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June 1, 2012

Rationing by Any Other Name

Reasons for resisting the push to limit medical care

Newspapers and magazines do not usually regurgitate ideas that have been bandied about for decades, especially when they are replayed one more time by the same leading author. Hence, it is telling that the New Republic republished in mid-2011 the brief by Daniel Callahan (this time co-authored with Sherwin Nuland). The authors call for a ceasefire in America’s “war against death,” arguing that those who surrender gracefully to death “may die earlier than [is now common], but they will die better deaths.” They urge the medical profession — and ultimately, the American people — to undergo a cultural shift they argue is necessary to prevent the otherwise inevitable financial failure of our health care system. This shift will replace a “medical culture of cure” with a “culture of care.” They note that “rationing and limit-setting will be necessary” to bring about this change. Callahan and Nuland point to evidence that little progress has been made in our quest for cures for chronic diseases (like Alzheimer’s) or will likely be made in our efforts to significantly extend our life expectancy. Given the marginal benefit and high cost of medical advancements, they argue that we need to invest much more of our limited funds in preventive, affordable care, rather than in strenuous efforts to wring a few more years out of life.

Callahan and Nuland call on us to abandon the “traditional open-ended model” of medical care.

Focusing on care for the elderly, the authors call on us to abandon the “traditional open-ended model” (which assumes medical advances will continue unabated) in favor of more realistic priorities — namely, reducing early death and improving the quality of life for everyone. They further advocate age-based prioritization, giving the highest priority to children and “the lowest to those over 80.”

Callahan sometimes comes across as though he advocates providing only palliative care to those who, as summarized by Beth Baker in her 2009 interview with Callahan, “have lived a reasonably full life of, say, 70 to 80 years,” offering them “high quality long-term care, home care, rehabilitation and income support, but not extraordinary and expensive medical procedures.” That is, we should ration health care for our elders, granting them mainly ameliorative care rather than vainly seeking to cure the unyielding chronic illnesses that plague them. In other texts, his argument is more hedged. However, he tends to hold that quality of life is more important than length of life, especially given that the last years of our lives are miserable, as our minds wander, and we are beleaguered by incurable diseases. Otherwise, our futile battle against death “may doom most of us . . . [to an end] . . . with our declining bodies falling apart as they always have but devilishly — and expensively — stretching out the suffering and decay.” They hence determine that the cutoff point, the age at which we should put our elderly on ice, is 80. As we shall see shortly, whether one reads Callahan’s statements as stark or as more nuanced, his argument faces the same basic challenges.

Daniel Callahan is the co-founder of a premier bioethics research institution, the Hastings Center. It has played a major role in the development of bioethics in the United States, and indeed the world. (Callahan’s co-author, Sherwin Nuland, was a practicing surgeon for 30 years and has authored several books on life, death, and medicine.) However, this essay (as well as previous writings by Callahan on the same subject) is neither a work of scholarship nor of policy analysis but of political advocacy. It employs emotive terms, rhetorical devices, and vague formulas to advance a cause. Thus, the New Republic article recommends that seniors be granted a “primary care” period, which at first blush sounds much less troubling than to argue that elder Americans will be provided only palliative care. However, on second thought, one recalls that primary care is the gate to secondary and tertiary care (such as surgeries, kidney dialysis, hip replacements, and chemotherapy). Hence, if this gate is shut, primary care becomes largely ameliorative care!

As part of their advocacy, the authors frame numbers to alarm us. For instance, they state that the cost of Alzheimer’s is expected to reach $189 billion in 2015 and will rise to a trillion dollars in 2050. This assumes no improvement in treatments, even of the kind l-Dopa provided for Parkinson’s and antiviral medications for hiv (two illnesses that were not cured, but the lives of those affected were made much better, longer, and more productive), let alone a partial cure (which we did find for several cancers). It disregards that, by 2050, the economy is going to be much larger as well and, hence, a nonpropagandist way to deal with such figures is to present them as a percentage of gdp and not as absolute numbers.

The authors set up numerous straw men — for example, that Americans seek to conquer disease and to live forever.

