So many Americans are now living to be old. And we require so much health care. Do these two facts mean we need to ration this care on the basis of age?
Since the 1980s, Daniel Callahan has been suggesting as much. And at a recent conference on end-of-life issues he raised again the questions that have made him a target for elder advocates.
This conference, sponsored by Boston College, drew to Newton some 65 presenters and attenders from around the country, researchers and practitioners in medicine, law, social work, and other fields.
As keynote speaker, Daniel Callahan asked the question “Does Age Matter?” making it the title of his talk.
Co-founder of the Hastings Center in Garrison, New York in 1969, Callahan has been talking and writing about medical ethics for many years. He has authored or edited 35 books and many articles. Mild-mannered though he is in his own person, he has managed to turn some of his critics into angry hornets.
- Aging and death are on a collision course, this keynoter points out, since most people – – in this country, at least – – do not die until well into their 70s or beyond. This increased longevity makes for three tensions:
- In the United States, old age is no longer seen as a time of certain decline and disability;
- Physicians do not accept the inevitability of death and most Americans believe unlimited benefits should be available to everyone;
- Older people should be treated on an individual basis, no matter what the pressures on Medicare and other funding sources.
Palliative care, as distinguished from medical services focused on cures, has become an ideal for at least some physicians. However, to make palliative care the norm, when cure is not realistic, requires an acceptance of death that goes beyond where many doctors are. A leading researcher among them, William Haseltine, has called death “nothing but a series of preventable diseases.”
Professionals with this mentality accept death only when technology cannot do anything more. Callahan believes that palliative care – – that is, the effort to keep patients as comfortable and as pain-free as possible – – should be much more honored than it is.
“Care must be seen of equal value with cure,” he says. For him the time has come for restoring a balance between the two. He would also like to see this kind of care made available to those patients who are not terminally ill.
Death should not be seen as the enemy. Callahan does not approve of what he terms the “medical arms race with death.” He takes as a fine model the practice of people in the Czech Republic, a place where he has spent considerable time. There people grow old and are allowed to die rather than being kept alive by technology.
Callahan feels some hope for a different future in our attitudes toward end-of-life treatment. “We are beginning to come to our senses,” he says. “It has been a wonderful ride, but we are reaching the point where enough is enough.”
“We have no moral obligation to keep people alive,” says this moral philosopher. Old people do not fear death in itself, he believes, only dying poorly, without any room for decisions being left to themselves and their families.
Not surprisingly, designated responders at the conference disagreed with Callahan’s main points. Sara Fry, a Boston College researcher with a background in nursing, stated that “age should never be a criterion for end-of-life care.” Instead, she sees the patient’s prospects or prognosis as the standard by which to judge. How well the patient can bear certain treatments is more relevant than age.
Later Fry would repeat her basic view: “No matter my age, I want a doctor to bring me a cure. I don’t want options eliminated because of age.”
Another respondent, David Solomon from Notre Dame’s Center for Ethics and Culture, judged Callahan not radical enough. He ought to have questioned the distinction between curing and caring, Solomon said, if only because patients see curing as caring.
“If you put curing and caring in tension,” Solomon claimed, “curing will win every time.” This respondent also said that it would be difficult to reduce medical benefits unless elders could be convinced it was for their own good.
John Paris, a Jesuit priest who is an ethicist on the Boston College faculty, recalled his grandmother who worked as a matron at Boston City Hospital. “It’s sinful what they’re doing to those patients,” she would have said. Father Paris sees acceptance of the human condition as the key to it all.
Readers will find discussed here only one session of a conference that lasted a day and a half and featured many other presentations rich in content. The part reported here, however, does raise some central questions that are bound to stir debate for the foreseeable future.
Richard Griffin