Setting Limits: Medical Goals in an Aging Society
A wise man, according to Spinoza, does not think about death. In our day, however, he would be regarded as very unwise if his failure to think about death led him to neglect making provisions for his family by leaving a proper will, arranging adequate insurance, and in some metropolitan centers even choosing where to live. Modern society, at least American society, confronts a problem, a whole series of problems, resulting from increasing longevity, changes in the pattern of family life, and a greater concern about the quality of life of the aged. Scientific medicine has been able not to renew life but only to prolong it. In a world of finite resources, physical and human, the public costs of prolonging life at some point become disproportionate to the social benefits. This is especially so when choices must be made about the investment of research funds and medical services for different age groups in the population, and for the study and treatment of different ailments.
Most human beings take for granted that since life is a good, if not an intrinsic good, then at least as a necessary condition for any other experienced good its preservation and extension are always a good. This assumption also seems to be behind the unsophisticated desire for immortality.
For many years, when I would ask my classes whether they would accept the gift of immortality, students would invariably respond that they would, until I reminded them of the Greek myth about the goddess Eos or Aurora, who fell in love with the mortal Tithonus. Eos besought the gods to make her lover immortal. They refused, but to console her they bestowed on Tithonus never-ending life. Not until Tithonus had become aged and feeble but could not die did the goddess and her lover discover what a poisonous gift they had accepted.
It is clear not only after a moment’s reflection but from a study of the representations of immortality in all ages and in virtually all the visual arts that when human beings desire immortality it is not eternal life they seek or yearn for but eternal youth. William Blake’s Reunion in Heaven shows a man and his wife in the prime of life, their small children, and even the family cat. The denizens of Heaven in all paintings I have seen seem hale and hearty even when gray-bearded, never in the last stages of doddering decay.
The progress of scientific medicine and industrial society has led to a changing conception of old age and of its place in society. It is still true that biology sets limits on what can be done, yet it is not biology but society that determines the place of old age in a culture, its authority, what is to be regarded as appropriate for the elderly, and the time and degree of retirement from active life because of old age. Regardless of what we deem desirable for the aged in our society, we must take our point of departure from the fact that until the last century or so average life expectancy was approximately thirty years but that today in the United States it is close to two and a half times as much and rising. The fastest growing age group in the population is made up of those who are over eighty-five, and in a couple of generations it is anticipated that 24 percent of the population will be sixty-five and older. At present, those over sixty-five, who constitute 11 percent of our population, account for more than 31 percent of total medical expenditures.
These figures and a discussion of the numerous problems arising from the health costs of providing decent medical care for the aged are contained in a thought-provoking, in some ways profound, work by Daniel Callahan, former editor of Commonweal, founder of the Institute of Social Ethics and the Life Sciences (The Hastings Center), and author of The Catholic Case for Contraception. His is a morally courageous book, challenging current widespread assumptions that we should prolong life by increasing medical care even if the result is worsening health throughout the United States.
Callahan argues in language more circumspect and sensitive than that of former Colorado Governor Lamm a few years ago that it is possible to limit care for the aged without any diminution of respect and concern or lack of appreciation for their worth to society. Callahan offers three principles to guide us in the medical treatment of the aged. “After a person has lived out a natural life span, medical care should no longer be oriented to resisting death.” By a “natural life span” he means a life whose opportunities “on the whole” have been fulfilled. He explains that he means by this “something very simple: that most of those opportunities which life affords people will have been achieved by that point.” These include “work, love, the procreating and raising of a family, life with others, the pursuit of moral and other ideals, the experience of beauty, travel, and knowledge, among others.” He does not deny that new “opportunities” may arise later in life, only that this is not “what occurs ordinarily.”
He admits that we cannot be very specific about the idea of a natural life span; it will vary from case to case and embrace personal as well as objective factors. But Callahan believes substantial agreement can be established when it has been reached in particular cases by the disinterested inquiry of responsible physicians. There is to be sure something inherently vague in Callahan’s first principle. He does not adequately define what an “opportunity” is, nor does he clarify how opportunities are “afforded” us by “life”; it seems instead that the kind of opportunities we have depend upon the kind of society we live inâ€”on its political organization and its level of technological and economic development. The obscurity of Callahan’s notion of “opportunities” extends to that of a “natural life span.”*
Determining when a “natural life span” has been reached, or when an “opportunity” has been fulfilled and when it is open, is admittedly difficult if not impossible to do by any formula or rule. Callahan, I presume, would agree that we can only decide case by case, but he does not present clearly the kinds of considerations that should be taken into account in making such decisions. My guess is that even those who rule out anything except age and medical condition as relevant would in most cases make the same decision.
