As advances in the investigation and treatment of cancer progress, there is good evidence indicating a significant disparity in the treatment of older cancer patients.1,2 National Cancer Intelligence Network data indicate that rates of certain definitive treatments, such as surgery and radiotherapy, are less likely to occur in older patients.3,4 This chapter aims to outline the ethical dilemmas of 'suitability' and 'appropriateness' in the treatment of older cancer patients. The process of consent, in accordance with the Mental Capacity Act (MCA) 2005,5 is defined, with clear explanations given of capacity assessment to help guide the treating team when attempting best interest decisions.
Ethics in the older patient
There are four overarching principles in medical ethics: (1) non-maleficence, (2) beneficence, (3) respect for autonomy and (4) justice, but these can often appear to conflict in approaches to older cancer patients.
Ageing undeniably affects patient fitness but not necessarily the appropriateness of treatment, and these are too often conflated: 'suitability' and age are not equivalent. All medical treatments may do harm, and some may kill. This is no more evident than in chemoradiation, where the burden of treatment may be too toxic for the ageing physiology. Efforts have been made to support oncological decision making with measures such as the Karnofsky and Eastern Cooperative Oncology Group performance status; however, evidence indicates significant interobserver variability. Therefore, many elderly care physicians have championed the development of Comprehensive Geriatric Assessment (CGA), which encompasses a wider range of domains to assess appropriateness and suitability for treatment:
For full information on the use of CGA in cancer care please see the International Society of Geriatric Oncology practice guideline.6
In the current paradigm of NHS cancer services, weighing the possible benefits against the known risks of treatment rests with the multidisciplinary team (MDT). When the risks are almost certain, and the benefits are unlikely, the balance is easily weighed against treatment. But too often in the older cancer patient beneficence may be considered simply as removing the 'risk of harm' caused by actual treatment. The morality of palliating pain and suffering is undermined if appropriate investigations and treatment are withheld by virtue of age. Prolonging a poor quality of life is unlikely to benefit the patient, but rarely is this distinction made in younger patients, where radical treatments are frequently justified. By providing informed consent, and respecting autonomy, it is the older cancer patient who can ultimately assign his or her own weight to the risks and benefits of treatment.
In the UK, a capacitous patient always has the right to refuse treatment, but there is no such right to ...