In the same vein, the authors keep setting up straw men — and then slaying them. Thus, they argue that Americans seek to conquer disease and live forever, citing one source who declares, “We do not appear to be moving to a world where we die without experiencing disease, functioning loss, and disability.” No evidence is presented that this is what Americans expect and, moreover, even if such evidence exists — such daydreams do not provide a moral foundation for ruling whether we should stop seeking to extend life and curb the ravages of disease.

Callahan and Nuland’s exhibit number one is infectious disease. They argue that “forty years ago, it was commonly assumed that infectious disease had all but been conquered.” This is false, Callahan and Nuland say, pointing out “the advent . . . of hiv as well as a dangerous increase in antibiotic-resistant microbes.” Ergo, we should note that “infectious disease will never be eliminated but only, at best, become less prevalent.” This is lessening of prevalence is dismissed — as if it were an unworthy goal.

The authors obviously deal with the U.S. because a mountain of good has recently been achieved overseas in exactly this department. In the U.S., the main reason relatively little has been achieved in fighting infectious disease is because many of them were largely licked by an earlier generation. Spurning efforts to eliminate diseases simply because new ones creep up is like resigning yourself to living in squalor because your home is “only going to get messy again.” Oddly, the example the authors cite as a sign that we ought to surrender to the inexorable, the spread of hiv, is a research field in which great achievements were made in the past decade.

Callahan and Nuland express exasperation with “the endless issuing of promissory notes” by medical researchers that have not been paid. With regard to chronic diseases, a major counterexample can be found in the very significant improvements in the treatment of diabetes in recent years.

In short, even if it is true that the pace of progress in medical care is slowing, it is by no means nearly as unproductive as the authors maintain. And the value of the achievable should not be dismissed because it does not meet some elusive dream; it should be appreciated because of the good that it is delivering.

End of life — or age-based rationing?

One of the major findings of the research on health care costs is that Americans use up more medical resources in the last year of their life than in any other previous years. For instance, findings from the 1992–96 Medicare Beneficiary Survey indicated that “mean annual medical expenditures . . . for persons aged 65 and older were $37,581 during the last year of life versus $7,365 for nonterminal years.” These and other such statistics seem at first blush to provide strong support for the Callahan thesis. However, at a second glance, one notes that many of these statistics apply to all last years of life — whether that of premature babies too small to make it, a young person with advanced cancer or aids, or that of select senior citizens. The relevant criteria is not age but rather the likelihood that a person can be cured, or at least restored to a meaningful life, able to love and serve, and whether his or her end is near. To put it differently, Callahan makes it sound as though as soon as the body turns 80, there is an abrupt change in our medical condition. The opposite is true: Our bodies gradually change, both before and after that age, and at a different pace for different people. Much of what Callahan is talking about holds for the last months, maybe year, of life, not for those who simply had 80 candles on their birthday cake. And as the average lifespan has been extended by eight to nine years since 1960, many of these years for many of those older than 80 were far from miserable.

If ration we must, we should limit care for all those who have a terminal illness and medically determined short time to live — whatever their age. Callahan claims that “Americans” (i.e., all of us) seek immortality, are unwilling to face death, and believe in the ability to extend life forever and a day. Actually, the caring professions have developed and society has embraced a way to proceed, which is not based on age. Namely, once a person is determined, typically by a physician, to have no more than six months to live, they are referred to a hospice (whatever their age), and there they get the Callahan treatment — ameliorative rather than therapeutic care. Moreover, the fact that millions of Americans write living wills and many ask to sign do-not-revive orders shows that Americans can and do deal with end of life issues.

Closely related is the question of what constitutes a worthy or productive life. Callahan and Nuland draw on a vague concept of being able to “manage society.” Once we go down this path, many others will draw, as they already often do, on the stream of earning.

This is a very treacherous basis on which to allocate health care resources. It does not respect assets other than moneymaking, such as the ability to give love (for which grandparents are quite well-suited, I can attest, as someone who has passed 80 and has thirteen grandchildren) or to be creative and serve the community through volunteerism. And it suggests that homemakers and those with serious handicaps are less worthy human beings than the moneymakers. Indeed, if earnings were the basis for rationing health care, the best and most exhaustive care would go to movie stars, heads of hedge funds, those who sell large amounts of fraudulent mortgages, and drug dealers.

