Health care technology, health care rationing, and older Americans: enough already!

As part of the health reform debate that is raging in Congress and the nation at the time this article is being written this time, frenzied claims regarding the advent of health care rationing continue to be exchanged by the more extreme wings of both major political parties. Politicians and commentators on the conservative end of the spectrum worriedly lament that passage of ObamaCare will usher in a new era of rationing that denies potentially beneficial treatments to vulnerable patients and their physicians, while liberal congressional and administration spokespersons vigorously deny those accusations. Attention has been explicitly paid to the subject of health care rationing in the United States-including the idea of using patients' chronological age as a criterion for rationing-in the ethical and public policy literature for several decades (Menzel, 1990; Smeeding, 1987; Symposium, 1992). Responsible commentators have recognized the inevitability of rationing health care in a real world of finite resources and infinite demands (both legitimate and unreasonable) but also have acknowledged the seemingly unmanageable methodological, political, and cultural can of worms that the challenge of rationing opens up (Aaron, 2008; Aaron & Schwartz, 2005). A major problem with the present (often uncivil) political discussion is that both ends of the spectrum make the same categorical mistake. Conservatives and liberals alike act as though (a) health care rationing would be a new, previously nonexistent phenomenon; (b) this new phenomenon, if it developed, would be evil; and (c) that rationing can be avoided by either maintaining the health system status quo or changing the system radically enough to wring out enormous undiscovered amounts of fraud, waste, and inefficiency. A more honest discussion, by contrast, would acknowledge that health care rationing in the United States is already a practical reality and can only intensify in the future regardless of the disposition of the current health reform debate (Kapp, 1998, 2002). Thus, a more fruitful allocation of intellectual and political effort should focus not on whether there will be health care rationing in this country's future but rather how it ought to be carried out in the most ethically palatable manner possible. A primary responder, for almost a quarter of a century, to the question of how health care rationing should be done in the United States has been philosopher Daniel Callahan. CALLAHAN'S PROPOSALS, THEN AND NOW Early Arguments Philosopher Callahan, a cofounder of the pioneering bioethics think tank The Hastings Center (http://www.thehastingscenter. org), broke new ground in 1987 with the publication of Setting Limits (Callahan, 1987). There, he set forth a fairly comprehensive proposal for radically altering the American health care delivery and financing system. The key component of his plan to enhance equal access to affordable care within a universe unfortunately but unavoidably characterized by limited financial, physical, and human resources was the utilization of patients' (or potential patients') chronological age as a categorical eligibility criterion for the receipt of particular forms of diagnostic or therapeutic interventions. Specifically, he proposed the creation and implementation of explicit, official rules disqualifying individuals who had exceeded a designated age threshold (roughly identified as 70-ish) from receiving (ideally at all but at least at public expense) certain aggressive forms of medical tests and treatments solely because they were deemed too old. Callahan expanded on this thesis a few years later in What Kind of Life? (Callahan, 1990), in which he derided the popular clamor for medical "progress" by arguing that, although many individual lives might be lengthened and improved by continuing to support medical innovation, the American population considered as a whole was quite healthy enough. …