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e Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine,
2022, XX, 1–12
hps://doi.org/10.1093/jmp/jhac038
Advance access publication 15 December 2022
Article
© e Author(s) 2022. Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc. All rights
reserved. For permissions, please e-mail: journals.permissions@oup.com
Recognizing the Diverse Faces of Later Life:
Old Age as a Category of Intersectional
Analysis in Medical Ethics
MERLEWEßEL*
Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
MARKSCHWEDA
Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
*Address correspondence to: Merle Weßel, PhD, Carl von Ossietzky University of Oldenburg, Ammerländer Heerstraße 114-
118, 26129 Oldenburg, Germany. E-mail: merle.wessel@uni-oldenburg.de
Public and academic medical ethics debates surrounding justice and age discrimination oen proceed from
a problematic understanding of old age that ignores the diversity of older people. is article introduces the
feminist perspective of intersectionality to medical ethical debates on aging and old age in order to analyze the
structural discrimination of older people in medicine and health care. While current intersectional approaches
in this eld focus on race, gender, and sexuality, we thus set out to introduce aging and old age as an additional
category that is becoming more relevant in the context of longer life expectancies and increasing population
aging. We analyze three exemplary cases on the individual, institutional, and public health level, and argue
that considering the intersections of old age with other social categories helps to accommodate the diverse
identities of older people and detect inequality and structural discrimination.
KEYWORDS: aging, discrimination, justice, intersectionality, old age
I. INTRODUCTION
Debates on justice and age discrimination in medicine and health care date back to the 1980s. In
particular, proposals of age-based rationing of health care resources were intensively discussed. While
some brought forward arguments in favor of “seing limits” to health care for the old (Callahan,
1987), others criticized these measures as a form of ageism, the discrimination of people due to their
(advanced) age (Rivlin, 1995). However, in these debates the “old” were treated as a homogeneous
collective. As such, the nuances and complexities of how age-based rationing could aect dierent
groups of older people in dierent ways were largely overlooked. For example, as women on average
have a longer life expectancy than men, they would be put at a much greater disadvantage through
rationing policies (Jecker, 1991; Miller, 2005). ese disadvantages can multiply further when addi-
tional social dierences are taken into consideration, for example, with regard to race, class, or disa-
bility (Rueda, 2021).
is example is signicant for contemporary medical ethical discussions surrounding aging and
old age. First, it illustrates that aging and old age are more visible and are consequently receiving
more aention in medicine and health care, in part due to increasing life expectancies and demo-
graphic aging. Age-related medical problems and medical ethical conicts occur more frequently
and take a more prominent place in the public and academic debates as the world’s population ages.
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2 • Merle Weßel and Mark Schweda
Consequently, aging and old age are moving to the center of contemporary medical ethics and bioeth-
ics discourses (e.g., Schermer and Pinxten, 2013; Schweda et al., 2017; Ehni et al., 2018; Wareham,
2018).
At the same time, the face of old age itself is changing. Today, the social and cultural diversity of
older people is more visible than in previous generations. us, the prevailing tendency to subsume
them under stereotypical notions of old age, rather than treat them as individuals with multifaceted,
complex, and diverse identities, is increasingly problematic. e lack of aention paid to the complex
interplay of age and other social categories, such as gender, race, class, or sexual orientation can lead to
the structural discrimination of groups of older people in medicine and health care. It may put them
at risk of receiving inadequate medical treatment, impede their access to and utilization of health care
services, as well as reinforcing social inequalities and their detrimental eects on health in old age.
erefore, older people’s diverse identities and living situations must be represented in a more ade-
quate way in medicine and health care services, and in the accompanying ethical debates. Being Black,
gay, or from a migrant background maers and needs to be recognized in older people’s interaction
with doctors, health care services, and health policies (Weßel, 2022; Weßel et al., 2021).
We suggest that medical ethical debates on aging and old age need a deeper engagement with the
feminist framework of intersectionality in order to improve the critical analysis of the discrimination
of older people in medicine and health care. Coming out of Black feminist theory, the concept of inter-
sectionality explains that structural discrimination cannot be identied adequately through one-axis
only analysis, but instead through the intersection of various social categories. Recent medical ethical
debates have adopted the approach to recognize diversity and detect structural discrimination with
regard to race, gender, and sexuality (Bredström, 2006; Hankivsky and Christoersen, 2008; Reisen
et al., 2013; Sangaramoorthy, Jamison, and Dyer, 2017; Beaudreau, ompson, and Pachana, 2019;
Cheema, Meagher, and Sharp, 2019; Wilson et al., 2019; Weßel, 2022; Faissner et al., 2022).
