There is a special feature of the health and welfare problems of the elderly population that sets them off from the other domestic problems of the developed countries of the world. They combine two difficult elements, complex enough when taken alone but much more so when combined. There is, on the one hand, the economic problem of finding ways to make adequate provision for the needs of the old, barely met with full adequacy in any country and full of greater threats in the future. There is also, on the other hand, the extraordinary delicacy needed to conduct serious public debate on the issues. At a time when many countries still struggle against a pervasive ageism, trying to open up new possibilities for elderly people and to foster new attitudes, it is exceedingly painful to contemplate further economic constraints, even rationing, to meet the impending economic problems.

Different scenarios for an ageing society presume different approaches to the meaning of old age. One scenario anticipates a Prolongation of Morbidity, where quality of life concerns might permit active euthanasia or suicide as a means of saving money. Those who believe in a Compression of Morbidity opt for health promotion to delay morbidity in favour of productive ageing. Optimists look to a scenario of Lifespan Extension, where scarce health resources are not expended for incremental gains in life expectancy but rather for basic research to postpone or eliminate ageing. Finally, those who emphasize Voluntary Acceptance of Limits identify the meaning of old age with voluntary acceptance of finitude, where claims of future generations might limit longevity for any one generation. Thus, contrasting meanings such as quality of life, productive ageing, indefinite survival and voluntary limits entail very different consequences for the allocation of scarce resources across age-groups and among sub-groups of the elderly population.

Therapies to save or sustain the lives of elderly patients are sometimes used when they can bring little benefit, and sometimes denied because of age to patients who could benefit. Selection for treatment should depend on balancing probable benefits and burdens for the patient and on the patient's preferences. Burdens include those of the treatment itself, the risk of complications and of extending life of poor quality. Factors to consider when deciding are illustrated by reference to intensive care, surgery, dialysis, cardiopulmonary resuscitation and tube feeding.

The growing number of oldest old has increased the need for social services and medical care in many countries during the last decade. These needs have been met with various strategies to make more effective and efficient use of resources. In many ways these changes have been successful, but at the same time the amount of success correlates negatively to the potential for further gains. That is, when the slack in the system has been drawn in, it is doubtful whether further gains can be made with these strategies. So what can be done if the public resources are restricted and needs continue to increase? Adequate solutions will require a wide perspective encompassing all the various services needed by elderly people. Decisions made in one sector necessarily have repercussions in other service areas. It is also essential to recognize the differences between sectors; guidelines and strategies developed within the medical sector are not always applicable in the social services sector. With Sweden as an example, the organizational and administrative changes that have occurred during the last decades are presented along with arguments for extending the discussion of strategies and priorities to include all kinds of service to the elderly population.

Daniel Callahan has maintained that a common understanding of the meaning of old age and the proper role of old people in society is a prerequisite for decisions on the distribution of health-care resources to the elderly. The call for such a common understanding is traced to the writings of Thomas Cole and Harry Moody. A discussion of their ideas is followed by a philosophical analysis of communitarian accounts of meaning and the good life in general. It is concluded that viable interpretations of the meaning of old age should comply with the values of liberal individualism. Meaning should be localised less at the level of global ideas and images and more at the level of local and heterogeneous practices. The practice of distributing health-care resources cannot and should not be regulated by communitarian interpretations of the value of old age. It would seem to be sufficiently infused by liberal individualist interpretations of meaning and justice.

The demographic revolution has caused turmoil in public policy, leading governments to scale down their commitments to the old, more in panic than in thoughtful response. At the same time, significant changes in family patterns have placed at risk the inter-generational support older people might have expected. Together these structural shifts have stimulated a new debate about the obligations one generation has to another. This essay attempts to bring together the several discrete debates about demography, family and the generational contract. In juxtaposing gerontological evidence and discussions with those about moral order and the state of the social contract in ‘post-modern’ society; it reaffirms the need for personal and social solidarity as the foundation for trust and reciprocity between generations.