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D1str1but1ve Justice 1,1d tne Allocation of Technolog1ca1 Resources to tne Elderly Robert M. Veatch, Ph. o. Professor of :-led1 ca 1 Eth1 cs Kennedy Institute of Ethics Georgetown University Washington, o.c.
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'\ DISTRIBUTIVE JUSTICE AND THE ALLOCATION CF TECll401.0GICAL RESOURCES TO THE ELDERLY INTRODIETION I. BASIC DESCRIPTIC. (F CCIPETIN& THEORIES fF DISTRIBUTIVE JUSTICE A. The Definition of Justice a. Justice IS I Princiele and IS I ThlO!J of Distribution c. Al trnative Theories of Justice 1. Lib1rt1ri1nisa 2. UtilitAr11n1111 3. Muhlln 4. Ep11tar11ni111 D. The Concept of tlll Safes, Nit E. Tne I11111ct of Theories of Justice ul!!!n the Del iverl of Heal th Care Services to the Eldrly in General 1. Li oertari ans .'l. Utilttartans ~l. Mu1aln 4. Eplttartans F. Iml!!~t of Theories of Justice on the Use of L1fe-5usta1nini T1ct1noloa1es wttn the Terainalll Ill Elderly 1. Th Concept of Termtnal Illness 2. The I!:J!11cat1ons of Various Theories of Justice Libert1r11nis11 b. Utilttarianfsm c. Mlxir.rln and E&al ttarian Aeeroacnes J:: ;( ,. ,, '. ,-' -~ 1 6 6 7 8 8 9 10 13 16 17 17 19 22 24 25 25 26 26 28 31
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G. The Interface between Ethics and EcoflGlilics of D1 stribut1ve Justice H. su-rz.of Iap11c.tions for Life-sustain1ng Technologies II. CCIISIDERATION CF AGE AS A CRITERICII IN TIE ALLOCATION OF TECHNCI.OGICAL RESOURCES A. Al! 1s I Direct and Indirect M11sure a. Arll!!nts in SU(!l!!!rt of the Use of Age as a Criterion 1. The Age-Der.llnds-ReSl!!Ct Ari!nt 2. Ali! as I Predictor of Ut111!;l 3. The Araurant for OVer-1-Lifetiwe Well Being 4. Tne Arl!ant fraa Contract a. Arl!LIIRU A9!inst tne Use of A1e IS I Criterion 1. Eg1lit1ri1nism with the Sltce-of-tia Persl!!ctive 2. Libertar11n1m .. ,~ 34 31i 37 37 40 40 41 42 43 45 46 47 3. The Rule Utili!l Ari!!ant Ai!1nst Uling AP! 111 Criterion 48 4. The L 1 fe-1 s-sacred Arl!rant s. The Use-of-Soc1ol!!lica1 Categories Ar!!nt c. Ml xed Ari!!r.ants Regardi !!I Ai! as a Criterion o. SIV1!!,I Lives Versus Saving Life-Years E. Intl!nerationl Resl!!!ns1b111t1es and Conflicts III. Tl HEALTH CARE RESOURCES THAT r-AN BE DISTRIBUTED A. Tne D1stfnct1on Between H1gn and Low Tecnnology 11 49 50 51 53 53 57 58
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IY. a. Spac11lized Settings c. Health Care Providers ~. Supf!Ort Syst1111 such 11 Falll111es1 COW1nities, Regions POSSIBLE BASES rE lIACROALLOCATION A. Ten Pou1ble Bases of D1str1but1on 1. Egua115I 2. Proportionality 3. Nffd 4. Dest re s. Abtlt~ 6. Social Usefulness 1. 111111 npness to Serve a. Effort 9. Previous Social Harw 10. Fee11ne of Bt1ng Han.ad a. Tne Exmple of AM! and DRGs V. POSSIBLE BASES m:' MICROALLOCATION A. Mlcroallocation on tne Bs1s of Usefulness a. Ep1l tt1r1an Mt croallocation 1. Randm Selection 2. Rat1on1!!9, l!L < \ ,. ... ... .., .. 60 Cil 63 bl 64 64 64 65 65 67 67 67 68 ti9 7U 7U 72 7a _74 75 75 ./ -
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.... ... 3. Glopr1pn1c1l Av1111bt119 c. AM!:!ISed Mtcroallocations YI. PUBLIC PCLICY OPTIONS A. Gln1r1l Policy Options 1. ll!!cr Ai! u a Mitter of Poli~ 2. Age as an Infonaal Poli~ 3. Conscious Policy ANIS of CO!!INISional Action 1. Act1v1t1es for Ir.-d11te Action Idlnt1fl and St.a!!l Existi!!I A1!b1s1d Allocation Poltc11s b. A Prosl!!cttve stugi of tlll Use of Al! 11 Crii..r1on 1n A11ocat19 tt..,.t Tr1apl1nt Funding c. A Cout!r1 SOIi of tbl USI of AM! II I Crf ter1on wtth Other U11s of Socto121tcal C1teaor111 d. Det1raln1 the De Facto Role of Al! tn Cl tntc1l Cllotces 2. Po115191!tion1 for Exilor1tion Usi!!II DRCis 11 a W!l of 1lloc1tf!!I on the Basts of Age b. Po11cf1s Differentt1t1ng Optional 1na Required Cc1re ') '.,., II!,~ 76 76 77 71 77 78 79 80 81 81 82 83 83 84 84 85