We best continue to respect all life and not allow the government to determine what makes a good life and when it is no longer a worthy one. And we best ensure that enough hospices are available — and of good quality — to those who choose to move there once they find out that their life is nearing a close, whatever their chronological age.

Slippery slopes

Revisiting these ideas now ought to be subject to particularly close scrutiny, because they are republished in the context of alarm about rising deficits and mushrooming health care costs. 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. 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. Once we set such a limit and accept the “cultural shift“ Callahan and Nuland call for, one that treats age-based rationing as morally justifiable, it is simple to show that, on average, those who are, say, 77 to 80, produce less and have greater care costs than those who are younger. 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. Fifty-five for El Salvador, and 43 for Afghanistan?

The possibility that using age-based rationing to ratchet down care will lead to troubling outcomes is far from mere speculation. For example, reports have indicated that in Britain, people older than 50 have been discouraged from seeking kidney dialysis treatment.

Moreover, it is essential to note that the concept of quality of life is a particularly slippery one. Once we cease to respect life per se and cherish only life of “good quality,” we truly open the door to defining which lives deserve to be saved and which do not, especially in hard economic times. 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.

No assured reallocation

Another major weakness of Callahan’s thesis is that it is based either on a complete misunderstanding of the way the American polity works or an unwillingness to face what it would take to introduce a regime of the sort Callahan advocates. 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. Hence, if tomorrow the government collects, say, $100 billion less in tax revenue from Americans to pay for Medicare, there is no reason to assume that these dollars will be employed for preventive care, youth care, or for any other form of health care. 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.

One of Callahan’s great merits is that as a fellow communitarian, he recognizes that we have obligations to the common good and not just rights and entitlements. (The issue was raised recently when neither Presidents Bush nor Obama called on Americans to make any sacrifices in the wake of 9/11 and the wars in which the U.S. is engaged.) 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. And in contrast to those who see our seniors as privileged and our youth as deprived, I see most seniors as having made lifelong contributions to society, while the youths’ turn has yet to come. Even if the cuts have to be made within the health care system, there are other ways to proceed.

Other ways

To argue against age-based rationing and the naïveté of reallocation is not to suggest that the cost of Medicare — or, more precisely, of health care — should not be reduced. 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 44,000 to 98,000 preventable deaths due to medical error each year, according to the 1999 U.S. Institute of Medicine report “To Err is Human.” While the report has been highly regarded and frequently cited over the past decade, a 2009 Centers for Disease Control and Prevention study found that 99,000 patients “succumb to hospital-acquired infections” annually. Experts hold that nearly all of those deaths are preventable.

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. According to the Office of Management and Budget, aligning Medicare’s drug payment policies with Medicaid’s policies would save $135 billion over ten years.

Next, we should cut reimbursements for those interventions for which there are no demonstrated benefits. Twenty percent of all medical expenditures were estimated to pay for medical care that is “inappropriate and unnecessary,” according to a 1990 study by the rand Corporation. Consistent with these findings, Henry Aaron, a leading expert at Brookings, noted that both 2008 presidential candidates “put forward proposals for curtailing waste in the U.S. health care system . . . based on estimates that various medical procedures are used inappropriately as much as one third of the time in the United States.” Among them are testing patients who have advanced, life-threatening illnesses for other diseases for which preventable treatment could not be provided in the time they have left on this earth, and screening for colon cancer, which, according to many experts, is inadvisable for the elderly, as it can result in complications that outweigh the potential benefits. Again, it is unlikely that waste will be completely eradicated, but surely significant strides could be made. And this particular opportunity for cost reduction and improved efficiency has been recognized by Obama’s Affordable Care Act, which establishes an advisory board specifically tasked with identifying and recommending policies to eliminate such waste in the Medicare program.

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 2003 comparative study found that U.S. administrative costs amounted to $30 out of every $100 spent on health care, compared to $17 in Canada. There are many reasons we cannot match Canada’s ways, but if we cut only part of the difference in administrative overhead, we would save tens of billions each year. One way this may be achieved is by using capitation, rather than reviewing every intervention. Another option is to follow the uk Tory government’s example and pursue what is called the Big Society program. 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.S. administrative costs could be reduced to merely the same level as the average for countries with mixed public-private insurance systems, $55 billion per year would be saved.

