Rational Choice?

Proponents of rationing health care on the basis of age say that society can't bear the economic strain that will follow the retirement of the baby boom generation. Critics say that the plan is not only unethical but unworkable.

When it comes to the idea that humans should embrace their own finitude--that, despite what Dylan Thomas says, we should go gentle into that good night--biomedical ethicist and Hastings Center co-founder Daniel Callahan might be the world's most vocal proponent. In his 1987 book, Setting Limits: Medical Goals in an Aging Society, Callahan wrote that medicine "should be used not for the further extension of the life of the aged, but only for the full achievement of a natural and fitting life span and thereafter for the relief of suffering." He advanced a vision of the elderly as "moral conservators": wise guides who should work one-on-one with the young to help them navigate through life, but who should also accept the limits of a "natural life span" of about 80 years.

One way to put this philosophy into practice, Callahan suggested, would be to allow the Medicare system to use an "age-based standard" to restrict coverage of life-extending treatments, such as organ transplants, bypass surgery, and kidney dialysis. With the huge gaps in medical coverage in the United States and the baby boomers headed for retirement, the consideration of age-based rationing of health care is even more critical today, as Callahan argues this month in a SAGE Crossroads discussion entitled "Should Age Count in Allocating Health Care Resources?" Debating the issue with Callahan, geriatrician Christine Cassel, president of the American Board of Internal Medicine, notes that there are better ways to cut medical costs than limiting care for the elderly, such as recommending only those procedures that have been proven to work.

Callahan's initial call for age-based rationing sparked immediate controversy. Critics deemed his ideas ageist (because they discriminate against the elderly), classist (because the wealthy can privately purchase lifesaving care that the poor cannot afford), and even sexist (because women tend to live longer than men and would thus be denied care for a greater number of years after the cutoff age). Village Voice columnist Nat Hentoff called the concept "intrinsically evil" and likened it to Nazism. Callahan, however, never meant for his plan to be imposed on seniors without their approval: The elderly would have to consent to the rationing after a broad and long-term societal rethinking of the relationship between the young and the old, as well as the basic purpose of medicine. "Time and debate," wrote Callahan, might render his plan more palatable.

Callahan is not alone. Over the past 2 decades, a number of thinkers have developed age-based rationing proposals. They are driven by the concern that caring for the increasing number of U.S. seniors will cause an immense economic burden on society. According to the United States Administration on Aging, by the year 2030 the number of older Americans--those age 65 or over--will nearly double, reaching 20% of the population. The way Callahan sees it, the government will have to draw some lines when it comes to how much and what kinds of medical care these American seniors will receive. Otherwise, the demand for expensive new technologies will become insatiable. "Health care for the elderly is in the nature of exploring outer space," Callahan says. "There may be no limits to how far we can go, but there may be limits to what we can pay for."

Why Ration?

Callahan's rationing plan draws upon a communitarian social philosophy that rebukes the elderly for wanting to treat their autumn years as a kind of second middle age, instead of devoting themselves to taking care of the young. "His notion is that if somebody dies of a heart attack on the tennis court at 92, that's bad, hedonistic, selfish," says Robert Binstock, a biomedical ethicist at Case Western Reserve University in Cleveland who has debated Callahan in the past. When first published, this scorn for selfish seniors comported nicely with the "intergenerational equity" movement, led by a group called Americans for Generational Equity, whose leaders argued that every dollar spent on older people is one fewer dollar spent on the young.

Other age-based rationing plans have sprung from different philosophical perspectives. In his 1988 book, Am I My Parents' Keeper?, for example, philosopher Norman Daniels proposed a thought experiment based on the famed thinker John Rawls's theory of justice. Daniels imagined a society in which citizens are allotted a fixed amount of money for health care over a lifetime. In the absence of any knowledge about how their lives will play out, Daniels concluded, most rational individuals would choose to allocate a greater portion of their funds to guarantee good health in their youth and middle age, reserving less of it for when they're old.

Such rationing proposals may seem outrageous, but several studies suggest that a tacit or "soft" ageism already pervades the U.S. health care system. According to a 2003 report by the Alliance for Aging Research, "in recent years evidence has been mounting to suggest that, at all levels in the delivery of health care, there is a prevailing bias--ageism--that is at odds with the best interests of older people." The report points to poor geriatric training for doctors, as well as the fact that the elderly are less likely to receive preventive care and disease screening or to be included in clinical trials. An April 2003 study in the Journal of the American Medical Association, for example, showed that 25% to 40% of Americans over the age of 65 suffer from hearing loss, but few seniors receive treatment for this condition from physicians. Meanwhile, according to a 2003 report by the Centers for Disease Control and Prevention, 90% of adults over 65 fail to receive appropriate screenings for illnesses. These shortcomings, according to the alliance, can be attributed to a subtle tendency among doctors and old patients alike to view serious ailments among the elderly as "simply a natural part of getting older."

The current ageist bias in the U.S. health care system lends at least some strength to the arguments of Callahan and others who advocate legal rationing. For if Callahan's views are outrageous, then so is the status quo. "Callahan's argument has the virtue of being very honest," says legal scholar Marshall Kapp, who directs the Office of Geriatric Medicine and Gerontology at Wright State University in Dayton, Ohio, and has written numerous articles about health care rationing. "He wants everything to be aboveboard and explicit."

