Healthcare rationing and end-of-life medical interventions in aging populations

¶ … Death and Natural Life

Since the age of modern medical intervention and surgery, healthcare in general, sanitation, and nutrition, human longevity nearly doubled in the Western Hemisphere during the 20th century (Yates, Djousse, Kurth, Buring and Gaziano, 2008). In most respects, that is a good thing, but there is also a dark cloud to the silver lining. Specifically, larger numbers of people continue living long beyond the age at which they would probably have died and for many of them, their last years of life may be more painful for them and for their families than they would have wanted to prolong through aggressive acute interventions as long as they did.

One of the consequences of the fast evolution of clinical medical science is that the vast majority of healthcare resources will inevitably be spent on the last phase of life, and often without necessarily generating value in terms of quality of life from public healthcare resource beneficiaries. That is not to suggest that healthcare should not work to prolong and maximize the quality of human life as much as possible. But there is no benefit to managing patients at the probable end of their natural lives exclusively as medical cases without consideration for whether prolonging life by artificial intervention is necessarily the optimal moral choice from some perspectives. Generally, if there is only a pessimistic prognosis for the objective quality of life for a patient of advanced age, making the most aggressive recommendations for clinical intervention of all of the natural ways that death otherwise occurs naturally from advanced age may not necessarily be the most ethical thing to do.

Natural Life Span vs. Maximum Life Span

Natural life span is not the same thing as maximum life span. The former refers to the life span or life-span range that is the most probable for a given person at the time of birth (Yates, Djousse, Kurth, et al., 2008). It reflects all of the factors and influences that typically determine longevity for the members of a given population. The maximum life span refers to the highest verifiably recorded age of any member of a given population; by definition, this represents the exception rather than the rule.

Age Discrimination vs. Race Discrimination

In principle, age discrimination is like race discrimination in that it results in different rights or treatment of certain people because of a shared characteristic and also because that characteristic is not something that is the result of choice. Just as nobody can control his or her ethnicity or skin color, nobody can avoid aging or deteriorating in health as a function of advancing age. However, age discrimination and race discrimination are much more different than they are similar, mainly because everybody ages and because there are objective rationale for certain kinds of different treatment of people based on chronological age that do not apply to racial discrimination. For example, race does not determine how physically capable a person is of performing a set of tasks or how long he or she may continue working for an employer, or how much he or she is likely to miss work because of health problems or how much the employer may have to pay out in healthcare costs over that employee's career with the organization.

Feasible Possible Alternatives

Instead of asking about or framing the issue in terms of the chronological age of patients, it might make more sense to focus on the underlying reasons that age is sometimes a reason to question aggressive medical intervention to prolong life. For example, there is nothing age-discriminatory of excluding cancer patients from organ transplants or from heart bypass surgery; and there is nothing age-discriminatory about excluding Alzheimer patients from major surgical intervention intended to prolong life at public expense. Certainly, all of those medical conditions are associated with advanced age in a correlational way; but the exclusion would not consider age per se. It would reflect the objective purpose of not using public funds to prolong life beyond the point where doing so could be futile from the cost-benefit or the relative quality of life. Under that approach, one-80-year-old patient might be denied coverage for a heart bypass because he has advanced cancer or Alzheimer's; but another patient of the same age without those issues and with a prognosis of living another five years might qualify for the same coverage. Admittedly, that introduces ethical issues in connection with relative material wealth and a two-tiered healthcare system based on wealth, but it goes a long way toward solving any problems over age discrimination.

Reference

Yates L.B., Djousse L., Kurth T., Buring J.E., and Gaziano J.M. "Exceptional

longevity in men: modifiable factors associated with survival and function to age

90 years." Archives of Internal Medicine, 168(3) 2008: 284 -- 290.