In response to:

The Uses of Death from the April 28, 1988 issue

To the Editors:

Sidney Hook’s “The Uses of Death” [NYR, April 28] supports, among other controversial views, the refusal of certain types of (expensive) medical treatment to the elderly. Hook envisages a medical board which would decide when a patient was no longer entitled to receive a treatment, even if the patient wished to have it and was able to pay for it.

This is very dangerous new territory: it extends the (fairly widely accepted) view that elderly patients should not be forced into fighting for life against their will to the (not at all widely accepted) view that a committee should be able to forbid patients from trying by all available means to prolong their lives.

Hook justifies this by referring to health care as “a form of social capital cumulatively built up over generations that someone without much money but in greater need may require.” As an argument for a publicly funded National Health Service this is unexceptionable, but it really will not do as an argument for singling out the treatment of elderly patients for vetting by committee. If Hook is proposing a general system of priority-setting within the available resources, with the aim of helping poorer patients, he should say so. In the present US system, a ban on certain treatments for the elderly would have minuscule benefits for anyone else and would merely stand out as a glaring anomaly.

Hook favors the same sort of anomaly when it comes to mandatory retirement and age limits for jobs. He gives the example of flight engineers, who he feels “should be strong enough to help the passengers in extreme situations”: “what people of sixty can do may be too much for those of seventy or more.” But if flight engineers need strength, this should be specified in the job description, and an attempt should be made to test applicants and (periodically) current staff to see if they measure up. The trouble with making age the criterion is that it is such a lousy predictor of “youthful” qualities: there are strong seventy-year-olds just as there are weak fifty-nine-year-olds (or twenty-one-year-olds, for that matter). On average, of course, older people will be less strong, but it is precisely the objection to agism (as to racism and sexism) that people are judged by real or imagined generalizations rather than as individuals. (Indeed, abolishing arbitrary age restrictions will even improve airline safety, if it forces employers to consider what sort of qualities they really need to maximise it, rather than lean on the shaky crutch of the employee’s birth certificate.)

Overall, Hook’s approach seems to treat the elderly as a special category of people, in whom a seemly retirement and a quiet death are the only acceptable forms of behaviour. As a mere thirty-eight-year-old, I find this rather chilling.

Dr. Nicholas Palmer

Basel, Switzerland

Sidney Hook replies:

The main thrust of my review of Daniel Callahan’s book, Setting Limits, was in defense of physician-assisted voluntary euthanasia. I regard that as the more pressing of the issues discussed, especially since Dr. Callahan strongly opposed it.

With respect to the point Dr. Palmer raises, I am assuming that in health-care situations in which we have limited resources that cannot be equitably and effectively distributed, we must adopt some general policies to determine priorities. For example, if there is a dearth of hearts available for transplants, as a rule they should go to those who have most of their life ahead of them rather than to those who are aged and infirm, however rich, whose prospects of survival, even with a transplant, are quite limited. Similarly where there is a need for supplementary blood of a special kind in short supply for the treatment of a rare blood-type disease. Whatever decision is made will seem calamitous to some of the parties affected. There are other orders of priority that must be developed by representatives of the community and the medical profession for guidance in medical treatment, research, and education. I did not single out treatment of elderly patients alone for vetting. The prolongation of life makes consideration of age more important today than ever before. This should be obvious in considering the acceptability by the community of the practice of voluntary euthanasia, especially in cases of terminal illness.

With respect to mandatory retirement because of age, my concern is to avoid inflexible rules for all institutions and modes of work. In some areas there is no reason to introduce a mandatory retirement age, e.g. the stage, movies, trade, selling, etc. I have given what seems to me good and sufficient reasons for holding to a mandatory retirement age in universities and other higher centers of learning and teaching, especially in overtenured institutions. In industries like airline transportation, where the lives of others depend upon the efficient functioning of personnel, a mandatory retirement age is prima facie justifiable. There is no way of testing the health and likelihood of sudden heart failure and other severe malfunctionings of the human organism for each individual, every time he or she appears for duty. We do know that statistically there is a greater danger of sudden physical and mental collapse for individuals in their seventies and beyond than for those in their sixties. That justifies a mandatory retirement age for those engaged in hazardous occupations, hazardous not merely to themselves but to others. It is a matter of common sense. I am confident that if Dr. Palmer had a choice between two airlines, one in which there is a rigorously observed retirement age for pilots and one in which there is no retirement age, other considerations being roughly equal, he would choose the first. If for whatever eccentric reasons he was indifferent to the choice, his family or loved ones would not be indifferent.

This Issue

November 10, 1988