Age-Based Rationing of Health Care

The idea of old-age–based rationing of health care in the United States began to emerge publicly in the 1980s and has been hotly debated ever since. In a 1983 speech to the Health Insurance Association of America, the economist Alan Greenspan pointedly wondered "whether it is worth it" to spend nearly one-third of Medicare, a federal program that provides national health insurance for virtually all people age sixty-five and older, on just 5 to 6 percent of Medicare insurees who die within the year (Schulte). In 1984 Richard Lamm, then governor of Colorado, was widely quoted as stating that older persons "have a duty to die and get out of the way" (Slater). Although Lamm subsequently said that he had been misquoted on this specific statement, he has continued to promulgate his view in a somewhat more delicate fashion to this day.

In the years following, discussion of this issue spread to a number of forums. Ethicists and philosophers began generating principles of equity to govern "justice between age groups" in the provision of health care, rather than, for instance, justice between rich and poor, or justice among ethnic and racial groups (e.g., Daniels; Menzel). Conferences and books explicitly addressed the subject with titles such as Should Medical Care Be Rationed by Age? (Smeeding).

The most prominent exponent of old-age– based rationing has been the biomedical ethicist Daniel Callahan, whose 1987 book Setting Limits: Medical Goals in an Aging Society received substantial popular attention. He depicted the elderly population as "a new social threat" and a "demographic, economic, and medical avalanche . . . one that could ultimately (and perhaps already) do [sic] great harm" (Callahan, 1987, p. 20). Callahan's remedy for this threat was to use "age as a specific criterion for the allocation and limitation of health care" by denying life-extending health care—as a matter of public policy—to persons who are aged in their "late 70s or early 80s" Nurses at a health care facility change the sheets, working around the elderly patient so that he does not have to get out of bed. (Photo Researchers, Inc.) and/or have "lived out a natural life span" (p. 171). Specifically, he proposed that the Medicare program not pay for such care. Although Callahan described "the natural life span" as a matter of biography rather than biology, he used chronological age as an arbitrary marker to designate when, from a biographical standpoint, the individual should have reached the end of a natural life.

Setting Limits provoked widespread and continuing discussion in the media and directly inspired a number of books (e.g., Barry and Bradley; Binstock and Post; Homer and Holstein) and scores of articles published in academic journals and magazines. Many of these books and articles strongly criticized the idea of old-age–based rationing. Nonetheless, the notion of limiting the health care of older people through rationing is still frequently discussed. Callahan continues to publish his view in both academic journals and more popular forums (e.g., Callahan, 1994, 2000).

The most important feature of this debate, from a societal point of view, is that it has introduced the idea that the power of government might be used to limit the health care of older persons through explicit public policy. Many observers of medical care in the United States have long acknowledged that physicians have informally rationed the health care of older persons through day-to-day, case-by-case decisions in various types of circumstances. Moreover, informal old-age–based rationing has been extensive for many years in the publicly funded British National Health Service, which operates within a fixed budget provided by the government. British primary care physicians serve as "gatekeepers," determining whether their patients will be referred to specialists or will receive various medical procedures. It has been well documented that because of budgetary constraints, older persons are systematically excluded from certain types of referrals that are made for younger patients (see, e.g., Aaron and Schwartz). But these practices are not official policy.