Manual Rationing Medical Care on the Basis of Age: the Moral Dimensions

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NHS organisations will need to be prepared to defend their decisions.


The news that the Cancer Drugs Fund was to be extended into delighted its proponents. However, it raised huge concerns for those that could see its obvious flaws.

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This paper reports findings from a qualitative research study which investigated local priority-setting activity across five English primary care trusts, between March and November This report explores the topical issue of whether health care should be rationed on the basis of age. Enter search term here. Filter results. Filter results Content type. Hence, this kind of writing is likely to be used as ammunition by those who want to reduce public support for health care in general and for the elderly in particular.

One ought to note that the fact that we are squeezed for funds can be used to justify rationing health care, and to insist that now we simply must limit those above a certain age to receiving mainly or only ameliorative rather than therapeutic care.

Rationing medical care on the basis of age - the moral dimensions

It logically follows — like a hangover after a night of boozing — that the cut-off age should be lowered if our economic condition further deteriorates. But then we can likewise say that about those who are somewhere between 72 and 77 , between 65 and 72 , and so on. And if other countries are to follow such a model, they will surely have to set a lower age. The possibility that using age-based rationing to ratchet down care will lead to troubling outcomes is far from mere speculation.

Moreover, it is essential to note that the concept of quality of life is a particularly slippery one. One may say that we are very short of resources, and hence must resort to rationing. However, this should be considered only if there are no other places to reduce health care costs — places where cost-cutting can be much more readily justified. And as I will show shortly, there is a surprisingly long list.

Callahan first off treats health care as if it were a hermetically sealed, discrete political and economic system.

In this Never Never Land, if fewer funds are allotted to elderly care, ipso facto, more will be available for child care and for younger people in general. This assumption ignores that elder care is largely publically financed, while younger care is not. And even if the funds remain within the public sector, it does not follow that reducing the Medicare outlays will not flow to some other expenditure, from ethanol subsidies to paying for the bombing of Libya, or to food stamps or raises for civil servants or God knows what else.

Some of these are worthy goals, but one should ask not only if they outrank helping the elderly to make even relatively small but high-cost health gains, but also what mechanism could be developed to ensure that whatever is cut from senior care will end up where it is supposed to land. However, before I would call on anyone to give up any beneficial medical interventions they seek, I would ask them — if save we must — to smoke less, drive less, and give up on status goods, among many other things. Even if the cuts have to be made within the health care system, there are other ways to proceed.

However, there are other ways which a normative analysis suggests should be considered long before one turns to reductions in therapeutic care for seniors and, more generally, to cutbacks in medical research and investment in new technologies.

If we must make cuts in Medicare, we ought first to make far more strides in reducing harmful activities. There are an estimated 44, to 98, preventable deaths due to medical error each year, according to the U. Experts hold that nearly all of those deaths are preventable.

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Study after study shows that even relatively small changes can reap major benefits. These include measures such as getting health personnel to cut their fingernails shorter, wash their hands even more often, use typed rather than handwritten drug prescriptions, use electrical shavers rather than razors in preparations for surgery , getting doctors to pay more mind to comments by nurses, and so on. The results are detailed in Safe Patients, Smart Hospitals , a book co-authored by Peter Pronovost and Eric Vohr, which advocates integrating strictly followed checklists into health care procedures, as well as abandoning the hierarchical structure of hospitals that often leaves nurses hesitant to challenge doctors when they make mistakes.

The book then shows the great reductions in medical errors that follow the introduction of checklists. Atul Gawande, a Harvard Medical School surgical professor, similarly argues for systematic checklists, offering numerous examples of greater success due to checklists, not only in the medical field but also in fields like aviation, a comparison that John Nance makes extensive use of in his book Why Hospitals Should Fly.

Next, we should cut reimbursements for those interventions for which there are no demonstrated benefits.

Again, it is unlikely that waste will be completely eradicated, but surely significant strides could be made. Equally important is to reduce administrative costs. The United States spends at least twice as much on administrative costs for health care as many other countries. For instance, a comparative study found that U.

One way this may be achieved is by using capitation, rather than reviewing every intervention. It allots a pool of funds to the physicians serving a given area and lets them make the allocation decisions within nationally established guidelines. A study by the Commonwealth Fund found that if U.

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Some experts snicker when people argue that one can achieve major savings by reducing fraud and abuse. There is less risk of exposure and less risk of punishment if caught. It does not seem too difficult to imagine that Medicare could be given more time and more resources to reduce such fraud. In short, one can readily demonstrate that before one denies beneficial health care to people of any age, even if the benefits are limited, there are other major areas to reduce outlays and put our health system on sound economic footing.

It is morally repugnant to deny people beneficial health care in order to save money before one engages in much stronger efforts to reduce harmful and useless interventions and to curb fraud, abuse, and costly paperwork. Moreover, I have no trouble envisioning an America in which, thanks to improved health care, including changes in lifestyles and in the environment, the average American lives to be years old and works until he is Average incomes would be lower, and hence people would buy fewer goods but spend more time in social and transcendental activities that are low in cost, such as hanging out with family, reading, taking walks, meditating, observing sunsets, and praying.

Callahan wrote:. He was right to identify those failings, all of which reflect a bad health care system. And as a fellow communitarian, I welcome his support for a solid and equitable social safety net. At what point does a political issue or position pass from simply being unfair, wrong-headed, or dangerous in some way or other, to being immoral? Ad hominem arguments combined with slippery slope predictions have become the accepted rhetorical style of conservative opponents of communitarian, social justice convictions.

Nothing is added, and much that is harmful is introduced into the public debate by the word immoral.

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My own observation is that neither liberals a. That our communitarian crowd favors a strong social safety net is a tribute to our wise even if politically controversial judgment about the common good, not a sign of superior morality. Sadly he is not alone in adopting a culturally relativistic definition of what is moral. And hence, of course, when there is no consensus, there are no moral standards and we are told there is nothing on which to base our moral judgments.

As I see it, there is a limited set of universal moral truths — human rights, for instance.

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