Of course, one may argue that living under any conditions, costs, and consequences is worthwhile in itself no matter what. This does not seem to me to be true. I believe I can convince anyone of a sound mind, even if he doesn’t care a fig about honor or moral decency, that sometimes it is better not to be than to be.
Callahan’s second principle is that “provision of medical care for those who have lived out a natural life span will be limited to the relief of suffering.” But suppose the temporary relief of suffering prolongs life without generally alleviating a person’s suffering. Suppose pain cannot be relieved. Suppose we are dealing with the current California case in which a man who has been permanently unconscious for five years as a result of a car accident can be maintained indefinitely by a nasogastric feeding tube. Under no circumstances would Callahan approve of active intervention to end life. At most he would approve of hospitals forgoing heroic measures such as the use of mechanical ventilators or expensive forms of intravenous nutrition to sustain life; but, surprisingly, he is resolutely opposed to voluntary euthanasia and medically assisted suicide even in cases of prolonged agony that can be terminated only by death. (He does not give an extensive account of his reasons for opposing euthanasia. He writes that “a sanctioning of mercy killing and assisted suicide for the elderly would offer them little practical help and would serve as a threatening symbol of devaluation of old age.”)
The third of his principles forbids the mandatory use of medical technologies to extend life for the elderly who have outlived their natural life span. Presumably this would apply to all, the elderly poor and rich alike.
Callahan’s position in some respects is not as radical as it sounds and is not far removed from attitudes and actual practices in some parts of the country. One does not have to agree with his views about the “natural life span” of individuals to agree with him that since our social resources are limited, we cannot regard medical research, treatment, and care as unlimited.
Preventive medicine is preferable, if successful, to any other kind, but without a sense of proportion the community can bankrupt itself by its programs of preventive medicine. The financial cost of prolonging the lives of the aged beyond the shifting natural life span is a relevant consideration not simply because so much money and effort are involved but because the cost may prevent us from using our resources to save and prolong the lives of those who have not had the opportunity to live out their natural span. The current allocation of public funds for safeguarding the health of different groups of the population, and for engaging in research to overcome the diseases that afflict them, can often be explained by the fact that old people vote, are well organized, and have well-paid and outspoken lobbyists, whereas children do not.
The Association for Retired Persons, for example, lobbies extensively for increased allocation of funds to scientific research designed to cure or control the diseases of the elderly. Other groups, such as the Gray Panthers and the National Association of Mature People, promote legislation that will protect the right of older people to work and to freedom from discrimination. It cannot reasonably be denied that longer lives increase the prospects of chronic illness, such as degenerative joint disease (osteoarthritis), Alzheimer’s, and senility secondary to cerebral atherosclerosis, which entails heavier medical costs.
Some policy to limit the kind and nature of medical treatment seems warranted. Just how such a limitation should be applied Callahan does not say precisely; but it is not difficult to conceive of a system by which a medical board would withhold various kinds of expensive treatment, including such procedures as kidney dialysis and administration of prolonged intravenous treatment, from very old patients whose condition had already deteriorated. That a man has the money to pay for all the medical care and skill available does not necessarily entitle him to them, because what his money buys is not merely a private good but a form of social capital cumulatively built up over generations that someone without much money but in greater need may require.
Because Callahan writes with sensitivity and common sense, I find surprising his opposition to euthanasia and assisted suicide. The reasons he offers seem to be inconsistent with his other views. We are dealing here with a matter not of money but primarily of compassion for the suffering of the terminally ill, the agonies of the irremediably stricken that may last for years, and their right to die with dignity, which should extend to those lying comatose and paralyzed, unable to control their natural functions. We do not know the relative number of people in these conditions, but in absolute figures they run into many thousands. Every nursing home has a few.
The notion is even frightening if it is interpreted to mean that access to medical treatment depends on whether one is held to have completed his life span. But as I understand Callahan he is not urging denial of medical care but only of the continued, indefinitely prolonged care "oriented to resisting death" and all the heroic measures and mobilization of resources that this involves.↩
The notion is even frightening if it is interpreted to mean that access to medical treatment depends on whether one is held to have completed his life span. But as I understand Callahan he is not urging denial of medical care but only of the continued, indefinitely prolonged care “oriented to resisting death” and all the heroic measures and mobilization of resources that this involves.↩