Taking up this debate, we argue that old age should be included as an additional and important
social category of intersectional analysis in medical ethics. To this end, we rst critically review recent
discussions on intersectionality in medical ethics. We then introduce old age as an additional category
of analysis, employing three exemplary cases that can highlight particular kinds of structural discrimi-
nation of older people: (a) the role of gender and sexual orientation in the diagnosis and treatment of
HIV/AIDs in old age, (b) the relevance of migration experience and ethnicity for older people’s access
to health care, and (c) dierences in health and life expectancy at the intersection of old age, gender,
and class. In discussing these examples, we demonstrate the analytical potential of an intersectional
approach to old age as a social category in medical ethics. In doing so, we make a twofold contribution
to ongoing academic debates. On the one hand, we enhance medical ethical theorizing by exploring
the relevance of intersectional analysis to detect structural discrimination of older people with diverse
identities and highlight their marginalization in medicine and health care. On the other hand, we
enrich debates on intersectionality by illuminating the ethical signicance of (old) age as a social cat-
egory in the context of justice in medicine and health care.
II. INTERSECTIONALITY AS AN ANALYTICAL TOOL IN MEDICAL
ETHICS
Intersectionality has been described as the “greatest contribution to women’s studies” (McCall, 2005,
1771). Kimberlé Crenshaw’s (1989, 1990) seminal work on the intersection of race and gender was
signicant in several ways. First, it identied the structural discrimination against Black women in
the United States as a specic form of discrimination not previously considered in sexism and rac-
ism debates. Second, it included the criticism of the long-standing feminist failure to recognize Black
women as a distinct group of women who fall out of the purview of traditional (i.e., white) feminism.
Understanding how their gender intersects with their race necessitates a dierent approach to femi-
nism (Davis, 2008, 68).
Crenshaw’s (1989) work opened up feminist discourses to the discussion of how various social
categories, such as class, age, disability, sexuality, education, religion, and many more shape both the
identity and the discrimination of women, which cannot be adequately addressed under the general
label of feminism. It contributed to the recognition within feminist theory that gender is not the only
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Recognizing the Diverse Faces of Later Life • 3
category that makes a woman (Davis, 2008, 68). However, despite its starting point in feminist theory,
intersectionality not only is about women and female experiences as such, but rather concerns the
critical engagement with social categories, such as gender, class, race, and power structures that all
people face (Davis, 2008). For example, Black males in the United States have the lowest life expec-
tancy at birth in comparison to white males, Black females and white females (Cruikshank, 2013).
Here the intersection of race (Black) and gender (male) creates a structural discrimination that aects
the life expectancy of Black men and becomes only visible when we combine the categories of gender
and race.
Intersectionality is not a xed system but rather a theoretical framework for open-ended analyses
of overlapping conicts and dynamics of dierent inequalities (Cho, Crenshaw, and McCall, 2013,
788). e general perspective is deconstructive: by analyzing and exposing the power structures that
constitute social categories, the intersectional approach questions their assumed self-evidence and
universality, and demonstrates how their intersection manifests multidimensional discrimination. It
provides an understanding of how and why categories, such as gender, race, or class, are understood
and described in the way they are and what power structures have led to this understanding. In this
sense, intersectionality is both analytical and at the same time emancipatory. On the one hand, the
deconstructive perspective deepens the understanding of social categories and their entanglement
with power structures. On the other hand, the insight into the construction of social categories within
existing power structures and the resulting structural discrimination critiques unjust power structures
and can lead to increased justice and equity.
Together with Leslie McCall and Sumi Cho, Crenshaw developed the approach into a set of
“engagements of intersectionality” (2013, 785). ey suggest three dimensions for the engagement
with the concept: rst, as a framework for investigating intersectional dynamics. Here the framework
is used to adapt intersectionality to a variety of context-specic inquiries, for example the interaction
of race, gender, and class, the constitution of regulatory regimes of identity, or the development of
alternatives to anti-discrimination laws. e aim is to create agendas that help to overcome the one-
axis perspective and advance multi-axial understandings of inequalities (Cho, Crenshaw and McCall,
2013, 785). e second engagement concerns the use of intersectionality as a theoretical and method-
ological paradigm. e debate focuses on how intersectionality as a theory and methodology has been
developed, adopted, and adapted within dierent disciplines, and reects on the advantages and limi-
tations of intersectionality. e core of the debate is if intersectionality indeed has a subject and, if so,
whether the subject is static or uid in terms of identity, geography, or temporality (Cho, Crenshaw,
and McCall, 2013, 785–6). e third engagement is as the basis of political interventions employing
an intersectional lens that reects on reality and the practice of intersectional critique and interven-
tion. Since intersectionality is not only considered an academic endeavor, it requires an engagement
with practice and the community; the reection of the transportation of scholarly discourse to the
community is a crucial aspect of any intersectional research (Cho, Crenshaw, and McCall, 2013, 786).
