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" 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.

Why ration?

Proponents of old-age–based rationing have set forth both economic and philosophical rationales for their views. Their economic argument is essentially that the costs of health care for older people will become an unsustainable economic burden for the United States during the next few decades because of population aging, thereby posing grave problems for the economy and making it very difficult for government to spend funds on other worthy social causes.

The number of older Americans will grow sharply during the first half of the twenty-first century as the baby boom—a cohort of seventysix million persons born between 1946 and 1964—reaches old age. At the turn of the century, persons age sixty-five and older were about 13 percent of the U.S. population and accounted for one-third of the nation's public and private health care expenditures (about $400 billion out of a total $1.2 trillion in 2000). Per capita spending on persons in this age range is four times greater than on younger persons, largely because older people are far more likely to need health care than younger ones. The total number of older Americans, which was thirty-six million in 2000, will be seventy-six million by 2030 and will constitute 20 percent of the population. Consequently, the aggregate health care needs of the older population will be even greater in the future than they are now. For example, the proportion of national wealth (gross domestic product) spent on Medicare in 1998 was 2.5 percent; it is projected to more than double, to 5.3 percent, in 2025.

Moreover, the number of persons of advanced old age—in their late seventies and older—will increase markedly, and in this older age range the rates of illnesses and disabilities requiring health care are much higher than among the rest of the population. Even if important advances are made in treatments, illness prevention, and health promotion, they are unlikely to have a major impact in terms of eliminating the overall extent of illnesses and disabilities in advanced old age, and on the costs of caring for older persons in the next several decades. Indeed, the implementation of such advances will probably lead to more intensive use of medical care.

The philosophical arguments for old-age– based rationing are more varied than the economic arguments. The philosopher Norman Daniels (1988), for instance, poses an abstract problem of justice by depicting a society in which each individual has available a fixed sum of money for his or her lifelong health care. Without our knowing our particular individual positions in such a society, Daniels asks: How would we allocate, in advance, the availability of funds for care at various stages of life? His answer is that we would choose to make sure that we had enough for health care in our early and middle years, and allocate very little for our old age.

In contrast, Callahan propounds a communalist philosophy. He argues that it is inappropriate for older people to pursue their individualistic needs and aspirations. As he sees it, the meaning and significance of life for the elderly is best founded on a sense of limits to health care, and recognition that life cannot go on for long and death is on the way. This meaning of aging envisioned by Callahan requires older persons to adhere to a value of serving the young through politics, and more directly in one-onone relationships. As he sees it, limiting lifesaving care for older persons would affirmatively promote the welfare of the elderly and of younger generations.

Critique of rationing proposals

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

See also Advance Directives for Health Care; Age Discrimination; Ageism; Functional Ability; Intergenerational Justice; Status of Older People; Wisdom.

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.