Age-Based Rationing of Healthcare

Thousands of people die annually - even in a developed country like the United States - for lack of access to organ transplants. Vastly greater numbers die worldwide for lack of access to immunizations, or antibiotics, or prenatal care. The inescapable question echoes around the world: When there is not enough for everyone, who gets it and who doesn't? Who lives and who dies?

Sometimes the problem is that health care becomes very expensive, or the resources allocated to it become limited by other priorities - perhaps misplaced ones. So it may be a question of tight money. But it also may be a question of absolutely scarce resources, like organs for transplant.

Valiant efforts have been made to save the lives of those who cannot get transplants. The artificial kidney - hemodialysis - was developed to save the lives of those who could not have kidney transplants. But then that created a new allocation problem: Who would get the available dialysis machines? There was quite an exposé in Life magazine a few decades ago about how hospitals were deciding who would live and who would be left to die. In many cases, according to this article, people who were socially attractive were the winners.

The matter went to the floor of the U.S. Congress. Congress, understandably, was not eager to tackle the issue of how to decide who should live and who should die. No Congressional hearings were held on the matter. Less than 30 minutes of debate took place on the Senate floor. Congress was able to escape developing ethical criteria by deciding to fund hemodialysis for everyone. But what was projected to cost a few hundred million dollars at the time quickly skyrocketed to two billion dollars, and it became clear that the next time a major artificial organ was developed, it could not simply be given to everyone. Ethical criteria would be unavoidable.

Now we have witnessed the use of a totally implantable artificial heart in humans, and huge demand is predictable. Other lifesaving technologies will not be far behind. The pressure to develop ethical allocation criteria will only be escalating in the days ahead.

One approach to this challenge is to bar older people from receiving life-sustaining health care such as organ transplants and implants - or possibly even limited intensive care space. There is evidence that similar age considerations affect treatment decisions in many areas of health care today, and prominent secular ethicists such as Daniel Callahan, Robert Veatch and Norman Daniels have all expressed support for some form of age-based rationing.

Why this mushrooming interest in age-based rationing of health care? The most commonly cited reason for limiting the lifesaving resources available to older people in the U.S. is the economic impact of the rapidly growing number of elderly persons. The percentage of the U.S. population over age 65 has grown from less than 2 percent in 1790 to nearly 12.5 percent in 2000. Particularly fast-growing are the ranks of the oldest persons - those 85 years or older. By 2000, their number in the U.S. had topped 4.2 million, representing 1.5 percent of the population; moreover, this number is projected to increase considerably in the future.

The mental association of age and cost is an understandable one. As the reasoning goes: Health care for elderly persons is costing more and more money, so in order to cut costs it will be necessary to cut back on the health care resources that will be available to them. However, health care costs are increasing due to a variety of factors, many of which have no special connection to elderly persons. Why then are older people singled out as a group to bear the brunt of cutbacks in lifesaving care? Moreover, although it is claimed, economically speaking, that elderly persons are receiving a "disproportionate share" of health care resources, the question must be raised: "disproportionate to what?" They are not receiving disproportionately to their medical need (assuming that medical criteria are being applied equitably to all). Why do those concerned about disproportionate shares so readily assume that the appropriate frame of reference for "proportion" is age?

These observations suggest that a more complicated economic trend is at work in the U.S. than simply a concern to reduce health care or other expenditures. There appear to be other reasons for targeting elderly persons for cutbacks. That lifesaving care is at issue even raises the possibility that there is something undesirable about elderly persons per se.

This outlook is attributable, at least in part, to the increasingly utilitarian orientation of U.S. society. Utilitarianism is an outlook that identifies right actions as those producing the greatest good for the greatest number of people. When employed consciously or unconsciously as a means of determining who should receive limited resources, it predisposes one to view people in terms of whatever contributions are valued most highly by the society, with a bias toward contributions most readily quantifiable and thus comparable.

In market-driven U.S. society, economic productivity is at the top of the list. So it is no surprise that older people, who are less likely to be viewed as economically productive, are not highly valued.