Taken together, the three engagements represent a heuristic tool, a “paern of knowledge production”
that schematically reects the uidity among the three dimensions and suggests a stronger embed-
dedness of practical applications of intersectionality in a theoretical framework (Cho, Crenshaw, and
McCall, 2013, 786).
Intersectionality has been used as a framework for investigating disparities in public health (Weber
and Parra-Medina, 2003; Rogers and Kelly, 2011; Hankivsky, 2012; Betancourt et al., 2016). Yet,
medical ethics only recently adopted the concept to address power structures and structural discrim-
ination in clinical medicine and health care. us, a target article in the American Journal of Bioethics
(AJOB) demands a conceptual intersectional framework for clinical medicine (Wilson et al., 2019).
It argues that intersectionality oers useful insights into the clinical environment because it draws
aention to complex identities and the structural practices that shape them. Additionally, it acknowl-
edges the multifaceted dierences that inuence doctor–patient relationships and require a reframing
of previous notions about the hierarchical, one-dimensional relationship between doctor and patient
(Wilson et al., 2019, 8–9). e article focuses on the individual level of the doctor–patient relation-
ship and appeals to the responsibility of the doctors to examine their own biases to avoid discrimina-
tory social and structural practices in clinical medicine (Wilson et al., 2019). Another piece highlights
the importance of recognizing oppression in medicine through an intersectional analysis. It goes even
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4 • Merle Weßel and Mark Schweda
further and suggests concrete methodological steps to implement intersectionality as a tool for seing
a research agenda, selecting research methods and analyzing empirical ndings (Cheema, Meagher,
and Sharp, 2019, 1). Indeed, in accordance with the “empirical turn” (Borry, Schotsmans, and
Dierickx, 2005) in medical ethics, intersectionality favors a strong boom-up approach. It starts from
the complexity of real-life problems to explore discrimination and structural inequality. With a strong
qualitative take, intersectionality provides the opportunity to contribute to empirical approaches in
medical ethics by focusing on individual experience. It helps explore complex power relations and
structural discrimination in medicine and health care and supports their ethical analysis and critique.
III. OLD AGE AS A SOCIAL CATEGORY—HETEROGENIZATION OF
OLDER PEOPLE IN MEDICAL DISCOURSE
Medical practices, health care services and institutions, as well as medical ethical theory are still not
suciently prepared for the full diversity of old age. Aging seems to strip people of their multiple char-
acteristics and social roles and ultimately leaves only the homogenizing category of old age (Victor,
2013). Biased one-dimensional images and structures regarding aging prevail, frequently emphasizing
negative aspects of functional decline and decit, dependency and limitation (Nelson, 2004). is
leads to a discrepancy between the multifaceted lived reality of older people and the limited roles and
options reserved for them (Riley, Kahn, and Foner, 1994).
Yet, intersectionality has thus far neglected the discussion of old age as a relevant social category
in power relations and structural discrimination as well. Initially, the focus was foremost on intersec-
tions of race and gender, later on class. Only recently, other social categories like sexuality or disabil-
ity emerged in the analysis (e.g., Moodley and Graham, 2015; Denninger, 2020; Lomann, 2020).
However, age, especially old age, and the related vulnerabilities in the context of power, structural
inequality, and injustice have not been discussed systematically from the point of view of intersec-
tionality. It is important to draw aention to old age as a social category for an intersectional analy-
sis in general, but also in the medical context in particular where older people represent the largest
age cohort of patients and, arguably, constitute an especially vulnerable group whose complexity and
diversity is oen overlooked (Eilenberger, Halsema, and Slatman, 2019; Weßel, 2022).
In the following section, we provide three cases in which old age can intersect with other social
categories, such as gender, sexuality, ethnicity, or class, in order to demonstrate the diversity of old age
and highlight the moral problems and conicts that can arise when the focus is on only one aspect, or
when other equally important dimensions are disregarded. We analyze these examples with the help
of the categorical complexity approach by McCall (2005). is approach explains how to understand
and to use social categories, such as gender, class, or age, in order to explore intersectionality in social
life (McCall, 2005, 1773). e categorical complexity is divided in three approaches: the intercate-
gorical, the intracategorical, and the anticategorical approach. e intercategorical approach analyzes
the complexity among several social groups, which means it does not focus on one intersection but
compares several intersections with the help of the same question. For example, it explores how the
experience of injustice in health care diers in several groups such as Black men, Hispanic men, and
white men. e systematic comparison of several social groups is deployed with the help of existing
social categories to reveal the relationships of inequality among them (McCall, 2005). e intracat-
egorical approach acknowledges the existence of stable social categories but takes a critical stance
toward them. e focus is on one social group which is set at an intersection and crosses the bounda-
ries of traditional groups. e group is analyzed with multiple questions to understand the complexity
of their lived experience (McCall, 2005, 1773–4). e intersection of race and gender can be studied
to analyze, for instance, where Black women experience injustice and how it varies in dierent con-
texts, such as health care and access to social services.