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' c. Extending Federal Allocation Principles to Private Insurers d. Developrant of Mltnods for Deterr.tlninp Publ 1c Consensus YI. PUii.IC PCI.ICY OPTIONS (~ONT.) a. Areas of congress 101111 Action (Cont.) 85 8:i 3. Lonp-terra Policy Alternatives 8u D1v1lop I Pol tq tnat No CIN Be Allocated on the 81111 of Ap 86 b. Regutr1n1 Opttonal Iurance for L1fe-Sustatn1ng Tecllnol ogtes 8ti c. Devel-nt of I List of TrNtants not to be Furldecl for Eldlrly Persons 87 c. Adeguaq of Ex1st1ng Federal Prop...,. tn Acht1vtn1 Just Allocation of Resaurces D. Chln,ps 1n Re1murs .. nt Systas CONCLUSION 88 88 89 .. -
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--j ., -1" "' TIie use of 1 tfe-sust1tntng technologies offers great llope for patients suffering frou cr1ttcal illnesses nd radical crises. Ml--, persons IN 111ve today because of hfe-11,tng 1ntt"ent1ons such 11 CPR Ind ant1btot1cs. Hl,-y ll1ve a.tr ltves 1111nt1tnec1 through the UH of renal d11ly1t1 and prolonged achlntcal vnt111t1on wll beyond the point Win u.y wuld 111,e ot11erwf11 died. Unfortu111tely SCla of tlllM persons hive tllefr ltves prolonged tn stgnfftcantly coapNNllflld condttton. Morlover, 111111 of Ula lffe-sustatning tnte"enttons ire ext.-..ly expenstve. TIie cOllbtnatton of 1 tfe mtntenance fn seriously dlbtliUtecl state ind the great expense of 1111nta1n1ng tlllt ltfe Mve r1isee1 questions of llllletller tt ts f1tr or Just or N1so111ble tlllt scarce resources be used tn tbts way. Furtben10re, 1 htgh percentage of persons atntainecl tllougll thlt use of 11fe-sustatntng tecllnologfes ire quite eldarly. Many have hid long, fruitful ltves. Others, even thOugb hiving U.tr 1 tves taapor1r1ly preserved, wtll dte after I relatively sllort period tn sptte of the intervention. Saa 11111 dte because tlll ltfe-su1iat11119 tldlnologtes are only taapor1rily successful tn 1rresttn9 the tlnlfnal condttton. Others are able to overcoue their or1g1na1 llldtc1l prabl11111 but still have rel1ttvely short ltfe-expectancy. Stlttsttcally, they wtll dte in a relatively short tta frou scme other c1111e. TIits report euatnes tne probleas 1f dtstr1but1ve Justice and the a1loc1tton of tecllnologtc1l resources to the elderly. In order
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-2-", ) -~ '> .J ... ... .._ tounderstancl the _coap 1 ex 1 ty of the eth1 ca 1 and po 11 cy prob 1 ee1s posed. 1 t fs ftnst nacessary to have I sense of the mjor c011pet1ng theories of dtstrtuttve justice. That w111 be the objective of thl ffrst part of thts analysts. WI 111111 SN that Heh theory of dfstr1but1ve Justice has ftl 0111 t11plfc1tfon1 for how health care resources are dfstrfbuted to the eldarly. The secona part of this report looks mre narrowly at the spectftc question of the use of age 1s I cr1terfon tn the 1lloc1tfng of tec11nologfc1l resources. WI shill exa11tne ttle question of whether ft 1s f1tr 1ne1 1tbfc1l to consider age 1s at lust one of tbl crftarf1 for dlcfd1fll wllo sboUld 91t I a11lysts rachfne w. s~ll confront the issue of llow the choice should be 1i11cle between two persons of sfgntffcantly different ages Wllln there 11 only one v1nt1l1tor or one dfalysts machine 1v11l1ble. In the tbfrd part of tnf s stuQ vf 11 provide I closer exafllnatfon of 11111th care resources SNfng wttethlr the nature of the resources 11111 have. 1 bNrfng on hoW they are dfstrfDwteu. SUch dfsttncttons 1s high tldlnology vs. low technology 1na acute vs. chronic fnt1rv111t1ons wtll be explored. The 1 a tar parts of tll1 s report w111 exuaf ne. 1 n turn. tbe poss 1 b 1 e principles of croallocation and aicroallocatfon and SOlil8 public policy options. Tne probl1111 of 111ocat1ny 11fe-susta1n1ng resources can Dest be introaucecl by considering a case problem. The case involves a patf~nt we Shill call Mrs. Bertha W1lson.
