Rationing by Any Other Name
Etzioni, Amitai, Policy Review
NEWSPAPERS AND MAGAZINES do not usually regurgitate ideas that have been bandied about for decades, especially when they are replayed one more time by the same leading author. Hence, it is telling that the New Republic republished in mid-2011 the brief by Daniel Callahan (this time co-authored with Sherwin Nuland). The authors call for a ceasefire in America's "war against death," arguing that those who surrender gracefully to death "may die earlier than [is now common], but they will die better deaths." They urge the medical profession--and ultimately, the American people--to undergo a cultural shift they argue is necessary to prevent the otherwise inevitable financial failure of our health care system. This shift will replace a "medical culture of cure" with a "culture of care." They note that "rationing and limit-setting will be necessary" to bring about this change. Callahan and Nuland point to evidence that little progress has been made in our quest for cures for chronic diseases (like Alzheimer's) or will likely be made in our efforts to significantly extend our life expectancy. Given the marginal benefit and high cost of medical advancements, they argue that we need to invest much more of our limited funds in preventive, affordable care, rather than in strenuous efforts to wring a few more years out of life.
Focusing on care for the elderly, the authors call on us to abandon the "traditional open-ended model" (which assumes medical advances will continue unabated) in favor of more realistic priorities--namely, reducing early death and improving the quality of life for everyone. They further advocate age-based prioritization, giving the highest priority to children and "the lowest to those over 80."
Callahan sometimes conies across as though he advocates providing only palliative care to those who, as summarized by Beth Baker in her 2009 interview with Callahan, "have lived a reasonably full life of, say, 70 to 80 years," offering them "high quality long-term care, home care, rehabilitation and income support, but not extraordinary and expensive medical procedures " That is, we should ration health care for our elders, granting them mainly ameliorative care rather than vainly seeking to cure the unyielding chronic illnesses that plague them. In other texts, his argument is more hedged. However, he tends to hold that quality of life is more important than length of life, especially given that the last years of our lives are miserable, as our minds wander, and we are beleaguered by incurable diseases. Otherwise, our futile battle against death "may doom most of us ... [to an end] ... with our declining bodies falling apart as they always have but devilishly--and expensively--stretching out the suffering and decay." They hence determine that the cutoff point, the age at which we should put our elderly on ice, is 80. As we shall see shortly, whether one reads Callahan's statements as stark or as more nuanced, his argument faces the same basic challenges.
Daniel Callahan is the co-founder of a premier bioethics research institution, the Hastings Center. It has played a major role in the development of bioethics in the United States, and indeed the world. (Callahan's co-author, Sherwin Nuland, was a practicing surgeon for 30 years and has authored several books on life, death, and medicine.) However, this essay (as well as previous writings by Callahan on the same subject) is neither a work of scholarship nor of policy analysis but of political advocacy. It employs emotive terms, rhetorical devices, and vague formulas to advance a cause. Thus, the New Republic article recommends that seniors be granted a "primary care" period, which at first blush sounds much less troubling than to argue that elder Americans will be provided only palliative care. However, on second thought, one recalls that primary care is the gate to secondary and tertiary care (such as surgeries, kidney dialysis, hip replacements, and chemotherapy). …