A New Debate on the Rationing of Health Services

It is 20 or 30 years from now. Your mother has osteoarthritis, a condition in which, in extreme cases, the joints--particularly the hips--deteriorate so much that they can no longer function.

Your mother has just reached this point, but, at 82 1/2, she is six months past the statutory definition of a normal life span. Joint replacement surgery may not be offered since it is a high-cost service likely to prolong your mother’s life without a cost benefit to society.

She cannot receive heroic treatment but she can be given pain relievers. Should her kidneys fail, dialysis is prohibited. Organ transplants are out of the question.

In today’s society, this imaginary situation would be exactly that: imaginary, perhaps unthinkable. But in the view of a prominent ethics scholar, age-based rationing of medical services must necessarily come to pass, probably, he argues, before the end of this century.

Daniel Callahan, director of the Hastings Center, an ethics think tank in Briarcliff Manor, N.Y., makes his case in a new book, “Setting Limits: Medical Goals in an Aging Society” (Simon & Shuster).

In “Setting Limits,” Callahan--a well-known contributor to scholarly journals, popular magazines and newspaper opinion pages--argues that the United States, where health care spending has reached about 11% of the gross national product, cannot afford to continue with unlimited increases in that area. That growth, Callahan notes, has continued largely unabated despite cost-control initiatives such as early release of patients from hospitals and restrictions on physician fees--and even though an estimated 60 million Americans have no health insurance or inadequate coverage.

The existing health care system is further compromised, Callahan argues, because many medical initiatives benefit the elderly at the expense of better health care for younger people. Therefore, Callahan writes, “Despite its widespread, almost universal rejection, I believe an age-based standard for the termination of life-extending treatment would be legitimate.”

Preemptively, Callahan poses in the book’s preface the first question any skeptic will certainly ask: Would Callahan, now 57 years old, accept such an age-based rationing system for himself 25 years from now?

“I do not know how I might react,” he writes. “I can only say that the writing of this book has forced me to think intensively about the course of my life and what aging will mean to me.”

Sipping coffee at an early breakfast recently, Callahan seemed to have reflected more on The Question. “I would accept the system (I propose) with two provisos,” he said. “The first is that between now and then (the time late in this century when this policy might come into being) we will all have had time to let it sink in and accept a different notion of aging and what it means to grow old.

“And it would be (possibly) 28 years before any of this would be seriously taken into account. I would begin making changes now because I knew I could not have (the kind of high-tech care the elderly routinely now expect). I would know I would be impelled to live a clean, nonsmoking life because I’m not going to have the system to bail me out. The system would be sending me a signal 10 or 20 years ahead of time . . . long enough to begin preparing myself.”

A Fair System

The question for the U.S. health care delivery system is no longer whether rationing will be necessary, Callahan said, but how to fashion the fairest rationing system. And since age governs so many aspects of life, it should determine the cessation of eligibility for heroic and expensive life-prolonging care, he said, noting that Great Britain already has extensive de facto age-based rationing.

Whether there would be an absolute prohibition on providing heroic and expensive life-prolonging care in old age--a system whose constitutionality Callahan himself seriously doubts--or whether the limit would be established by regulatory means, by cutting off Medicare benefits for such services, for instance, remains unclear, he said.

If the latter course were chosen, Callahan conceded, economic circumstances would further divide the wealthy and the nonwealthy by making life-sustaining care available to those who could afford it while poorer people were left to die.

As part of the package, Callahan said he would largely halt biomedical research intended to primarily benefit the old. While that might be nearly impossible, he argues that research should be redirected to programs primarily of benefit to younger people. Research projects would be evaluated in terms of cost and the number of people they would benefit if successful: “At that point, I would want to say, ‘What would be the cost of doing it (eradicating Alzheimer’s disease, for instance) and how ought we, then, to balance that cost over and against other social needs?”

A ‘Waffler’

Callahan concedes he is guilty of “waffling” since he recognizes, he said, that our society probably never will apply strict age-based rationing of medical services to older people who are physically healthy and mentally alert.

Those against such rationing of services--and there are many--often cite what some have called the Holmes-Picasso argument. That is the observation that Supreme Court Justice Oliver Wendell Holmes, who died in 1935 at age 94, and the artist Pablo Picasso, who died at 92, would have had their lives shortened by the policies Callahan proposes.

‘A Duty to Die’

When former Colorado Gov. Richard Lamm suggested in 1984 that terminally ill patients--elderly ones, in particular--have a “duty to die,” the remark set off a firestorm of protest. Lamm--now a Denver attorney--says Callahan may have the beginnings of a debate even more heated.

“When I said that, I really was making a philosophical statement,” Lamm said. “Callahan’s thesis is much more explosive, much more controversial.”

There is every indication that the intense controversy has already begun. Dr. William Schwartz, a Tufts University health care expert identified as the leading proponent of the inevitability of rationing of some sort, called Callahan’s idea of denying life-saving services based solely on age “almost inconceivable.”

Schwartz concludes that extensive rationing is inevitable in American health care, but “my feeling is you can’t use age. There is no such thing as a statistical point after which you shouldn’t invest any further in a life,” Schwartz said.

“I don’t know how you would do it. It depends on the quality of the life.”