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' -3Mrs. Bertha Wt 1 son 1 t ns by herse 1 f 1 n a rettr1111nt condau1n1um 1n Florida. Her hllsband, who had been I pllys1c1an, died twen't.Y years previously. SIie is 87 yNrs old. SIie n1s 1rt11rttis, Hrly signs of cta1ntia, 1 cardiac 1rr11ythlrla, SClill problews from walking fraa I hip tbat my require surgery, and ts Hg1nn1ng to show signs of kidney failure. She has discussed with her pbystcian the posstb1111.Y of aovtng to a nursing IIGlle. She was found wandering recently several olocks froa her IIGlle. She also needs cloN supervtston for tbl taking of her heart mdication. SIie ts not 1t 111 happy about got ng to the nursing hOlill. In !act, she may refuse. If she does go to tbl nursing hClill, s11e1 her physician, and ult1111tely tbe soctet, face several difficult questions. Who will pay for that care? Shaula Mltclicare provide ttle coverage? If so, should 1t also provide ttle htp replac1111nt? Should 1t provide the d1a1ysts? Should her condition deteriorate, should 1 o (do not resuscitate) order be written for her tn case of I cardiac arrest frcx.a ner 1rrhythat1? Should parenteral fluidS and n1so-g1str1c feeding be provided? Assuu1ng she desires any or 111 of these treatants and health professionals are 1vatl1blt and w1111ng to provide thelil, should I WOClln !") : .~-
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' -4wttll 111 of these serious aaedfcal proDleas and a very short ltfe expectancy be rece1vtng the treauants under consideratton. Should tier age be a factor 1n miking a,-, of these decisions? Tbt case, Wll1ch ts I coraposfte of three re11-11fe situations, poses 1 set of newer b1oetll1ca1 problms raised by the increasing abf11t, of 1i11d1cal technology to prolong ltfe. In the 1970s the crtt1ca1 radical e-thfcal f ssue for raany people was establishing the right of terufnally 111 persons to refuse treatment. As that rtght ts fncreastngly recognized, SG1.11 patients, perhaps Mrs. Wilson, are dlcidtng that even tllough tbetr prospects are not good and tlletr 11fe expectancy ts short, t1111 prefer to have ltfe-sustafntng treatants. TIie fact that many of tlllse persons are quite elderly and therefore hive relatively snort ltfe-expectanctes. introduces tne role of age as I critical factor 1n allocating 11fe-sustain1ng technologies to the elderly. In certain countries of the world age .ts an igportant cr1ter1on in dectdfng who gets scarce radical resources such as dialysis 111ct1ines. In Britain 80 percent of dialysis centers exclude persons over 65. In Finland 89 percent exclude those 65 and older (Prottas. Segal, and Sapols~ 1983, p. 98). Although this may reflect I a>roaa tnforral consensus rather than a formal policy (Wing, 1983, p. 1157), the pattern at the level of tne 1nd1v1dua1 d11lysts center 1s clear. On the other hand, 1n other countries. such as Israel and the United States, dialysis center po11c1es that exclude on tne basts of age are alr.10st unheard of (See Table I). :
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.._ f) '. ,..., -5' Table 1: Age as a Selection Basis in Dialysis Centers Nltfon Percent of Centers Percent of Centers Excluding S5+ Excluding 65+ Austrf 0 41 Belgfuu 0 32 Dem11rk 11 56 Finland &b 89 France 0 6 West Germany 0 2 Greece 4 26 Ireland 33 67 lsr11l 0 10 Italy 1 12 Luxllilbourg 0 0 Nltb1rl1nds 0 40 Norway 0 56 Spafli 1.5 54 SWedln 0 42 SWitzerland 0 30 United K1ngdaa 35 80 United States 0 0 Adapted froa A.J. Wing et al., COC1b1ned Rert of Rea!lar D1alys1s Trans l1ntatfon 1n Euro VIII 1977 Ta61es V and Viii in 8.H.8. It 1s re caap11c1tld thin 1t u1ght appear to detera1ne exactly whit accounts for these differences. While SOlill lillSt surely be explained on thl blsfs of variations in fNlinys about whether the eldurly are entitled to dialysis, other factors also COlill into play. Differences 1n levels of resources, for ex114>le1 appear to play SOl.ll role. Moreover, age ray bl being used as aft indirect measure of SOlill other variable that 1s considered to be I re1e,1nt basis of 111ocat1ng care. It ray indirectly measure likelihood of successful treatmnt. Oecision-111kers may, for 1x111pl1. hold that dialysis should go to those for whor.a 1t will _.:
