The Redefinition of Aging in American Surgery

For over three decades, progressively increasing rates of surgery among adults aged sixty-five and older have been recognized as a major component of growing U.S. health care costs (Bodenheimer 2005a; Pauly 1979; Wennberg 2010). Predictions that the aging of the population will cause further growth in the utilization of surgical services (Etzioni et al. 2003a), combined with questions surrounding the cost-effectiveness of medical care for older U.S. adults (Cutler, Rosen, and Vijan 2006), have led policymakers to debate the wisdom of age-based rationing of health care resources in general and invasive and costly procedures in particular (Baicker and Chandra 2010; Brody 2012; Callahan 1987; Levinsky 1990; Persad, Wertheimer, and Emanuel 2009; Reese et al. 2010). Past efforts to understand the reasons behind increasing rates of surgery among older adults have commonly focused on explanations related to the nature of health insurance in the United States, technological advances in medical care, and changing population demographics. Economic arguments have stressed the role of incentives created by fee-for-service insurance programs and Medicare's coverage of most U.S. adults aged sixty-five and over as encouraging high overall rates of surgery in this population (Bodenheimer 2005a; McGuire 2000; Valvona and Sloan 1985; Wennberg, Barnes, and Zubkoff 1982). Alternate explanations have pointed to technological advances in surgery and medicine that have expanded the scope and safety of operative care (Bodenheimer 2005b; Cutler and McClellan 2001), increases in life expectancy over time (Rice and Feldman 1983), and the “compression of morbidity” into a shorter period before the end of life (Fries 1980; Mor 2005) as phenomena that have created an expanded role for surgical interventions at later points in the life course. These explanations provide only a partial account of how surgical procedures grew to become a commonplace feature of medical care for older U.S. adults during the twentieth century. Excluding obstetrical care, the principal focus of surgery in the United States during the century's first four decades was the treatment of acute illnesses and injuries in children and the middle-aged (Collins 1938); today most nonobstetrical surgical procedures are carried out to treat cancer and the effects of chronic illnesses in older adults (Buie et al. 2010). This shift was not merely a straightforward response to financial incentives, novel technologies, or population-level demographic changes; rather, it involved fundamental transitions in medical thought related to surgery and aging that yielded new perspectives on the relevance of age to surgical decisions and the proper role of surgery in the life course. For this article, we studied this transition in medical thought through an examination of two case studies; namely, the expansion of general surgical procedures among older U.S. adults between 1945 and 1965, and the spread of coronary artery bypass grafting (CABG) among the U.S. elderly between 1975 and 1995. In choosing these two case studies, we sought to understand prominent themes, arguments, and perspectives that characterized professional discourse surrounding the diffusion of invasive procedures in the elderly as an innovation in health care at different moments in time and with regard to distinct surgical technologies and degrees of operative risk. Notably, our examples come from periods during which surgical utilization increased for the U.S. population as a whole; yet through them, we show how in each case surgeons employed analogous arguments against the validity of chronological age as a criterion for specific types of operative interventions, often in the face of high operative mortality rates for older versus younger patients. We describe how such arguments repeatedly sought to negate the relevance of age to medical decisions by searching for other phenomena—such as the presence or absence of coexisting diseases—to explain apparent age-related outcome differences. We examine how these arguments worked together to frame surgery in the elderly as uniformly beneficial, and how, in so doing, they contributed to the establishment over time of surgical intervention as a normal feature of aging in the United States. Finally, by highlighting how these perspectives have ultimately come to be called into question by contemporary observers, we explore the ways in which the views of aging that they embraced pose distinct challenges for current health policy efforts to define the appropriate role of surgical intervention within an aging population.