For our subsequent analysis, we adopt the third, anticategorical approach. is approach decon-
structs dierent social categories and analyzes them separately to grasp the complexity of intersec-
tionality. e anticategorical approach rejects the idea of stable categories and studies the process of
categorization to capture the complexity of lived experience. It suggests that social categories should
not simply be looked at separately, but the process of categorization, as well as the exclusion and hier-
archy of categories, must be taken into account. us, to study the intersection of race and gender of
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Recognizing the Diverse Faces of Later Life • 5
Black women, rst the categories race and gender are analyzed separately to understand how discrimi-
nation based on race or gender is constructed, for example, through social structures or political insti-
tutions, as well as historical experience. In the context of race, the experience of Black men is the main
focus and the very dierent experience of Black women is oen not seen, since it is not the same. For
example, police violence against Black people very oen only discusses male victims and marginalizes
the experience of police violence against Black women, as suggested by the #sayhername-movement
(Crenshaw et al., 2015). Aerwards, the structure of the intersection is analyzed to demonstrate how
the categories of gender and race make visible what was previously excluded by looking only at one
single category. is is necessary because inequality does not appear homogeneously within a sin-
gle category but indeed as a relationship between social categories. Under certain circumstances, the
interaction may create inequalities that do not appear in others, so that social categories are not xed
in their relationships but uid in relation to their context.
Conducting an intersectional anticategorical analysis of the three examples, we illustrate the theo-
retical, as well as practical potential of intersectional approaches to detect inequity and discrimination,
and provide a beer understanding of diversity and its eects in medicine, health care, and medical
ethics. e rst example indicates how the intersection of old age, gender, and sexual orientation inu-
ences the individual experience of diagnosis and treatment of older, heterosexual women with HIV/
AIDS. e second example shows how migration experience and ethnicity creates inequality in old
age on the institutional level in the context of access to health care services. e third example focuses
on how class and gender intersect with old age on the structural and public health level and inuence
health and mortality in old age. Taken together, these three cases aim to illustrate that an intersectional
perspective is relevant at all three levels of medicine and health care and that it can help to detect
structural discrimination that cannot be tackled by a one-dimensional understanding of inequality
and injustice in this eld.
Old Age, Gender, and Sexual Orientation in the Context of HIV/AIDS
From early on, the implicit standard addressee of preventive, diagnostic, and therapeutic measures for
HIV/AIDS was the young homosexual male. is is problematic because it can perpetuate stigmatiz-
ing stereotypes and discrimination; queer men might be seen exclusively in connection with HIV/
AIDS. However, it can also have the eect that the health care needs and risks of other less prominent
risk groups are systematically overlooked by doctors and health care professionals, possibly resulting
in the underdiagnosis and undertreatment of conditions, as well as the ensuing detrimental health
eects. Indeed, when it comes to HIV/AIDS awareness, the invisible and neglected counterpart of
young gay men seems to be older heterosexual women.
Of the 38,793 new HIV diagnoses in the United States in 2017, 6,640 were “people over 50,” which
amounts to about 17 percent of all new infections. However, these diagnoses are simply subsumed
under a broad and ultimately indenite age category and are not registered in as much detail as in
other age groups, e.g., the group between 25 and 29 years (Centre for Disease Control and Protection,
2018). is appears symptomatic for a more general age bias in the context of HIV/AIDS. us,
although heterosexual women over 50 years are among the groups with the highest new infection
rates, they are oen neglected in the prevention, diagnosis, and therapy of HIV/AIDS.
is may point to structural discrimination at the intersection of age, gender, and sexual orienta-
tion on the individual level of the doctor–patient interaction. Although the diagnosis rates among
older heterosexual women are already signicant, the undetected numbers might be even higher. e
(early) detection of an HIV infection is based strongly on the doctors’ identication and interpreta-
tion of the symptoms and the way they connect these symptoms with the possible HIV infection.
However, HIV/AIDS is a stigmatized disease, especially among older patients. It is associated with
drug use, sex work, and homosexuality. Even if patients are aware of their symptoms or suspect that
they might have contracted HIV, they may not be open about their sexual behavior to the doctor
(Shen et al., 2019).