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-6' n : :,;--. J ,,: '~ ,: be aost.successful. If authorities in various countries differed 1n tbetr 'beliefs about whether the elderly could benefit froa dialysis as lilUch 11 younger persons, they would differ in tlltf r treatmnt of the elderly. In any case, it is clear that different patterns of allocating lif1-sust11ning resources to the elderly exist. Different theories of d1str1butive justice lead to different allocations not only for dialysis but for the other technologies under invest1gat1on--resuscitltion, prolonged lillChanical ventilation, ant1b1ot1cs, and nutr1t1onal support and hydration. This analysts ex11.11nes the maJor theories of justice and their i111p1ct on the allocation of life-sustaining technologies. BASIC DESCRIPTION OF CQl.lETING THEORIES rE DISTRIBUTIVE JUSTICE A. Tne Def1ntt1on of Justice The probl of how to allocate resources ethically 1s now non111ly referred to as the probl of distributive justice. Justice ts 1 deceptively amiguous terw though. Aristotle (1962, v. 1) first distinguished between what he called the broader and narrower senses of the t1r111 Justice. In the broader sens,. justice ra11ans roughly the sara as t11e right. Thus one might say it is u_njust to tell 1 1 ie. Justice in the nari-owr sense, according to Aristotle, refers to fair distribution. It is in this second, narrower sense that we shall examine justice 1n the distribution of scarce life-sustlining technologies. our question 1s thus, what are the ajor theories of a just distr1bution and Whit are their implications for the Yse of aye as a basis for allocating ltfe-sustaintng technologies?
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., -7{1 '' ., a. Justice as a Principle and as a Theory of Distribution our project 1 s made more coaplicated by tne fact that even when we lfaft our attention to the d1stributfve aspect, justice is often thought of 11 one UDng several fundlrillnt41 ethical principles {Ross, 1939, p. il; National Corafssfon for the Protection of Huraan Subjects of BfOClldfcal and Behavioral Research, 1978, Beauchamp and Childress, 1993). As a single principle 1t will tell us only one aspect of our moral duty--our prfra facie duty to use the standard term. A prf...a facie GU1.Y 1s a duty consideriny only one aspect oi-principle of action~ Sf net there lilly be any prilill facie duties and they may cor.ae 1 nto conflict, an ethical th~ory wfll hive to fncluae an account of what should happen when prfma facfe duties conflict. The result will be what ts referred to as a duty proper. Justice ts a prfm facit du1;y that 1s identified with sa111 character1st1c thought to be a proper bsis of distribution such as equali~, netd, arit, or desert. It provides one 1l1r.11nt taken into account in decfaing wt11t is I fafr dfstribution. It will have to be related to other baste principles (such as auton~ or beneficence) in order to determine Whit the proper action on balance 1s--our duty proper. Exactly hoW Justice is related to the other duties wtll depend on ones etllfcal theory. The principles ray be balancea--traaed off against each other--or they may be ranked in soae order of priority. The result ts that ff Justice 1s pr1ncfp111 then ft 1s possible for an action to be Jus~ but nevertheless not the right thing to do--because other principles take preceaence. Justice r.-..y also be used as a teru referring to the overall theory of how things get dfstrfbuted. In this sense a theory of justice is a ; ;
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-8iV-theory of d1str1bution tai1ng into account not only characteristics sucn as nNd or rit, but also how these are related to pro1.10t1on of hurdln freedOlil or production of benefits. It 1s in th1s last sense that we shall explore the problea of justice in relation to the aistr1but1on of 11fe-susta1ning technologies. c. Alternt1ve Tneor1es of Justice Four raaJor answers are co1.1,1only gi_ven to the question: how are goods fairly distributed? They are, the libertarian, ut11 itarian, rau1m1n, and egalitarian positions. S0r.1e theories (such as Rawls's [1958; 1971] maximin position) are mant to apply only to the basic institutions of society. Others have broader implications. Since we are primarily concerned about the basic social practices of our society, this d1st1nction will not be critical. A nurJ>er of helpful reviews of these positions have now been published (Buchanan, 1981; Beaucharap, 1982). 1. Libertarianism L1bertar11niSJ.1, the first of tr1e four theories we shall explore, 1s one of I group of theories tnat spell out what persons are entitled to possess. As sucn they are sOL11tir.1es referred to as entitlllilent theories. Libertarianism, given current renewed eraphasis and respectaD111~ by the 1974 publication of Robert Noz1ck's Anarchy. State and Utopia. holdS that persons ire entitled to what they possess provided they acquired it fairly. For Nozick that is by ,1eans of gift, exchange, or original appropriation of previously unowned property. Heavily influenced by John Locke and the image of original appropriation frora a state of nature, Noz1ci's position places yret er.1phasis on individual 1 iber~. Persons are pen.11 tted to <10 ,1hatever they want with what they possess provided th~y do not violate the holdings of others. It is .:
