Health Care for an Aging Population

Allocation of health care resources and access to them is a widely debated issue throughout the world. This book is a collection of essays by multiple authors in response to Daniel Callahan's book Setting Limits: Medical Goals in an Aging Society. Callahan proposed withholding lifesaving treatment from the very elderly as a form of rationing. The discussion relates to the American health care system although the broader issues are applicable elsewhere, with future resources being more limited and with ever-expanding numbers of elderly patients requiring treatment. There is consensus amongst the authors that the US health care system needs reform, with universal right of access for all to basic health care but that non-basic care is not a universal right. The specific health needs of the elderly must be met ahead of high-technology acute care, with special reference to long-term and home care with palliation and relief of suffering. The positive image of aging needs to be promoted, stressing the large contributions that elderly people have to make to society, in the face of the current climate of intergenerational conflict that is so pervasive. Rationing of health care will become imperative as there is increasing demand, but in an era of cost containment resources are finite and therefore will be limited. The methods by which rationing can be applied and savings achieved are addressed in this book, with a variety of proposals. Rationing can be resource-based, applied by government, legislators or administrators, or it can be patientcentred, performed at the site of delivery by physicians. Callahan's proposals are discussed in detail in chapter 6 where the scarcity of resources is stressed and the importance of allocating such resources effectively and with maximal medical benefit is seen as paramount. Some authors think age-based rationing is ethically immoral, taking care away from those most deserving and most in need. Callahan and others have agreed that it is a form of discrimination against the elderly, but contend that the alternatives may be even worse, limiting health care to younger individuals who have not yet achieved their full potential in life. He feels that the elderly themselves would see the sense of his argument if the issues were properly addressed. Stysma thinks that Callahan has used age wrongly, when quality-of-life considerations actually underlie his argument. If a natural lifespan is adopted for rationing, then it ignores the significant quality of life possible for the healthy elderly person with an eminently treatable infection. Perhaps the most important issue to be discussed in this book is the nature of rationing. In the present climate, rationing does occur in an implicit manner which is not perceived as iniquitous, such as lack of provision of nursing-home beds or lack of availability of dialysis facilities. Callahan has merely brought rationing to the attention of a wider audience and has provoked much discussion as to how it should be applied. There is little doubt that in future rationing will have to be explicit, with widespread discussion and debate in a democratic fashion. The community to which it will be applied will have to be prime movers so that the self-imposition of such rationing is acceptable. Alternative proposals should not be discounted out of hand since much current policy has not been subjected to the same scrutiny. Flexible categorical rationing which has been the subject of public debate may be a good compromise, setting priorities clearly but allowing for discretion by the physician in individual cases. However, more fixed targets may be required if budgetary constraints are to be met reliably. Dr Hackler has edited a fascinating collection of opinions from leading ethicists, philosophers and physicians. Their concerns for the future of the American health care system can be extrapolated to all societies, since the aging population and the provision of health care to increasing numbers of elderly patients is a worry for all concerned. This book is thoughtprovoking and whilst not reaching a consensus opinion, aims to provide several possible alternative strategies to deal with this daunting problem for all providers of health care.