Hostname: page-component-8448b6f56d-cfpbc Total loading time: 0 Render date: 2024-04-24T22:14:52.119Z Has data issue: false hasContentIssue false
  • English
  • Français

Just Caring: In Defense of Limited Age-Based Healthcare Rationing

Published online by Cambridge University Press:  22 December 2009

LEONARD M. FLECK
Get access Rights & Permissions [Opens in a new window]

Extract

The debate around age-based healthcare rationing was precipitated by two books in the late 1980s, one by Daniel Callahan and the other by Norman Daniels. These books ignited a firestorm of criticism, best captured in the claim that any form of age-based healthcare rationing was fundamentally ageist, discriminatory in a morally objectionable sense. That is, the elderly had equal moral worth and an equal right to life as the nonelderly. If an elderly and nonelderly person each had essentially the same medical problem requiring the same medical treatment, then they had an equal right to receive that treatment no matter what the cost of that treatment. Alternatively, if cost was an issue because the benefits of the treatment were too marginal, then both the elderly and nonelderly patients requiring that treatment ought to be denied it. If there were something absolutely scarce about the treatment, then some fair process would have to be used to make an allocation decision (and that fair process could not use some age cutoff among the allocation criteria).

Type
Special Section: Open Forum
Information
Cambridge Quarterly of Healthcare Ethics , Volume 19 , Issue 1 , January 2010 , pp. 27 - 37
Copyright
Copyright © Cambridge University Press 2010

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. Callahan D. Setting Limits: Medical Goals in an Aging Society. New York: Simon and Schuster; 1987.

2. Daniels N. Am I My Parents’ Keeper? An Essay on Justice between the Young and the Old. New York: Oxford University Press; 1988.

3. This could be a very long list, but we will simply list more prominent critiques. See Binstock RH, Post SG, eds. Too Old for Health Care? Controversies in Medicine, Law, Economics, and Ethics. Baltimore, MD: Johns Hopkins University Press; 1991; Moody H. Aging: Concepts and Controversies. Thousand Oaks, CA: Pine Forge Press; 2000; Moody H. Ethics in an Aging Society. Baltimore, MD: Johns Hopkins University Press; 1992; Kilner J. Life on the Line: Ethics, Aging, Ending Patients’ Lives, and Allocating Vital Resources. Grand Rapids, MI: W.B. Eerdmans Publishing Co.; 1992; Smeeding T. Should Medical Care Be Rationed by Age? Totowa, NJ: Rowman and Littlefield; 1987.

4. Harris J. The Value of Life. London: Routledge and Kegan Paul; 1985.

5. Williams A. Intergeneration equity: An exploration of the ‘fair innings’ argument. Health Economics 1997;6:117–32.

6. Harris J. Cardiac surgery in the elderly. Heart 1999;82:119–20.

7. Europe is facing a comparable problem with the aging out of its population. “In Europe, predictions from the Statistical Office of the European communities (EURO-STAT) estimate that from 2010 to 2030 the population of octogenarians in 25 countries of the European Union will increase by 57%. By 2050, the population of those aged 80 and older will increase by 180%.” See Cvachovec K. Coronary artery bypass surgery in the very old: Light at the end of the tunnel or a dead-end road? Journal of Cardiothoracic and Vascular Anesthesia 2007;21:781–3 at pp. 781–2.

8. As numerous policy analysts have noted, advancing medical technologies are the primary driver of the problem of escalating healthcare costs. See Bodenheimer T. High and rising health care costs. Part 1: Seeking an explanation. Annals of Internal Medicine 2005;142:847–54. Bodenheimer T. High and rising health care costs. Part 2: Technologic Innovation. Annals of Internal Medicine 2005;142:932–7. See also Aaron HJ, Schwartz WB, Cox M. Can We Say No? The Challenge of Rationing Health Care. Washington, DC: Brookings Institute; 2005. In 1993 in the United States we were spending $912 billion on healthcare. The estimate for 2009 is that we will spend $2.5 trillion on healthcare and $4.4 trillion in 2018 (or about 20.3% of our projected Gross Domestic Product at that time). See Sisko A, Truffer C, Smith S, Keehan S, Cylus J, Poisal J, et al. Health spending projections through 2018: Recession effects add uncertainty to the outlook. Health Affairs 2009;28:w346–57.