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J : n, I\ ~-V ,.: .J.. V .J.. -9obvious that different persons possess dffferent amount of resources--1tt11er because they were fortunate enough to inherit thllil or were fortunate enough to receive natural endo-.nts that 111ke 1t possible for thlll to accuaalate thea. Holders of entitllli1ent theories of the libertarian kind are not distressed with this result. They reject any particular end state or pattern as tne ethically correct distribution of goodl. If sODe possess a great deal and others do not, that is unfortunate, -but not unfair--provided goods were not unjustly appropriated. Nozick and otner 1ioertar1ans dO not oppose redistributions that wake the less fortunate Detter off. They simply oppose governmentally forced red1str~butions. Those who possess may voluntarily give away what they possess as an act of ch1r1Q. That would perhaps De a kind or noole thing to do, out 1t cannot be required of them. 2. Uti11tar1anism If l ibertari1nt111 takes the prtnc1ple of 1 fberty as the daafnant ethical principle in determ1n1ng a Just d1str1but1on~ ut11itlrian1sm, a second Jor position, takes beneficence.or the rax1miz1ng of utility as daratnant. Solle of the mst taportant thinkers (Benth11:11 1967. r4111, 1967, Stdgw1ck, 1966) in the history of ethical theory have adopted this position. It 1s the position that what sakes an action or practice right ts sfaply that 1t produces the greatest good. Al though sGLae ut11 itarians bring other principles into account arguing that these other principles are indirectly practices or patterns that are ways of producing the grNttst good, the ut111tarians we are interested in 1t this point (the ones SOlilltilills called act utilitarians), consider an act to be right when 1t prodUCes the greatest good. Applied to prob18LIS of d1striout1on, the pattern of dtstr1but1on that will be tbe r1-t one 1s the one that
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-10. proe111ces the most good. That is the moral logic behind rany policy analyies such 11 those using cost-benefit and cost-effc~1veness 1n1lyses. They ire techniqus for calculating the nenefits and harm of alternative policies 1n order to deteru1ne which one w111 produce the greatest good overall. Thus a straight forward cost-benefit 1n11ys1s 1s conctuctea only by one who has rade an 1apl1cit cocmitr.1ent to uttlitartan1sm of this kind (or at least f1ndS the question of Which pol icy will 111Xtmize the good consequences to be relevant). By contrast 1 l1bert1ri1n might consider 1t irrelevant that taking sora resources fraa one wllo possesses tha and redistributing thelil would incruse the total U1DUnt of pd. If persons have liberty rfgtlts of possession, thin the fact that another pattern produces mre benefit w111 not be an 1rg111i11nt for a lillndlted redtstrfbut1on. 3. Mlx11i11n The ltbertartan and ut111tarian patterns of distribution are obviously very different. They have 1ttr1cted ny followers. What 1s striking, however, ts that nei'ther necessarily involves any red1str1uut1on to aet tne neeas of tile poor, the s1ck, the least well off, or the elderly (Who are poor, sick, or lust well off). Ltbertartantsa would permit such redistributtons 1s I ratter of charti.,. Ut11ttar1an1sm would be open to redfstributtons to the poor 1-f, and only if, red1 str1but1 ng resources increased the total llilOUnt of 900d 1n the socieQ. Such redtstr1but1ons tn favor of the less well off do often increase the tota 1 ariOunt of good because the h1n.1 that 1 s likely to be done to the wealthy person 1s less than the good that could be done for poorer persons with the s11.11 resources. Thus as an empirical tter, redistributions tn favor of the less well off w111 often increase
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-.. ... -110 {' ,J ... Ju overall uttlt~. WtNtn they uo, they will oe appropriate, but only because tlley are tncre1sing utility; not because there 1s any inherent moral prtnc1ple that favors equ1ltey or red1str1bution on the basts of need. ~rs. ttowever, dO nots the drive toward greater equality as r.11rely a strategy that non.111ly 1a11ximtzes benefit. They are concerned IIIOllt those special cases where dtstrtbuttng things more equally or d1str1but1ng tn proportion to need w111 actually decrease the total aggregate welfare. The allocation of 1 ffe-sustatning technologies 1s a aJor area wllere distributing resourc11s to tne least well off 1s not always going to mxiuize the good. The aost important example is John Rawls. Whose A Theory of Justice (1971) bis reoriented twentieth century phtlosopt,ical and public policy analysts of the probleras of distribution. Rawls sets out to ffnd the fullClllillntal principles for the baste institutions of a society. Hts atbod ts a contract mtnod, but ft ts taportant to separate the contract r.1111:llod froa the substantive answer Rawls provides.