Additionally, health care professionals oen do not consider sexually transmied diseases and
HIV/AIDS when older patients present symptoms. Many doctors show a bias in the context of sexual
activity of older patients. Routine HIV tests are not common in this age group and not oered on a
regular basis by health care providers. HIV symptoms in older patients are sometimes mistaken for
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6 • Merle Weßel and Mark Schweda
signs of age-related diseases like dementia, which can lead to a delay of testing and diagnosis (Nguyen
and Holodniy, 2008, 456). With sexual activity, age apparently functions as an intersecting discrimi-
nating factor because neither sexual orientation nor sexual activity is usually on the radar in the exam-
ination and diagnosis process, which can lead to late detections of sexually transmied diseases and
cause health hazards for the patient, as well as additional costs for the health care system due to unnec-
essary testing (Beaudreau, ompson, and Pachana, 2019, 135; Shen et al., 2019). is illustrates that
age can be a relative category. In other areas, people over 50 would not automatically be considered
old. Yet, in the context of sexual health, old age is already ascribed when people, especially women,
are not in the reproductive phase anymore. is is not related to medical facts but to an ageist social
understanding of sexuality that does not correlate with the real-life experience of older people (Bauer,
McAulie, and Nay, 2007; Nguyen and Holodniy, 2008).
us, for older heterosexual women, the intersection of the social categories of gender (being a
woman), age (being over 50 years of age), and sexual orientation (heterosexual contacts) can contrib-
ute to an increased risk of infection with and underdiagnosis of HIV (Nguyen and Holodniy, 2008).
When only regarding one of these categories, such as looking at gender or sexual orientation, this
special-risk group of older heterosexual women could not be detected. An intersectional approach
thus helps to create visibility for people who remain invisible in one-dimensional considerations of
HIV infections that only take into account gender or sexual orientation. is way, it may help improve
clinical diagnosis itself (Cho, 2019). Further research needs to show whether stronger dierentia-
tion of the various risk groups might indeed lead to segregation and thus undermine solidarity within
the collective of people aected with HIV/AIDS. Nevertheless, the intersectional perspective draws
aention to ethical issues of justice and discrimination of older, heterosexual women in the individual
doctor–patient relationship in the rst place. Without recognizing the intersection of gender, sexual
orientation, and age, it would not be possible to capture the multilayer stigmatization and discrimina-
tion that especially older, heterosexual women face in the context of HIV/AIDS. e ensuing health
risks due to late detection and insucient treatment may occur as a new medical and ethical issue in
an increasingly older society.
Old Age, Migration, and Ethnicity in the Context of Health Service Access
At the institutional level, the intersection of old age and migration experience constitutes a special
situation for older people and their access to and accessibility for health care services. Several stud-
ies show that the migration process, as well as the situation of a migrant, increases the vulnerability
for mental and physical disease, and at the same time decreases access to health care services (Igel,
Brähler, and Grande, 2010; Lood et al., 2014; Yeboah, 2017). Aging contributes to the marginali-
zation of health-related issues at the intersection of migration status, ethnicity, and age. While older
migrants face the same health problems as other older people, they are also confronted with addi-
tional stressors due to their migration experience and ethnic background, which are not adequately
addressed in oered health care services (Silveira and Allebeck, 2001). Considering only the age of
the person would not acknowledge these stressors. However, focusing solely on the migration experi-
ence would exclude the special needs of older people. Only by taking an intersectional approach and
considering old age, migration experience, and ethnicity, can the specic needs and possible discrim-
inations constituted by the intersection be detected.
An ethnographic study shows that mental health among older people in the Somali community in
East London is aected by their migration experience (Silveira and Allebeck, 2001, 309). Migration
usually took place at an earlier stage in their lives but still overshadows their experience of aging and
may cause mental health issues, such as depression (Silveira and Allebeck, 2001). A lack of family
support, language and cultural dierences, as well as the oen-futile desire to return to their home
country contribute to the development of depression in old age (Silveira and Allebeck, 2001, 310). At
the same time, their insucient integration into society or the community leads to a lack of access to
health care services. As migrants, they are oen not aware of the services oered to older people and
do not receive help when needed. Information services fail to cater to them due to language issues or
limited social interaction with the community, for example, places where older people usually meet
and interact, like the church or the community center (Silveira and Allebeck, 2001). ese factors
accumulate over time and are accompanied by health issues like physical illness caused by a heavy
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Recognizing the Diverse Faces of Later Life • 7
workload and an unhealthy lifestyle, for example, smoking, bad nutrition, or failing to consult a doc-
tor, which create health hazards for older migrants (Silveira and Allebeck, 2001, 314).
