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Age-Based Rationing of Health Care - Critique Of Rationing Proposals

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The economic argument for old-age–based rationing has several major weaknesses. First, empirical evidence contradicts the assumption that population aging leads to unsustainable health care spending. Retrospective studies in the United States and elsewhere indicate that population aging, in itself, has contributed very little to increases in health care expenditures; among the major contributors have been new medical technologies and their intensive application. Moreover, cross-national studies (e.g., Binstock) provide no evidence that substantial and/or rapid population aging causes high levels of national economic burden from expenditures on health care. Health care costs are far from "out of control" or even "high" in nations that have comparatively large proportions of older persons or have experienced rapid rates of population aging. The public and private structural features of health care systems—and the behavioral responses to them by citizens and health care providers—are far more important determinants of a nation's health care expenditures than population aging.

Even if one were to accept the notion that greater and official health care rationing is essential for the future of the U.S. economy, it is not at all clear that old-age–based rationing of the kind that Callahan and others propose would yield sufficient savings to make a substantial difference in national health care expenditures. Although the proponents of rationing have not identified the magnitude of savings to be achieved through their schemes, it is possible to construct an example. Each year about 3.5 percent of Medicare is spent on high-cost, high-tech medical interventions for persons age sixty-five and older who die within the year. Suppose it were possible (although it rarely is) for physicians to know in advance that these high-cost efforts to save lives would be futile, and that it would be ethically and morally palatable for them to implement a policy that denied treatment to such patients, thereby eliminating "wasteful" health care. The dollars saved by rationing such care for persons age sixty-five and older (an age cutoff about fifteen years younger than proposed by Callahan) would be insignificant. In 1999, when Medicare expenditures were $217 billion, only $7.6 billion would have been saved through such a policy that, in any event, would be very difficult to implement practically, ethically, and morally. Viewed in isolation this is a substantial amount of money. But it would have only a negligible effect on the overall budgetary situation in the short or long run.

Economics aside, there are social and moral costs involved in policies that would ration health care on the basis of old age. One possible consequence of denying health care to aged persons is what it might do to the quality of life for all of us as we approach entry into the "too old for health care" category. Societal recognition of the notion that elderly people are unworthy of having their lives saved could markedly shape our general outlook on the meaning and value of our lives in old age. At the least it might engender the unnecessarily gloomy prospect that old age should be anticipated and experienced as a stage in which the quality of life is low. The specter of morbidity and decline could be pervasive and overwhelming.

Another cost lies in the potential contributions that will be lost to all of us. Many older persons who benefit from lifesaving interventions will live for a decade or more, and perhaps will make their greatest contributions to society, their communities, and their families and friends during this "extra" time. Human beings often are at their best as they face mortality, investing themselves in the completion of artistic, cultural, communal, familial, and personal expressions that will carry forward the meaning of their lives for generations to come. The great cultures of the world have viewed elderly persons as sources of wisdom, insight, and generativity (creativity; causing to be), as if in the process of bodily decline the exceptional qualities of the sage emerge. Generativity does not correlate with youth. Erik Erikson (1964) and others have argued that some forms of generativity may be more likely when one has completed a great measure of the developmental challenges that the life course presents.

Perhaps the foremost potential cost of any old-age–based rationing policy would be that it could start society down a moral "slippery slope." If elderly persons can be denied access to health care categorically, officially designated as unworthy of lifesaving care, then what group of us could not? Members of a particular race, religion, or ethnic group, or those who are disabled? Any of us is vulnerable to social constructions that portray us as unworthy. Rationing health care on the basis of old age could destroy the fragile moral barriers against placing any group of human beings in a category apart from humanity in general.

ROBERT H. BINSTOCK

BIBLIOGRAPHY

AARON, H. J., and SCHWARTZ, W. B. The Painful Prescription: Rationing Hospital Care. Washington, D.C.: Brookings Institution, 1984.

BARRY, R. L., and BRADLEY, G. V., eds. Set No Limits: A Rebuttal to Daniel Callahan's Proposal to Limit Health Care for the Elderly. Urbana: University of Illinois Press, 1991.

BINSTOCK, R. H. "Healthcare Costs Around the World: Is Aging a Fiscal 'Black Hole'?" Generations 27, no. 4 (1993): 37–42.

BINSTOCK, R. H., and POST, S. G., eds. Too Old for Health Care: Controversies in Medicine, Law, Economics, and Ethics. Baltimore: Johns Hopkins University Press, 1991.

CALLAHAN, D. Setting Limits: Medical Goals in an Aging Society. New York: Simon and Schuster, 1987.

CALLAHAN, D. "Setting Limits: A Response." The Gerontologist 34 (1994): 393–398.

CALLAHAN, D. "On Turning 70: Will I Practice What I Preach?" Commonweal, September 8, 2000, pp. 10–11.

DANIELS, N. Am I My Parents' Keeper? New York: Oxford University Press, 1988.

ERIKSON, E. H. Insight and Responsibility: Lectures on the Ethical Implications of Psychoanalytic Insight. New York: Norton, 1964.

HOMER, P., and HOLSTEIN, M., eds. A Good Age: The Paradox of Setting Limits. New York: Simon and Schuster, 1990.

MENZEL, P. T. Strong Medicine: The Ethical Rationing of Health Care. New York: Oxford University Press, 1990.

SCHULTE, J. "Terminal Patients Deplete Medicare, Greenspan Says." Dallas Morning News, April 26, 1983, p. 1.

SLATER, W. "Latest Lamm Remark Angers the Elderly." Arizona Daily Star (Tucson), March 29, 1984, p. 1.

SMEEDING, T. M., ed. Should Medical Care Be Rationed by Age? Totowa, N.J.: Rowman & Littlefield, 1987.

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