The utilitarian way of thinking that sustains the emphasis on youth and productivity in the U.S. has been harshly criticized. For instance, comparing everyone's social contribution is extremely difficult, since everything potentially of benefit to anyone in society must be considered. Utilitarian thinking has also been castigated for its lack of inherent protections against how badly a person or group can be treated if society finds such treatment to be economically beneficial. However, even if a utilitarian way of thinking were workable and theoretically sound, the question of what should count as a contribution to society remains. The tendency to focus on economic contributions in the United States is rather different from the perspective of some other societies around the world. There are indeed viable alternatives to the economic, individualistic, youth-oriented outlook so influential in the United States.

The biblical materials also present a view of older people that is not conducive to age-based rationing. Two characteristics stand out at various points in the biblical writings. Those who are elderly are generally wise (Job 12:12), and they are generally weak (Eccl. 12:1-5).

Both the wisdom and weakness of the elderly people call for appropriate responses: the responses of respecting and protecting. We respond appropriately to wisdom by respecting those who have it. The young are to resist the temptation to despise the old (e.g., Prov.23:22), and instead are to recognize gray hair - i.e., old age - as a crown of splendor (Prov. 20:29). People are to "rise in the presence of the aged," says the Lord. They are to "show respect for the elderly." This particular command is one of seven commands in Leviticus 19 (v.32) that ends with something like the words "I am the Lord" - thereby underlining their importance by emphasizing God's authority. But only this command regarding elderly people adds the call to "revere your God."

It appears here that the connection between God and older people is special. God is not simply saying that this, like all other commands, should be obeyed. The point is that obeying this command in particular expresses a special reverence for God. By showing respect for the elderly, we are revering God. In God, then, older people do not have a hopeless end; they have an endless hope.

If we rightly respond to wisdom by respecting, we appropriately respond to the relative weakness of the elderly by protecting. God is frequently portrayed in biblical writings as the protector of the weak (Exod. 22:22-27; Ps. 10:14, 35:10, 140:12; Acts 20:35; 1 Cor. 8:9-12; 2 Cor. 12:9-10), and God's people are challenged to be the same (Prov. 31:8-9; 1 Thess. 5:14). So it is not at all surprising to find God affirming: "Even to your old age and gray hairs I am he, I am he who will sustain you" (Isa. 46:4).

That God says "even" emphasizes that, from a human perspective, it is easy to find reasons to support younger people. However, in this utilitarian world, it is all too easy to neglect older people. King David saw that in his day, which is why he implores God to sustain him, as he puts it: "even when I am old and gray" (Ps. 71:18). Because God is a sustainer of elderly people, it is natural to expect that godly people will do the same (e.g., Ruth 4:15).

God's identification with the plight of the helpless has understandably been heralded as a theological cornerstone for treatment of today's elderly. From this perspective, the elderly are as worthy of staying alive and even receiving lifesaving care as anyone else. In fact, whether a particular society values the wisdom of the elderly or not is ultimately beside the point. All persons are God's creation in God's own image (Gen. 1:27) and are the objects of God's sacrificial love in Christ (John 3:16). God pours out the Spirit on the old as well as the young (Joel 2:28; Acts 2:17). It is this basic equal worth of all that demands that all be respected and that the weak - those who fall short of the equal status others experience - accordingly receive special protection.

What are the implications of all this for age-based rationing of life-sustaining health care? Most obviously, a straightforward utilitarian exclusion of older people, because they are less productive in some sense, is straightforwardly unethical. It misunderstands what is important about a person and it rests on a philosophy that undergirds some of the most oppressive attitudes and episodes in the history of humanity.

But there are other justifications for age criteria that do not overtly appeal to utilitarian values. What about them? First of all, it is unavoidable that the intuitive appeal of such justifications is greatly strengthened by the utilitarian social context. Against such a backdrop, we should be highly skeptical of arguments for age-based rationing of life-sustaining health care, no matter how philosophically pure they may appear. But we also need to address such justifications on their own terms.