Language plays a particularly signicant role for the health of older migrants and deserves more
detailed consideration. Alizadeh-Khoei, Mathews, and Hossain (2011) investigate the access to
health care services of older Iranian-born immigrants in Sydney, Australia. ey argue that especially
immigrants with lile or no English skills experience problems regarding access to and use of health
care services (Alizadeh-Khoei, Mathews, and Hossain, 2011). First, a lack of language skills leads to
poverty, dependency, and solitude, which have negative eects on the mental and physical health of
the older people. Second, it creates cultural and social barriers to seek and access health care services
(Alizadeh-Khoei, Mathews, and Hossain, 2011). Finally, language can be a marker of racism in health
care. eir migration status per se does not lead to discrimination, but the fact that their rst language
is not English. Migrants from English-speaking countries would not experience the same exclusion.
Additionally, stigma around the foreign language might occur. Western or Northern European lan-
guages carry less stigma than Eastern European or Middle Eastern languages. Additionally, related
racist prejudice toward the ethnic group speaking this language contributes to discrimination and
exclusion (Yoo, Gee, and Takeuchi, 2009). As a result, older migrants oen experience higher levels
of mental distress, more limited physical function, lower well-being, but a greater need for help and
assistance with activities of daily living. However, they are much less likely to use aged care services
because of language barriers and a lack of awareness due to both societal segregation and discrimi-
nation than older people without a migration experience (Alizadeh-Khoei, Mathews, and Hossain,
2011).
Intersectionality is a helpful tool to identify the special situation of the multiple marginalization
of older migrants in the context of health care institutions. Usually, they have been marginalized
before due to their migration status and maybe their specic ethnic group. However, growing older
adds another layer of marginalization to their life experience. ey nd themselves confronted with
a new intersection based on their migration status, their ethnicity, and their old age. e care ser-
vices provided for older people in general are not adapted to the specic reality of older migrants
(Alizadeh-Khoei, Mathews, and Hossain, 2011). e resulting multiplication of marginalization is an
ethical problem needing to be addressed. e injustice and discrimination faced by migrants all their
lives are aggravated when growing old, while the combination of racism and ageism is not adequately
addressed in medical ethical discussions thus far. With the help of an intersectional lens that draws
aention to the multidimensional eects of aging and its challenges, multi-categorical ethical prob-
lems can be made visible. However, two questions could be raised. First, one might doubt whether
health care services are relevant for older migrants, because their needs may be catered for within their
ethnic communities. is intersectional analysis only focuses on the ocial services but does not
pay aention to informal care within communities which might be just as helpful for older migrants.
Second, the inclusion of the categories in the analysis might impose certain limits on our understand-
ing. While ethnicity and age are considered, one could ask whether gender might be equally impor-
tant, since the experience of male and female older migrants could be very dierent. is touches
on the methodological issue of category selection within an intersectional approach, which we tried
to address with the use of the anticategorical approach. Despite these possible limitations, using an
intersectional approach to identify the multidimensional marginalization of older migrants can help
to provide health care services and suitable information tailored to their needs. Improved inclusion
could lead to fewer health issues related to their migration status and increase their overall well-being,
while decreasing the time and resources spent on solving health issues that could be more easily iden-
tied with awareness of their diverse identities.
Old Age, Class, and Gender in the Context of Health and Life Expectancy
Aging is usually viewed as a process of progressive decline and degeneration. Indeed, with increasing
chronological age, the burden of diseases and impairments rises signicantly (Niccoli and Partridge,
2012). As a result, older people are frequently singled out as the demographic group with the greatest
demand and highest per-capita costs for health care (Dall et al., 2013). e rise of their absolute num-
ber as well as relative proportion in the course of population aging is oen depicted as a vital challenge
for health care systems, and this regularly provokes suggestions of age-based rationing of health care
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8 • Merle Weßel and Mark Schweda
resources (Lamm and Blank, 2005). At closer inspection, however, it turns out that this close associa-
tion of aging and health impairments is anything but an objective natural principle. As a maer of fact,
class as well as gender factor heavily into the age-related dierences in health.
Socioeconomic factors have a tremendous impact on health. us, people from the lowest stratum
are also those with the poorest health and lowest life expectancy (Bartley, 2016). ey are more fre-
quently and earlier aected by typical age-associated diseases such as diabetes, cancer, cardiovascular
diseases, and dementia. In the United States, the dierence in average life expectancy between the
highest and the lowest stratum amounts to approximately ten years (Chey et al., 2016). Even in
European welfare states, the dierence is still signicant (Zaninoo et al., 2016). Explanations for this
nexus range from income, living and working conditions (e.g., nutrition, environmental stress, and
pollution) over educational and lifestyle factors (e.g., health literacy and behavior) to access to and
utilization of medicine and health care (e.g., insurance status, service quality, participation in preven-
tion) (Bartley, 2016). It is also important to recognize that the detrimental impacts of class on a per-
son’s health status show a tendency to accumulate over the life course, thus intensifying in the process
of aging and culminating in old age (Willson, Shuey, and Elder, 2007).