* Rawls (1971. p. 302) argues that two baste principles would emerge tlllt tell us wt11t a Just distrtoutton would be: *1111 contract thod ts to attmpt to detenaine the baste prtnctples by asking lllllat rational. self-interested persons would agree to if they _.. Drought toge1:ber to write the rules for the society under conditions he refers to as tne veil of ignorance. The ve11 of ignorance is 1 condtt1on which atteupts to nullify the specific contingencies of persons. Under such I hypothetical condition, persons contracting for a set of prtnctples would not ,now ceri.in kinas of particular facu: their places 1n society, cl1ss position or social status. their personal fortunes 1n the d1strtbution of natural assets and abilities. inte111yence, stntngth, ana the 11,e (1971, p. 1J7). They would also not know me1r tndtv1dual life plans. their fnd1vidua1 psycnolog1es. or the particular ctrc11111tanc1s of their society. They would know, however, the general facts of hu111n socie~: political affairs. principles of
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--12 L f\ J '"". .-. V -Each pe_rson is to nave an equal right to the mst extens;ve total systlla of equal basic liberties corapattble with a simt~ar systlla of 1 f berty for 111 Social and econaufc inequalities are to be arranged so that they IN both: (1) to the greatest benefit of the 1Nst 1dV1nt1ged, consistent witn the JUSt savings pr1nc1ple, and (b) attached to offices and positions open to all under conditions of fafr equali~ of opportunt~. What is crttical for our purposes fs the following: (1) There ts an initial presuaptf-on of equalfty of outcOIII tn the d1strfDut1on of resources. (2) Libert stands in I special place such that equalt~ of 11bn.J takes precedence and cannot be overca111 even to provide benefits for the least wll off. (3) Inequalities are toleratad ff, and only if, they redound to the benefit of the least well off. Stnce the second principle of Rawls 1s designed to mxfmize the position of the a1n111111 or least well off group, the theory of distribution articulated ts often referred to as 1 maxtmin posft1on. It holds that there fs soathing mrally compelling about arranging resources so that the group on the bottaa ts as wll off as possible even ff the result 1s thli the aggregate IIIOUnt of gOOd ts not as great as tt could have been wfth saae other distribution. econautc theory, the basts of social org1ntz1tfon, and the laws of huran psychology. Tne result ts a hypothettc1l construct, ataphor for t11p1rtt111~ and altrutsu. R1wls argues that the baste principles that persons would adopt under these conditions of the veil of ignorance are thoN tllat are required of mraltty. He never argues that such contracting could take place, only that ff we want to know what moraltty requires we should try to tmagtne such I social contracting process and try to deduce what would result.
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r. -'--,.-~ .. ---.. ... -13. ~ ,.., .J ... VU Rawls, like the l1bert1ri1ns, holds that S0'11tb1ng counts other than N .. .1111111nt of good in I soc1e~. While for the libert1ri1n1 it 1s the rtgll'tl tht accrue frGlil personal possession, for the lillX1a1n tlleor1st ft ts getting tllose on the bottoa 11 well off s possible. This provides ,-rful tntellectual fr.U11WOrk tt11t overcoas SOIII of the st severe problas with ut111tartan1sm. Mutatn theory, for 1xupl11 squares with IIY people's aorl ntutt1on tnat slavery ts wrong regardless of fact tllat tt dNs re good that hara. 4. Eplitart1n1a Mlxtllfn tlleory ts one exa,aple of theory of Justice ttllt places special mphaifs on tlll nds of the least wll off. It starts 111th 1 pre11&1ptton of equality 1s I check against indtvtclull liberty and 191re91te social welfare. lIU1a111 theory bas thus servlCI n important lternative theOry to l1bert1rt1n nd utflftari1n appl'OIChes to dtstrtbutive justice. It resonas well with taportant relfgtous and secular strnds of Western thOught. Sor.II, howtVer, have pointed out that IIIXiatzing the posft1on of the 111st well off group does not necessarily require 110Vin9 toward yra1ter equality. In fact, mutmtn theory provides 1 fr1111NOrk for deciding precisely When tnequalittes are morally 1ppropri1te. Seweral cmntators (Barry, 1967; Barry, 1973; Niels1t11 1979) hive thus SNn ftt to dtsttngufsh between Rawls and other maxtmfn ttleortsts, on the one hnd, and true or r1dtc ega11tartans on the other. True or radical egaltt1ri1ns are c0111ftted 1n I straight forward 111nner to the goal of equa111., per se. As K11 Nielsen (1979, p. 212) puts ft, the tncaa Ind lth ts to be so divided t111t each person will have a rt gttt to an equ11 share.