9. See Note 8, Sisko et al. 2009.

10. Almost 82% of the elderly have at least one chronic condition, 65% have at least two chronic conditions, and 25% have four or more chronic conditions. The reader should think of heart disease or cancer or lung diseases or kidney disease or diabetes or stroke or dementias or arthritis or sensory deficits, and so forth. Although many of these conditions are ultimately fatal, the period of time for which individuals can survive has increased dramatically as a result of costly contemporary medicine. This is reflected in the Medicare cost statistics cited earlier. See Wolff J, Starfield B, Anderson G. Prevalence, expenditures and complications of multiple chronic conditions in the elderly. Archives of Internal Medicine 2002;162:2269–76.

11. This sentence needs a qualification because the Medicare program has significant copayments and deductibles. Those serve as an effective barrier for the elderly in roughly the lower half of the income spectrum. They cannot demand everything, no matter what the cost. More economically well-off elderly have supplementary insurance that eliminates those barriers and allows them to demand whatever they see as medically beneficial for themselves.

12. The most often cited estimate of that annual number in the United States is 22,000 premature deaths attributable to being uninsured. See Dorn S. Uninsured and dying because of it: Updating the Institute of Medicine analysis on the impact of uninsurance on mortality; 2008 Jan; available at http://www.urban.org/url.cfm?ID=411588&renderforprint=1 (last accessed 19 July 2009).

13. See, for example, Huber CH, Goeber V, Berdat P, Carrel T, Eckstein F. Benefits of cardiac surgery in octogenarians—A postoperative quality of life assessment. European Journal of Cardio-Thoracic Surgery 2007;31:1099–105. Filsoufi F, Rahmanian PB, Castillo JG, Chikwe J, Silvay G, Adams DH. Results and predictors of early and late outcomes of coronary artery bypass graft surgery in octogenarians. Journal of Cardiothoracic and Vascular Anesthesia 2007;21:784–92. See also the case of Hazel Homer who, at age 99, received an advanced pacemaker and defibrillator to assist a failing heart. She is alive today at 104; Hartocollis A. Rise seen in medical efforts to treat the very old. New York Times 2008 Jul 18.

14. Shim JK, Russ AJ, Kaufman SR. Risk, life extension and the pursuit of medical possibility. Sociology of Health and Illness 2006;28:479–502, at 496.

15. For a profoundly effective understanding of what it means to be uninsured the following Kaiser Family Foundation website ought to be visited for in-depth interviews with a number of such families. These are the kinds of injustices that are essentially morally invisible at a broader social level. See Shirk M. In Their Own Words: The Uninsured Talk about Living without Health Insurance; available at http://www.kff.org/uninsured/2207-index.cfm (last accessed 19 July 2009).

16. Brody B. The macro-allocation of health care resources. In Sass HM, Massey R, eds. Health Care Systems: Moral Conflicts in European and American Public Policy. Dordrecht: Kluwer Academic Publishers; 1988:213–36.

17. See note 6, Harris 199:119.

18. See the fuller exposition of this argument in Dey I, Fraser N. Age-based rationing in the allocation of health care. Journal of Aging and Health 2000;12:511–37.

19. It should be noted that this particular issue will be just as much an issue in Europe as in the United States. Simply having a universal healthcare system does not address this issue as a justice issue.

20. This is what John Rawls refers to as the “burdens of judgment.” Our moral arguments and moral theories will often not be powerful enough in complex circumstances to yield a uniquely correct moral response. See his Political Liberalism. New York: Columbia University Press; 1993.

21. See my book Just Caring: Health Care Rationing and Democratic Deliberation. New York: Oxford University Press; 2009, especially Chapter 5, for a fuller exposition of the role of rational democratic deliberation in yielding just healthcare rationing policies.

22. I address this issue more comprehensively in an earlier essay: Just caring: Assisted suicide and health care rationing. University of Detroit Mercy Law Review 1995;72:873–99.

23. See Callahan D. What Kind of Life: The Limits of Medical Progress. New York: Simon and Schuster; 1990, especially Chapter 2.