At the same time, gender also plays an important part at the intersection of old age and class. In gen-
eral, women have a considerably higher average life expectancy than men in nearly all Western indus-
trialized societies. us, although women with a lower socioeconomic status may have a poorer health
and life expectancy in old age than more privileged women, men with the same socioeconomic back-
ground still die earlier (Cruikshank, 2013). Male individuals, especially from underprivileged classes,
frequently show more unhealthy lifestyles in terms of eating habits, physical inactivity, and alcohol,
tobacco, or drug consumption (Gareld, Isacco, and Rogers, 2008). In addition, they are more prone
to injury and premature death due to dangerous driving behavior, violent conicts, and a higher suicide
rate (Möller-Leimkühler, 2003). ey oen have more strenuous jobs and riskier working conditions.
At the same time, underprivileged men show much less health awareness, health literacy, and health
behavior. ey rarely seek professional help for physical or mental health impairments and make less
use of regular checkups and preventive measures (Galdas, Cheater, and Marshall, 2005).
e intersection of age, class, and gender is even more critical as the inuence of social and cultural
factors and framework conditions is frequently denied, resulting in a naturalization of the connection
of aging and decreases in health and functionality. By eliminating the socioeconomic and sociocul-
tural aspects from the picture, aging appears as a natural process of degeneration, and old age accord-
ingly as an inevitable state of burden and impairment, rather than an indicator of social grievances
(Calasanti and King, 2015). In the context of medicine and health care, this negative, decit-oriented
view can lead to the stigmatization and discrimination of older people and may therefore unfold as a
self-fullling prophecy. For example, qualitative studies indicate that long-standing decit-oriented
ideas of aging and old age inuence health care professionals’ aitudes towards older patients as well
as their treatment decisions (Ubachs-Moust, 2011; Kydd and Fleming, 2015). One consequence can
be premature claims of medical futility that result in the exclusion of older patients from necessary and
useful medical services.
Indeed, there are signs that in the UK doctors have a tendency not to resuscitate older persons
(Ebrahim, 2000). Studies in the United States found that the proportion of recommended health
care that patients actually received declined with their age (Asch et al., 2006) and that there is
implicit age-related rationing on several levels (Kapp, 2002). An analysis of hospital discharge data in
Germany revealed that older patients receive less costly treatment for the same diseases than younger
ones, indicating that old age constitutes an implicit criterion for the allocation of health care resources
at the bedside (Brockmann, 2002). ere is evidence that this kind of ageism aects underprivileged
groups even harder, since they oen lack the capabilities and resources to resist, or to compensate for
or push back against disregard and discrimination by health care professionals and authorities (Walsh
et al., 2010). While there may be legitimate arguments for age rationing as such, this could eectively
create considerable disadvantages regarding health and health care at the intersection of age, gender,
and class (Grzanka and Brian, 2019).
e interaction of ageism, socioeconomic disadvantage, and gender discrimination in the context
of health and health care cannot be detected, and its social causes are not investigated thoroughly or
critically reected upon without an intersectional perspective. It helps to deconstruct the allegedly
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Recognizing the Diverse Faces of Later Life • 9
natural connection between old age and poor health and to uncover the multiple discrimination of
underprivileged older people whose socioeconomically caused health impairments slowly accumu-
late over their life course only to be shrugged o as acceptable symptoms of biological senescence
and objective indicators for medical futility or criteria for health care rationing in old age. Yet, the
question can be raised whether this is really an intersection or rather the result of an additive process
in which class and gender are added to the category of age in a hierarchical way. It is important to ask
this question in any intersectional analysis, since the risk of using the social categories in an additive or
hierarchical way contradicts the idea of the equal situating of social categories that are required for an
intersectional analysis. Nevertheless, the point of view of intersectionality sensitizes us to dierences
that run along the demarcation lines of specic social groups that would otherwise fall through the
conceptual and normative matrix of public health research and practice, as well as of prevalent ethical
discussions of justice in health care and society at large. At the same time, the example shows that
the structural discrimination involved in intersectionality must be conceptualized as a relational and
contextual phenomenon. Under certain circumstances and in certain respects, otherwise privileged
groups such as men can be considered as disadvantaged and discriminated. In fact, individuals and
groups can be marginalized and disadvantaged in a certain context and respect and at the same time are
perhaps privileged in another. Intersectional perspectives are particularly suited to disentangle these
dierent respects, levels, and contexts of discrimination, which stay invisible and cannot be described
by examining only one social category or one dimension, such as sexism or racism. ey can thus
contribute to the development of more targeted and eective public health research and intervention
strategies tackling the multifactorial set of conditions behind persistent disparities in health and life
expectancy (Bauer, 2014).