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-14-~' (~!"~ t, _. ..: ... V i...,.; The taportant test case for separating maxfm1n theorists and 1911ttar11ns ts bow they t11ndle situations where the best way to improve tlll lot of the lust well off ts to caevote 1ub1t1ntt1l resources to taltld elites in orcaer to give thH 1n tncentfve to use thetr skills to NNftt thOse on tlle bottoll. Mutatn theorists hold ttllt 1n these ctrc1a11tances justice requires that the resources be gtven to the well off elites even though 1nequalft1es w111 1ctu11ly f_ncrease. True e91ltt1rt1n1 are deaply distressed at the increases of fnequaltty because tlley -ral taport1nc1 to equ1l1~ 1s well ~ 1ncreas1ng welfare. Saa egalttart1ns dHl with thts by 1111111 the equality ts WIit the pr1nctple of justice requires Wlltle other prtnciples atght penrlt Ute tnaqualftfes to exist provided certain cond1t1ons are at. For example, egalitartn afgtlt hold that tllOse on the bottalll nave a claia to equality Ulat they can watve When 1t 1s tn thatr interest to do so. The result 1111 appear 1fat11r to Rawls's auiatn principle, but 1n Rlwls's caN tt 11 not only right but Just for the tnequ1lity to exist and those on tlll bottoll 111ve no spectal role 1n approving of the fnequ111ty. For tlll egaltt1rf1n11 on the other hand, the fnequaltty 11Q be perutttld or tolerated provided tlll lttast well off consent, Dut ft f s not Just. The uutatn theorists thus provide tlle fnttllectual foundation for Nhlt 1 s 1a111tt referred to 11 trf Ck 1 e down theory. Accordf ng to tr1Ckle dOIIII theory, those on the top are to be benefttted because 1n dotng_so till benefits trickle clown and eventually help those on the bottaD. True egalttarians face a problera that waxtatn theorists avoid. One way to 111v1 full equality 1s to have everyboQ equal, but at such a low
PAGE 21
-15~. ,. ,.., J ~ ,J level a.at everyone 1s dNd. The first suffering group that had an tncurllale prabl wuld appear to cOlililllld such resources that 1t would cre1ta a otta11l111 ptt. TIits ts, tlltrefore, 11111tta1 referred to as a. INIUC11l111 ptt or tnftntte dllillnd 1rguraant 191tn1t 191ltt1ri1n1a. Defelldlrs of 191lttartanta have several responses 1v1tlabl1. Ont 11 to point out that 191lttart1n Justice itself sets soa limits. If 111 resources were devoted to persons wttb tnc11r1bl1 d111111. others would. actually be worse off._ thus coaandtng I return of s .. of the diverted resources. A sacond re1pon11 ts to suggest tllat lllllere tlllt group would bl bitter off wtth 1111q111lf1.,, they could surrendlr tllltr Justice-based cla1 to equa111.,. A 1:lltrd possible solution to 1:tle tnftntte Clllllnd pNDl 11 to trllt justice 1s a pr1wa fact pr1nctp11. Egalitarians taking 1:111s view would bold that one r1gbt-lllk1ng dllracttrtst1c of actions ts tblt they prodUCt greater equality. Tlllt cbaractertsttc of actions would Ulen lllve to bl ca'1btnea tn soae way wiat tne 01:btr prtma fact prtnctpl111 ta1111 11111t1ng thl trapact of the prtnctple of Justice. TIit tnftntte dllilllld would cs whenever other prtnctples outwetgbed the prtnctpl1 of 191lttartan justice. One way or anotlllr till true 191lft1rt1ns do not accept tile tdll that Justice pendts or requires 1nequa11t11s w11tnev1r tt ts tn tlll interest of Ult lst off for theli1 -to ext st. They see SGlillthfng tnhlrently rtgllt-lllktng about equality per se. We are tllus 11ft with four baste 1ltern1ttv1 theories for structurtny soctetal tnstttuttons when ft COlillS to dtstrtbuttny resources. Each contains I baste assur.tptfon aDout the correct
PAGE 22
