Scenario #1: Your husband of forty years has been diagnosed with bladder cancer. The doctor reports that the protocol would normally be surgery to remove the tumor, followed by a series of chemotherapy treatments over a period of four months. However, the doctor says, your spouse is ineligible for the treatment because he is sixty-seven years old.
Scenario #2: Just at the time your wife is hospitalized following a stroke, you learn that the National Institutes of Health has announced that it is discontinuing funding for research on cerebrovascular disease. Medical staff at the hospital indicate that once your wife is stable, she will be transferred to a nursing facility where she will remain until her death. She will be kept comfortable, but she is ineligible for medical treatment because she is seventy-two years old.
Scenario #3: While traveling home by car following a vacation, your spouse begins to complain of severe chest pain. You exit the interstate at the next city and find a hospital emergency room where the doctors confirm that your spouse is having a heart attack, but that there is nothing that can be done except to keep him comfortable because he is eighty years old.
Your first response to these scenarios is probably incomprehension: They are so bizarre as to be unbelievable. But if that’s your first response, it should not be your only response. Each of these scenarios has one thing in common: health care rationing among older adults. This is not a new item of discussion in our national debate on strategies to achieve health care reform. It has been around for some time, and as the discussions in the administration and congress get more and more substantive, and legislation begins to emerge, it will appear as an item “on the table.”
According to the Centers for Disease Control, “the United States is on the brink of a longevity revolution. By 2030, the proportion of the U.S. population aged 65 and older will double to about 71 million older adults, or one in every five Americans. The far-reaching implications of the increasing number of older Americans and their growing diversity will include unprecedented demands on public health, aging services, and the nation’s health care system.”
An article by Clair Andre and Manuel Valasquez entitled “Age-Based Health Care Rationing” published by Markkula Center for Applied Ethics at Santa Clara University indicates that “the fastest growing age group is the population aged 80 and over—the very segment of the population that tends to require expensive and intensive medical care. The projected demands from a growing elderly population on a health care system that is already taxed to the breaking point, together with continual advances and availability of expensive life-extending technology, have led to troubling questions about society’s ability to meet future health care demands, and to the increased tolerance of proposals for rationing.”
The inability to provide the necessary funding to assure the continuation and quality of such care, is a very real problem that does not admit of easy solution. But limiting health care accessibility by age is not a solution.
In 1987, a bioethicist by the name of Daniel Callahan published a book entitled Setting Limits: Medical Goals in an Aging Society (Simon and Schuster; Georgetown University Press, 2003) in which he argued that changing conceptions of medicine, changing conceptions of health, and changing conceptions of life have all melded in such a way that it has become necessary for us as a society to ask: “[W]hat are we to count as good health, or a decent life span, or bodily wholeness? Those are increasingly hard questions to answer, primarily because medical progress constantly pushes forward the frontiers of health. It invites, indeed seduces, us to set an ever-higher standard of what should count as ‘good health’ and an acceptable life span” (16).
When growing numbers of baby-boomers in the U.S. begin to draw on Medicare, this will bring stress to the government’s capacity to fund that program. Reform of national health care may include a combination of government and private insurers, but that in itself does not answer the questions of either quality of life (“good health”) or health care costs (“affordability”). People like Callahan are arguing that there are limits to what can be achieved in gaining economic control of health care by cutting costs. The other side of the equation needs to be given serious attention, and for Callahan that means reducing benefits. More particularly, it means reducing benefits among those health care consumers who are the greatest in number relative to the greatest expenditures: older adults!
Rationing health care is being presented as an economic issue. In an interview with New York Times columnist Jane Gross in November, 2008, Callahan observed, “The biggest change in the last 40 years is that there are no limits. There’s nothing we can’t do for an old person, and there’s a lot of pressure to do it. This is considered progress, and it’s considered ageism to be skeptical. But we can’t go on this way. It’s unaffordable. And it’s the hardest dilemma in our society because there’s no good way to deal with it other than saying ‘no.’”
When people—politicians or citizens—talk about the “business” of health care, the discussion inevitably revolves around costs and profit-and-loss issues. Much of the funding for medical research is provided by government agencies, undertaken in major academic research centers where the advance in medical technology and knowledge is correlated with the capacity to receive massive amounts of funding. At the same time, health care consumers are very conscious of escalating costs, diminished or limited coverage, expanding deductibles, and excluded conditions. The number of uninsured in this country grows daily, but the figure tossed around is generally in the vicinity of 47 million people.
It is, at some level, comprehensible to talk about health care reform with dollars-and-cents associated with the discussion; after all, from one angle, health care is a business, indeed a very big business in our economy. According to the Physicians for a National Health Program, a group advocating for a single payer health care system, the U.S. spends $7,129 per capita on health care, twice as much as any other industrialized nation. Yet no one is arguing that our health care system is adequate to the health care needs of our citizens and permanent residents. PNHP notes that 31¢ of every health care dollar spent is related to medical paperwork and administrative costs of the health care insurance industry.
It is not unreasonable to ask about the social benefits of health care expenditures. Those who argue for health care rationing contend that resources spent on prolonging elder life can more usefully be spent on maximizing the health of younger persons. In this argument, there is a judgment implied that the older one gets, the less value one’s life holds for the society. The value of a life for a marriage or family or community is mitigated by the larger social value of investing limited resources in younger people who, after all, are presumably working and contributing to the expansion of the nation’s economy.