IV. CONCLUSION
e three cases discussed illustrate how the diversity of older people is oen overlooked in medicine
and health care as well as in the accompanying medical ethical discourses. Older people are oen still
seen as a homogeneous group subsumed under the sweeping category of old age. is does not do
justice to the fact that they have diverse identities reected in multiple categories, just like younger
people. e older migrant does not stop having a migration experience when he or she grows old. Old
age constitutes a new intersection that enriches and complicates the previous identity of a person,
rather than replacing or erasing it. Yet, until now, medicine and medical ethics tend to overlook the
diversity of older people on the individual and the institutional, as well as on the public health level.
Intersectionality can be useful as a theoretical framework and a methodological approach to detect
and analyze the diversity of older people in the context of medicine and health care. By helping to dis-
cover vulnerabilities and oppression, it also contributes to the discourse about ethical problems in the
context of old age. It makes visible the complexity of injustice, multidimensional marginalization, and
discrimination of older people on the individual, the institutional, and public health level. Yet, inter-
sectionality is not a completely developed framework and still poses several challenges (Muntaner
and Augustinavicius, 2019). One challenge is the perceived open-endedness of social categories and
intersections of social categories. is can pose epistemic problems when it dissolves manifest struc-
tural discrimination into an innitely complex kaleidoscope of individual dierences. Moreover, it can
also have ethically and politically problematic consequences, since it may undermine a sense of group
solidarity and the ensuing empowering eects. Methodological approaches, like the one by McCall
(2005) used in this article, help to tackle this criticism by systematizing the analytical approach and
focusing on the detection on discrimination and only then in a second step on the resulting identities.
Furthermore, we still need an in-depth understanding of the specicities of old age in the context
of intersectionality. Indeed, age may be a special category in several respects. First, it has an inherently
temporal dimension. Regardless of its varying sociocultural constructions, age always has to do with
states and processes in time. erefore, old age is the result of the process of aging and is connected
to a particular temporal segment at the end of the individual life course. It is in this sense an intrinsi-
cally transitional and terminable social position. We were not always old, and we will not always stay
old. At the same time, old age is also a generally foreseeable and accessible social position. It aects
almost every one of us sooner or later. All people inevitably traverse the dierent life stages and one
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10 • Merle Weßel and Mark Schweda
day reach old age and experience the perspective of becoming and being old (unless they die young).
e signicance of these specicities of old age for intersectionality deserves further exploration and
discussion. us, the temporal dynamic of aging seems to interact with other social categories in an
amplifying way so that the eects of discrimination in the respective domains (e.g., gender or class)
accumulate over the life course and culminate in old age. Furthermore, the temporal accessibility of
aging and old age may have important implications for the mechanisms and consequences of “other-
ing” and discrimination in this context, since the demarcation line between the “self” and “the other”
is bound to be traversed over time. Indeed, age-based discrimination has been called a kind of “preju-
dice against our future selves” (Nelson, 2004).
Eventually, the ethical adaptation and conceptualization of intersectionality in the context of old
age can also contribute to a mutual clarication and theoretical advancement of both medical ethics
and feminist theory. From the point of view of moral philosophy, intersectionality is ultimately about
(in-)justice. It is useful to detect and criticize complex forms of multiple structural discrimination. A
more detailed ethical explication and discussion of this underlying concern with (in-)justice can help
to clarify and strengthen the normative foundations and thus the legitimacy and persuasiveness of
critical intersectional analyzes.
Conversely, the perspective of intersectionality can at the same time help to elucidate certain con-
ceptual and methodological problems of the ethical discussion of justice. Indeed, the original image
of the intersection of multiple trac routes seems to capture and substantiate a central tension at the
very heart of the idea of justice. On the one hand, it implies a fundamental opposition against any
arbitrary unequal treatment and thus a strong commitment to the idea of generalizable principles
and criteria, for example, of resource allocation in medicine and health care. On the other hand, it
also requires an uncompromising consideration for the specicities of each single case and thus for
the irreducibly individual perspective and experience of those aected and the complexities of their
social, cultural, and economic situatedness.
ACKNOWLEDGEMENT
e authors thank Cai Weaver for his thorough and helpful language editing.
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