There was a set of discussions regarding the ACA and the
limiting of services under Medicare regarding those over 65. Of course those in
the Administration voiced their objections to such an assertion yet there were
members of the White House staff who actually discussed such options in detail.
In a recent article by a former White House adviser on the
ACA the individual states[1]:
This means
colonoscopies and other cancer-screening tests are out—and before 75. If I were
diagnosed with cancer now, at 57, I would probably be treated, unless the
prognosis was very poor. But 65 will be my last colonoscopy. No screening for
prostate cancer at any age. (When an urologist gave me a PSA test even after I
said I wasn’t interested and called me with the results, I hung up before he
could tell me. He ordered the test for himself, I told him, not for me.) After
75, if I develop cancer, I will refuse treatment. Similarly, no cardiac stress
test. No pacemaker and certainly no implantable defibrillator. No heart-valve
replacement or bypass surgery. If I develop emphysema or some similar disease
that involves frequent exacerbations that would, normally, land me in the
hospital, I will accept treatment to ameliorate the discomfort caused by the
feeling of suffocation, but will refuse to be hauled off.
What about simple
stuff? Flu shots are out. Certainly if there were to be a flu pandemic, a
younger person who has yet to live a complete life ought to get the vaccine or
any antiviral drugs. A big challenge is antibiotics for pneumonia or skin and
urinary infections. Antibiotics are cheap and largely effective in curing
infections. It is really hard for us to say no. Indeed, even people who are
sure they don’t want life-extending treatments find it hard to refuse
antibiotics. But, as Osler reminds us, unlike the decays associated with
chronic conditions, death from these infections is quick and relatively
painless. So, no to antibiotics.
As we had noted previously, this same author has written
that the young and old should be left to perish for the best interest of all[2].
In this paper he promulgated the proposal that when a severe expansive disease
explodes that the young and old could or should be allowed to perish and
maximize the benefit of the most productive to society. This he has termed the
Complete Lives System. He states:
Because none of the
currently used systems satisfy all ethical requirements for just allocation, we
propose an alternative: the complete lives system.
This system incorporates
five principles: youngest-first, prognosis, save the most lives, lottery, and
instrumental value. As such, it prioritizes younger people who have not yet
lived a complete life and will be unlikely to do so without aid. Many thinkers
have accepted complete lives as the appropriate focus of distributive justice:
“individual human lives, rather than individual experiences, [are] the units
over which any distributive principle should operate.”
Although there are important differences between
these thinkers, they share a core commitment to consider entire lives rather
than events or episodes, which is also the defining feature of the complete
lives system. Consideration of the importance of complete lives also supports
modifying the youngest-first principle by prioritizing adolescents and young
adults over infants.
Adolescents have
received substantial education and parental care, investments that will be
wasted without a complete life. Infants, by contrast, have not yet received these
investments. Similarly, adolescence brings with it a developed personality
capable of forming and valuing long-term plans whose fulfilment requires a
complete life. As the legal philosopher Ronald Dworkin argues, “It is terrible
when an infant dies, but worse, most people think, when a three-year-old child
dies and worse still when an adolescent does”; this argument is supported by empirical
surveys.
Importantly, the prioritization
of adolescents and young adults considers the social and personal investment
that people are morally entitled to have received at a particular age, rather
than accepting the results of an unjust status quo. Consequently, poor adolescents
should be treated the same as wealthy ones, even though they may have received
less investment owing to social injustice. The complete lives system also
considers prognosis, since its aim is to achieve complete lives. A young person
with a poor prognosis has had few life-years but lacks the potential to live a
complete life.
Considering prognosis forestalls
the concern that disproportionately large amounts of resources will be directed
to young people with poor prognoses. When the worst-off can benefit only slightly
while better-off people could benefit greatly, allocating to the better-off is
often justifiable. Some small benefits, such as a few weeks of life, might also
be intrinsically insignificant when compared with large benefits.
Saving the most lives
is also included in this system because enabling more people to live complete
lives is better than enabling fewer. In a public health emergency, instrumental
value could also be included to enable more people to live complete lives.
Lotteries could be used when making choices between roughly equal recipients,
and also potentially to ensure that no individual—irrespective of age or
prognosis—is seen as beyond saving. Thus, the complete lives system is complete
in another way: it incorporates each morally relevant simple principle.
When implemented, the complete lives system produces a priority curve
on which individuals aged between roughly 15 and 40 years get the most
substantial chance, whereas the youngest and oldest people get chances that are
attenuated
Namely in his analysis those between 15 and 40 are deemed
worthy of treatment and those younger or older are left by the wayside. This
paper was a clear predecessor of his proclamation of 75 as a maximum lifetime,
no matter what. This not only goes beyond rationing it enters the field of
state based euthanasia.
Again one must remember that this person has been and
continues to be a spokesperson for the current Administration. Are these pure
academic musings or are they a recipe for the future of health care. Clearly the
first academic paper attracted some attention but it may have been dismissed as
the musings of a pure academic. On the other hand and in my opinion the second
outcry demanding a death at a certain age is almost an affirmation of adherence
to this policy.
The overall objections to this type of thought are as
follows:
1. The very personal discussion is perhaps in my opinion beyond
the norm. This is most likely a very private and personal issue and frankly one
does not then take your personal description of life and then expose it
publicly as a mandate for all. Between excess ego and limited social skills
perhaps a better approach would apply.
2. However, it should be noted that this same person had
examined and proposed an option of allowing early or late life death by the
process of selection based on metrics adjudged by the State.
3. Individuals who bring this type of thought process may
find a home in the academy but when they enter the arena of public policy then
there is a demand for closer scrutiny and analysis, if not outright rejection.
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