Abstract Because pneumococcal disease is a major problem among the elderly, pneumococcal polysaccharide vaccination is widely promoted. However, Sir William Osler called pneumonia the friend of the aged, leading to an ethical discussion. Mortality from pneumonia is higher with increasing degrees of underlying illness, outweighing the age effect. Although some symptoms are less common in the elderly, other symptoms are not and the duration may be longer. Problematic criteria for limiting pneumococcal polysaccharide vaccination include age, social value, and quality of life. Recommended criteria for limiting vaccination include autonomous patient refusal, imminent death, and lack of medical benefit, as would be seen in hospice cases.