The United Kingdom came close to the kind of arrangement that Callahan and his colleagues would like to see in the United States. Research conducted in the 1980s found that its National Health Service (NHS) excluded the elderly from particularly expensive treatments on a systemwide basis due to strict budgetary limitations. "They never called it rationing by age, but it was sort of well understood that people over a certain age would be told that certain medical interventions were 'not medically indicated' for them, like kidney transplants," explains Kapp. Kapp says the U.K. system isn't so blatant any more. Callahan, however, recalls that it was studying NHS practices that first sparked his interest in the concept of age-based rationing.

The Counterpoint

Besides charges of ageism, classism, and sexism, legal critics question whether any attempt to ration health care based on age would constitute a breach of the 14th Amendment's guarantee of "equal protection" to all citizens. Callahan rejects this notion, countering that the current Medicare system contains an "age bias" because participants must be 65 to receive its benefits. More broadly, Callahan alleges that his rationing idea has been widely misunderstood--particularly the fact that he never said it should be implemented immediately. "I've always said at some point we're not going to be able to afford this Medicare program, but usually my hypothetical future tends to get dropped," he says. But for critics such as Cassel, an age-based rationing proposal doesn't make sense now or in the future.

Cassel, like Callahan, endorses the use of some form of rationing to cut health care costs. But she would use a different yardstick to determine who gets what. Rather than limiting treatments available to the elderly, Cassel would draw upon the so-called "evidence-based medicine" movement and ask which type of interventions work for which people--and which produce results that can justify their costs. The current medical system is rife with treatments that are relatively useless but have long been prescribed for various reasons--in some cases, sheer habit. By some estimates, only a small percentage of widely followed medical practices are supported by the most rigorous type of clinical trials. As a result, commonly prescribed treatments frequently end up being challenged by comprehensive studies, as was the case last year with hormone replacement therapy for women after menopause--which might do more harm than good. Cassel calls for a new "public awareness of the fact that not everything works as well as anything else" in medicine, and she says that when it comes to overpriced and ineffective drugs and treatments, "we need to get serious about those types of rationing before we start cutting people off on the basis of their age."

Furthermore, Cassel objects, defenders of age-based health care rationing cannot possibly fix upon an age at which to cut off treatment without being arbitrary and intruding upon the decisions that physicians make on a patient-by-patient basis. "One 80-year-old is not another 80-year-old," says Cassel.

Finally, Cassel rejects the notion that it's possible to limit funding for lifesaving treatments on the one hand but still allow treatments that improve quality of life. For example, one of her patients is a 99-year-old woman suffering from a heart disorder for which the cure is a pacemaker, a relatively expensive piece of medical technology that might not be covered under a plan like Callahan's. "You can say you shouldn't give her the pacemaker," says Cassel. "But if you don't give her the pacemaker, she's going to fall down and break her hip," resulting in considerable suffering. "It's not so simple, scientifically and clinically, to make the distinction between what's going to relieve suffering and what's going to prolong life," concludes Cassel.

Critics of Callahan's age-based rationing plan have cited a wide range of other objections. For Case Western's Binstock, the biggest concern about health care rationing is that it would lead us down a slippery slope. "To single out any group and say they're not worthy of [health care] is a really dangerous thing for society and for all of us," he says. As for the notion that our current health care system is on the verge of breakdown, Binstock says that the whole premise is faulty: "There are these things that are taken for granted as a catechism: Health care resources are scarce and what we spend keeps growing, and it'll ruin us. And there's been no evidence of that."

A Question of Values

In the end, we might not be able to avoid some form of health care rationing. When it comes to the provision of medicine, says Kapp, "there's no system in any country, I would suggest, that currently exists or ever will exist that gets around the problem of making choices about who gets what." Of course, our societal philosophy and values will ultimately determine how we decide to make these choices and whether we make them explicitly or implicitly. The difference between Callahan and his critics with regard to health care rationing ultimately reflects a more fundamental disagreement about the nature and value of old age.

Callahan, like Leon Kass, chair of the President's Council on Bioethics, is deeply suspicious of the notion of life extension because of its potential impact on society and on what it means to be human. In an article in the May 2003 issue of the conservative journal First Things, for example, Callahan charged scientists who speculate about extending human longevity with "a pervasive vagueness about what our lives and our societies might be like if we lived dramatically longer lives." By comparison, he celebrated the Christian vision of eternity as much more thoroughly nuanced, appealing, and emotionally satisfying. Should modern biology somehow bestow upon us a "quasi-immortal life," Callahan writes, "[it] would not be the end of our problems with finitude. It could just as well be the beginning of new ones that would make us nostalgic for our mortal past." From this perspective, it's no wonder that Callahan finds the idea of denying lifesaving care to the old morally justifiable, whereas his critics believe that government should intervene and even encourage the elderly to rage against the dying of the light.

Chris Mooney is a freelance journalist who has only medical disaster coverage and is deeply concerned about the denial of medical care to the young.