Age-based rationing Some Facts • 1980, 1986: those over 65 consumed 29%, 31% (respectively) of health care Age-Based Rationing? expenditures • Prediction: by 2040 elderly 21% of population and 45% of health care money. The Harm This Does Three Concerns • Economic burden on young • Intergenerational equity: Health care going to elderly at expense of children (6x • Too much emphasis on health care as much spend on elderly compared to compared to other needs under 18). • Elderly dying consume 1% of gross national product. • Expenditure for technology (research, etc.) helping mainly the elderly Challenges Raises Larger Issues for Medicine • What helps elderly helps all (e.g., relieves • These issues not easily dealt with in a burden of care from children). democracy concerned with short-term • Elderly get more because they need more, • What is the appropriate role of so it’s not “disproportionate.” medicine? • Callahan (thesis): the future goal of medicine in the care of the aged should be improving quality of life, not extending life. Medical Ethics 1
Age-based rationing Opposing View of Our Culture Raises Larger Issues for Society • New understanding of aging needed: one • “Modern Maturity” and “Prime Time: Older can have a meaningful old age limited in years a time for education, travel, leisure. time. • An extended middle age without work • Our culture needs a more supportive responsibilities attitude toward aging and death. • Culture should recognize (p. 841) that the primary orientation of the elderly “should be to the young and the generations to come, not to their own age group.” Callahan: a “Natural Life Span” Applied to Health Care Spending • We should accept something like Biblical • Communal programs (government) should idea of a natural life span, beyond which help people live a natural life span. we don’t fight to extend. • Research priorities should reflect this. • Medicine should work to prevent • Health care should not be based only on premature death and mainly relieve need without regard to age. suffering afterward. Childress—A Different View British Experience Quotes Robert Browning: • No official barrier to dialysis, but • Many centers denied care to patients (e.g., one 68 years old) purely based on age or “Grow old along with me (e.g., a 60-year-old) with age as one The best is yet to be reason. The last of life for which the first was made.” Medical Ethics 2
Age-based rationing Is Age Discrimination Like Racial or Consider Three Possible Sexual Discrimination? Approaches • We don’t have control over it • Rawlsian • However, we all go through different • Utilitarian stages – Cost-benefit analysis – Cost-effectiveness analysis • Expressive or symbolic significance Rawlsian Approach Should We Use Cost-Benefit Approach? • What policy would we accept in original • “Biggest bang for the buck” in all areas. Compare money spent on different forms of position? health care both with other forms and non-health • Using “maximin” idea (we’d want to avoid care expenditures. the worst), we might want to be • Needs to consider $ value of human life guaranteed a certain age – Expected future earnings • Might be rational to adopt a health care – [More usual now] Willing to pay to reduce risks. strategy to increase change of reaching a Problems with surveys. normal life span. Either of these might give less weight to elderly “Symbolic” or “Expressive” Cost-Effectiveness Analysis Significance • Recall Callahan (class) on “feeding the dying.” “Doctors should not • Need not consider $ value of human life but compare starve patients” different health policies for how much “good” they • Pres. Commission: “a society’s commitment to health care reflects produce. some of its most basic attitudes about what it means to be a member of the human community.” • “Good” often translated into QALYs: “quality adjusted life • Also, when Pres. Commission represents CBA, it included value of years.” “communal solidarity” as benefit. – Need to determine what percentage of a “quality” life a given • Maybe this is just a broadened form of utilitarianism (as was Callahan disability represents. on feeding dying) • Will come up in other issues; e.g., is surrogate motherhood “selling a – Example: treat a blind person and a sighted person. If being blind baby” or “renting a womb” represents a reduction of 20% in quality, then prolonging life gets • Related to commodification . If we treat body a certain way (e.g., 20% fewers QALY points. neomorts), that has a “negative symbolic significance. – How do we get these numbers? Can surveys determine this? • Might withholding avaiable medical care from the elderly be immoral (even if cost-effective) because of its “negative symbolic – How many additional years would you need to live for you to choose being blind (deaf, on dialysis, with arthritic pain, etc.) or how many fewer significance”? years would you choose if you could be free of a problem? Medical Ethics 3
Age-based rationing Great Test Question Effects of the “War” Metaphor Many medical practices have been evaluated according to what we might call “standard” ethical arguments or criteria such as the risks or costs versus the • Our “battle” against disease may increase health care benefits (consequentialism) or the extent to which a practice accords with certain rules, rights, or standards of justice (nonconsequentialism). budget too much. Fighting an evil. Your question: What should we make of appeals that seem to go beyond these “standard” • Gives greater priority to critical care and fighting “killer ones: for example, Callahan's opposing withdrawal of food and water because diseases” over prevention and chronic care of the symbolic significance of feeding; appeals to the “yuk” factor; arguments that something is immoral because it is “unnatural” and various arguments of • Emphasis on technological intervention. (Typically Kass (e.g., his thought experiment on “neomorts” and his discussion of repugnance in the cloning essay). American? Tertiary care.) a) Indicate and explain several points in the course where authors (or we in class) referred to considerations of this kind. • Leads to overtreatment, especially of terminally ill. Death b) Should we regard these considerations as (a) genuinely important, new, is the evil to fight and overcome with “heroic” efforts. and not taken into account by one of the two standard theories; (b) impor-tant but actually part of standard considerations when properly reformu-lated; (c) • Maybe we need metaphor of nursing . hazy and irrational considerations that are best ignored? You may wish to argue for the importance of some kinds of considerations and against other – Interesting to consider different “ethic” of physicians and nurses. kinds or you might be asked to focus on one of these kinds of arguments; for example, the appeal to the “natural” or Kass’s “repugnance.” Medical Ethics 4
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