In his remarks on May 13, 2009, following various meetings with representatives from insurance and drug companies, physicians and hospitals, and labor unions as well as leaders of some major corporations, President Obama reiterated that “our health care system is broken. It’s unsustainable for families, for businesses. It is unsustainable for the federal government and state governments.” He pressed on to say that any health care reform bill that comes to him from Congress must reflect three basic principles: “first, that the rising cost of health care has to be brought down; second, that Americans have to be able to choose their own doctor and their own plan; and third, all Americans have to have quality, affordable health care.” Certainly there is much in this statement that can be assuring to people; health care costs must be lower, patients get to choose their own doctors, and care must be available to everyone.
But sustainability is a forward-looking issue, a future-tense problem that grows out of the current situation. Even the president himself has indicated that, looking out into the future, health care could very well entail a form of rationing. For this he has been taken to task in editorials and among advocacy organizations (see Washington Times, LifeNews, Wall Street Journal, and even the Libertarian Party).
But he nonetheless speaks and thinks about health care reform and sustainability as one who has experienced the issues related to health care rationing. In an interview with David Leonhardt published in the New York Times Magazine on April 28, 2009, the president commented on the health of his grandmother just before her death, noting that she had been diagnosed with terminal cancer and shortly thereafter fell and broke her hip, quite possibly as a result of a mild stroke. When given the choice of having hip replacement surgery in her current condition, including a weak heart that might not survive the surgery, she elected to have the hip replacement surgery. The president noted this situation posed “a very difficult question.” But he also went on to say that “[i]f somebody told me that my grandmother couldn’t have a hip replacement and she had to lie there in misery in the waning days of her life—that would be pretty upsetting.”
In this same interview, the president acknowledged that one responsible role the government could play in health care is to be “an honest broker [between patients and providers] in assessing and evaluating treatment options,” especially with regard to Medicare and Medicaid “where the taxpayers are footing the bill and we have an obligation to get those costs under control.” To my ears, this sounds like having the government making or influencing health care decisions for those whose personal and financial circumstances do not allow them the prerogative to make their own health care decisions.
But presenting the issues in the discussion about health care reform only in terms of the economics is in its own way profoundly misleading. Denying medical care that may extend life because of the age threshold of a patient strikes me as profoundly immoral. I am not unaware of the complexity of the issue. When ten people need a heart transplant, and there is only one heart available, someone other than the patient decides who gets it, and there is a set of guidelines by which such decisions can be made.
Medical personnel are constantly advising families on the likelihood of various outcomes when medical technology is used to continue life for a patient under certain circumstances. And as we learned with Terry Schiavo, family and loved ones fight amongst themselves over when to terminate medical care. But no matter how heart-rending the Schiavo situation was, it nevertheless underscores a basic point, namely that individuals and families have the freedom and the right to make health-care decisions, including decisions about end-of-life care. In the absence of a living will, individuals who are unable or incapacitated to make these decisions for themselves should have the legal protection that allows their families to make these decisions.
Unlike Callahan and others who are arguing for rationing, I think depriving a person of health care decision-making is tantamount to depriving an individual of life, liberty and property (one’s health, self-determination and decision-making capacity are in my mind a Lockean form of property), and such deprivation is not defensible on economic grounds. Nor is it defensible to suggest that older adults with reasonably good physical and mental health could be exceptions to the rationing rule. Who gets to define what is “good physical and mental health” in this exception to policy?
How we as a society regard our older adults and treat the chronically and terminally ill among us is not just a social or a medical issue, but also a moral issue. The same can be said for rationing health care for older adults. It is therefore somewhat troubling to read the president’s comments on this in his interview with David Leonhardt. He stated: “I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels. And that’s part of why you have to have some independent group that can give you guidance. It’s not determinative, but I think has to be able to give you some guidance. And that’s part of what I suspect you’ll see emerging out of the various health care conversations that are taking place on the Hill right now.”
I for one welcome the president’s call to have a conversation about these matters, but this should not be a conversation taking place only among politicians, physicians, researchers, technologists, business people and ethicists as the president suggests. Health care consumers need also to be present in the discussion, including those who are in the demographic that would be affected most by a policy of rationing, i.e., older adults.
From the perspective of the Christian faith, I regard all of life as a gift from God. I also hold that each human being is a unique instance of the extraordinary generosity of the Life-Giving Spirit. Society has neither the obligation nor the right to terminate a life. Rather the obligation laid upon society and each individual therein is to care for, tend to, and love all those who inhabit the shared space of this creation. It is the duty of each to assure and work for the well-being of all, and to enhance and preserve the freedom, dignity and honor of each and every one. As the conditions that make it possible for all to flourish, the common good is not “common” if it excludes our oldest and wisest from participating in our society in ways that honor their contribution.
Health is not a commodity, bought and sold on the open market. Health care is not a product that is driven by production and sales, profit and loss, economies of scale and market competition. Health and health care are fundamental human rights, and any attempt to encroach on these rights by policy or criteria that relegate some to disproportionate treatment or denial of treatment is at its base unconscionable and immoral.
Health care reform is needed in the U.S. Deeply entrenched interests are resistant to proposals for reform, and many others are equally vocal in pressing for one or another of several policy solutions. Whatever emerges on the other end of the debate and legislative process must satisfy two concerns that I hold as non-negotiable: affordable and accessible health care must be available to all, and health care rationing for any group must be categorically rejected.
I do agree with Callahan on one thing. As a diverse society, we do indeed need to discuss the meaning of health and illness, the quality and value of life, the meaning and significance of aging, and yes, even the aims and goals of medicine. If this conversation is blended with the one President Obama is calling for, than perhaps some other alternative to health care rationing can be found that meets his three criteria and is sustainable and universal in scope.