Some experts snicker when people argue that one can achieve major savings by reducing fraud and abuse. 60 Minutes, though, has documented how the Medicare fraud industry in South Florida is now larger than the cocaine industry, due to the relative ease of swindling Medicare. There is less risk of exposure and less risk of punishment if caught. Crooks buy patient lists and bill the government for expensive items, ranging from scooters to prostheses, to the tune of some $60 billion a year. Because Medicare is required by law to pay all bills within 30 days and has a small accounting staff, it often cannot vet claims before the checks must be issued. By the time Medicare authorities find out a storefront’s bills are phony, the crooks have closed their operation and opened one next door under a different name. It does not seem too difficult to imagine that Medicare could be given more time and more resources to reduce such fraud.

In a series of articles on health care costs published in the New York Times in late 2011, Ezekiel Emanuel, M.D., Ph.D., suggests a number of ways to cut costs in the health care industry. He proposes implementing electronic health records and streamlining the billing process, which could save $32 billion per year, with twenty percent of that savings going to the government. He also suggests that $80 billion could be saved each year if chronically ill patients can be encouraged to use “high touch medicine,” a system of coordinated, high-quality care in which patients’ conditions are frequently monitored to prevent crises that lead them to emergency rooms.

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. All this can be accomplished without giving up the “war against death” — a war that we know cannot be won, but that nevertheless should be fought, if only to wrestle out of death’s arms as many worthy years for as many people as possible.

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 100 years old and works until he is 80. The average work week for all Americans would be reduced to, say, 25 hours, so that there would be work for all. 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.

The foundations of moral judgments

After i published a brief along the preceding lines about ways to reduce health care costs and thus Medicare outlays, Callahan posted a comment in the Hastings’ Bioethics Forum blog under the title “The Political Use of Moral Language.” He raised issues whose importance extends well beyond the future of health care and the ethical ways to rein in its costs, as important as these are in their own right. Callahan wrote:

Amitai Etzioni, a prominent social scientist and leader of a communitarian movement, published an article in February arguing that it would be “immoral” to cut Medicare or Social Security benefits unless we first eliminate a range of pathologies in our health care system. “If we must make cuts,” he wrote, “we ought first to cut those budget items that in effect pay for harmful activities and then those without discernible social benefits.” He had in mind such long-time villains as excessive administrative overhead, waste and fraud, direct-to-consumer advertising, unnecessary treatments, and medical error.

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. But are those on the other side of the aisle “immoral”? 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. My own observation is that neither liberals (a.k.a. progressives) nor conservatives have a monopoly on morality. 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.

Callahan’s comments show that even a bioethics giant, and a fellow communitarian, can make a mistake, and not a trivial one. 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. Life and health over death and illness in all but exceptional circumstances, for example. These truths are, as the founding fathers put it so well, self-evident. (As a deontologist would put it, these are moral causes that speak to us directly.) In the subject at hand, I need no community to approve a standard that will inform me, if one has a choice between saving money by cutting reimbursement for beneficial procedures, say kidney dialysis, or cutting the funds that pay doctors who run two cts on the same patient on the same day or blowing money because insurers refuse to use the same claim form, which is the moral direction to go. It may not be politically practical, but there is no question what is right. (And the fact that one may find some very limited conditions under which the suggested statement will not hold just shows that some philosophers are sharp, not that we lack foundations for moral judgments.)

Callahan correctly points out that I use normative arguments for a political purpose. All political acts and decisions have a moral dimension, and if we do not judge, it will not stop others from laying moral claims, just mute our side. Moreover, is this bad? I am trying to shame and lose votes for those who pass immoral laws that provide obscene profits to health insurers and exorbitant salaries for their executives while cutting funds for health care for poor children and many more such policies. I stand content to be judged accordingly.

Callahan truly crosses a line when he jumps from my position that some people make immoral choices to argue that they must be bad people (his non sequitur), and therefore accuses me of ad hominem attacks. As I see it there are some bad people, those who have no moral conscience, the psychopaths. Most people struggle between their debased and nobler sides, and I am out to give whatever support I can to their better angels.


Amitai Etzioni is director of the Institute for Communitarian Policy Studies at George Washington University. He is indebted to Courtney Kennedy for research assistance on this article.