Markkula Center of Applied Ethics

Aged-Based Health Care Rationing

By Claire Andre and Manuel Velasquez

Challenges for an Aging Society

I hate the men who would prolong their lives
By foods and drinks and charms of magic art
Perverting nature's course to keep off death
They ought, when they no longer serve the land
To quit this life, and clear the way for youth.
-Euripides 500 B.C.

Has the time come when we decide that prolonging the lives of the elderly who "no longer serve the land" is truly a burden on the youth of society? Is the day of rationing our nation's health care services on the basis of age close at hand? As the ranks of the elderly swell, and demands on the nation's scarce health care resources increase, the once whispered suggestions that health care should be rationed by age are now growing audible.

Currently, about 12% of the population is 65 years or older. By the year 2030, that figure is expected to reach 21%. The fastest growing age group is the population aged 80 and over -- the very segment of the population that tends to require expensive and intensive medical care. The projected demands from a growing elderly population on a health care system that is already taxed to the breaking point, together with continual advances and availability of expensive life-extending technology, have led to troubling questions about society's ability to meet future health care demands, and to the increased tolerance of proposals for rationing.

Perhaps the most prominent advocate of aged-based rationing is Daniel Callahan, author of Setting Limits. In this book, Callahan proposed that the government refuse to pay for life-extending medical care for individuals beyond the age of 70 or 80, and only pay for routine care aimed at relieving their pain.

Justifying the Limits
Those, like Callahan, who support proposals to ration life-extending medical resources on the basis of age maintain that such a rationing system would bring about the greatest good for the greatest number of people. While the health of the young can be ensured by relatively cheap preventive measures such as exercise programs and health education, the medical conditions of the elderly are often complicated, requiring the use of expensive technologies and treatments -- and often, these treatments are ineffective in providing any tangible benefit for either patient or society. In short, the costs that arc incurred to prolong the life of one elderly person might be more productively directed toward the treatment of a far greater number of younger persons whose health can be ensured by less costly measures.

Furthermore, the advocates of rationing argue, society benefits from the increase in economic productivity that results when medical resources are diverted from an elderly, retired population to those younger members of society who are more likely to be working.

Advocates of health care rationing also argue that issues of justice are at stake in this social debate. It's estimated that the government now spends more than $9000 per elderly person and less than $900 per child each year. The skewed distribution of health care resources, they say, is not only detrimental to the overall health of the society; it is also unjust, because the elderly receive a disproportionately large piece of the health care pie, while a far greater number of younger people are deprived of an equal share of the nation's health care resources. Moreover, "need" should not be a fundamental criterion for determining how much health care the elderly (or others) are allotted. In the context of constant technological innovations to prolong life at all costs, the "needs" of the elderly know no bounds and drain the pool of resources that ought to be made available to all age groups.

Many advocates of rationing also support Daniel Callahan's contention that the drain on health care resources to extend the lives of the elderly has the effect of violating the rights of the young to live out a "normal" life span Elderly persons, they say, ought to bc entitled to treatment to relieve pain and suffering, but by the age of 70 or 80, they have lived out a natural life span and achieved most of life's goals and possibilities, and therefore they ought not to receive treatments to extend their lives at the expense of those who have not lived out a normal life span.

Finally, those in favor of age-based rationing claim that withholding treatment from the elderly would not be unjust, as critics claim, because, as they point out, everyone grows older. If we treat the young one way and the old another way, over time, each person is treated the same. Thus, a health care policy that treats the young and old differently will, over time, treat people equally.

Against Age-Based Rationing
The arguments presented by the advocates of health care rationing provoke strong disagreement. The claim that rationing would bring about the greatest balance of benefits for society is disputed by those who argue that any rationing policy depriving the aged of live-saving medical care would result in enormous costs and few benefits. For the young, such a policy would lead to heightened levels of anxiety and fear as they approached old age, while the elderly, not wishing to die and feeling abandoned by society, would despair.

Furthermore, if financial savings were achieved by rationing care by age, there's no guarantee, given our present political system, that any savings on the old would actually be directed to the young, or that they would result in real improvements in the overall health of our citizenry. The actual benefits would depend on what kinds of resources were transferred to what sorts of treatments.

Opponents of rationing argue that there are other policies, far less harmful to society, that could be adopted to deal with the increased demands on the health care system as the population ages. For example, society could transfer funds from military spending to health-care, and could enact reforms to improve efficiency and reduce costs in the health care system.

Others who oppose rationing health care on the basis of age argue that a mere consideration of benefits and costs fails to give due weight to other more important moral considerations, such as justice and rights. Justice, they argue, requires that people be treated similarly unless there are morally relevant reasons for treating them differently. In determining who should or should not receive health care, it is relevant to consider a person's need for health care, the likelihood of recovery, or the likelihood of improving a person's quality of life. Age, however, reveals little about a person's medical need or prognosis, and should no more influence the distribution of health care than race or sex. It is the medical liabilities we often associate with old age, not age itself, that count as relevant reasons for treating people differently. If our aim is to use costly resources more effectively, then we ought to deny treatment to all patients whose prognosis indicates a short life span, chronic illness, or little likely improvement in the quality of life, rather than denying treatment simply on the basis of age.

Moreover, it is argued proponents of age-based rationing try to pit the young against the old as if providing benefits to one group means unfairly taking them away from members of the other group. But, this is mistaken. We don't claim that it is unjust to spend more educational dollars on children than on adults. Similarly, it is not unjust to spend more medical dollars on the aged than on the young, so long as every individual has the same access to medical care over a lifetime.

Those who oppose rationing health care by age argue that such a policy would violate our moral sense of respect for persons. Embarking on age based health care rationing in order to cut health care costs or to increase productivity treats the elderly as a mere means to economic ends, failing to respect the fundamental dignity of persons.

Furthermore, to claim that it is better to preserve the lives of the young than those of the aged is to assume that the lives of the aged have less value than those of the young. In fact, many opponents of age-based health care rationing argue that in modern society, all people have a fundamental right to the medical care they need to maintain good health and a reasonable quality of life, regardless of any characteristic, be it race, religion, sex, socioeconomic class -- or age. Assuming that an elderly individual no longer has this right, or that an elderly person's right is diminished, is just wrong. To claim that the elderly's right to health care must be restricted because they have achieved a "natural life span" -- that they have no life goals or possibilities -- is simply erroneous. In fact, their major life achievements may still be ahead of them. The right to health care does not diminish with age. An aged person has as much of a claim on medical resources as the young person, and consequently age-based rationing is an unequivocal violation of this basic right.

As medical technology continues to advance, the ranks of the old and the very old continue to grow, the costs of health care continue to increase, and the competition for scarce health care resources grows ever more intense, our society will be forced to confront the issue of health care rationing, or at least the problem of equitable distribution of limited health care resources. The strategies that we adopt in trying to balance the needs of a changing population to the supply of resources may establish important precedents with implications reaching far beyond the health care field.

Further reading

Dan W. Brock. "Justice, Health Care, and the Elderly," Philosophy & Public Affairs, Vol. 18, No. 3 (Summer, 1989) pp. 297-312. (Princeton, NJ: Princeton University Press).

Daniel Calahan, Setting Limits: Medical Goals in an Aging Society, (New York: Simon and Schuster, 1937).

"The Graying of America," Philosophy & Public Policy, Claudia Mills, editor, Vol. 8, Number 2 Spring 1988) pp. 1-5. (College Park, MD: Institute for Philosophy and Public Policy, University of Maryland).

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