian or egalitarian distribution under consideration of individual capabilites. 23

24. Overview I. Why is there a promise of new interventions into aging? II. How can access to interventions into the aging process be evaluated in general from a perspective of justice? III. What would this access and its consequences look like if such interventions become available in the near future? IV. How can this predicted access be evaluated from the justice framework developed before? V. What shall be done? 24

25. Ethical and legal recommendations 3 Options: 1. Prohibition, limits to access 2. Provision, widespread access 3. Prevision, setting priorities in research 25

26. Thank you! This work is supported in the context of an ERA-AGE post-doc-fellowship FLARE, Funded by the German Ministry of Education and Research 26