-16-d1strtbut1on. These four baste approaches to the probl&1s of d1strlbuttve Justice provide the framework for our examination of the ; ('. C ~-' J ...... -. v ._,, tapact on the dlltvery of health care servtc1 to the elderly 1n general and the use of the ltfe-sustatntng tlehnolog1es of tbts stu~ in particular. D. The Concept of tne Safe~ Net Salll theorists (Fried, 1975) follow I stratagy of following one tblory of Justice for c1rt1tn levels of distrtbutton and another theory for other levels. Salill, for exaple, adopt the r.11J,11i11n or egal it1rt1n 11111 for d1str1button 1n order to provide persons with Da1ic minilllil of servtc11 netdad to survive. This ts variously referred to as 1 decent atnt-, a t11r share, or an adequate l1ve1. When two dfff .... nt distributional the0r1es are coa,tned in tll1s way so that everyone has an entitlllillnt to SOIII baste nec11sit11s and free 111rket forces prevail lbOVe the floor of 1s1c s1"tc1s, the approach ts now comonly referred to as offering a safety net below which persons Should not be allowd to fall. Dlteratning where that floor of support ts ts crtttcal 1n dettrm1n1ng the extent to which the d1str1button ts essentially egaltt1rt111 or lfbertartan. E. TIie l1i1p1Ct of Theories of Justice upon the Delivery of Health Care Se"tces to the Elderly tn General The tapltcations of these theories of Justice for delivery of health care services to the elderly are li10re difficult to deterT.11ne than 1t 1i1Q appear. Each theory contains wttlltn 1t possible grounds for supporting health care services for at least SOlill of the elderly wane it also contains reasons why the elderly mtght not yet services.
PAGE 23
-17-0 f Ft J .. : ., -J .... 1. L1bertartans L1bertar11ns w111 allocate health care services Dy relying on tne rfghts of tndtv1duals to dispose of till assets they justly possess 1n the vay they wnt to dt spose of ttllla. Tht s wt l1 favor those who poisess resources: ney, goods, natural resou~es, talent, power, or the c1p1ct~ to eltctt charity. In w111 lfmtt access to those do not posses~ these resources. H. Trtstrua Engelhardt (1981) provides a good eX111ple. AlthOUgh he does not apply ht~ interpretatton spec1f1ca11y to Ula elderly, he aakes clear thlt the theory's 1ap11cattons would apply to tlllra 11 well as others 1n the population. Pre.....,ly tllose WIG were Ible to acquire suDstlnttal resources caurtng their working years or by tnsurance polfctes (tncludfny Mlcltcare) tlllt would continue tnto yurs of Nt11'1111nt would nave health care serv1ces-prov1dld if tbly chose thlll. Mlcltcare or any other insurance could not, however, N COlilplllsory under 1 ltbertartan approach. Those WhO were not ule to accuaul1te adequate resources, who had used theu for other purposes uncludtng Nrl ter purcll1se1 of health care), Who had refuMd to buy insurance woluntartly, or wao had been refused insurance blcluse they were bad risks would be out of luck. It would bl unfortunate, 1>ut not unfair. Robert Sidi (1971) offers I rather staple, but dr1111t1c account of the 11bertlr1an approach to 111ocat1ng professional services. Ctttng the classics of 1 tbertartan rights tradition tncludtny Locke, Sade (1971, p. 1289) claim that, t41dfca1 care ts neither I right nor I prtvtlege; ft ts a servtce tnat ts provided by doctors and others to people who wtsn to pure111se tt. It ts the prov1s1on of ttlts service that I doctor dependS upon for hts ltvelthood, and 1s hts mans of supporttny his 0111111fe.
PAGE 24
-18-'. (\ "' JI .J.. .,_111 this might sound cruel, defenders of libertarian approaches potnt out thl adY1nt1 .. 1 of tlltir approach. Persons who vert not required to spend part of thl1r earnings for COfilPUlsory h11lth insurance could be buying otner goods, presuaably goods t111t ortng tll even greatar blppi~ss tllan the benefits they predictably would have rec11vea tf tllly had bOUght thl hea.ltn insurance. Moreover, anyone who wanted io, une11r till l ibertari n approach, could buy any at x of 1 nsur1nc1 he des1 red provtdld only thlt there was enough of I raarktt for tt for soraone to sell till coverage. Even 1 f SOUi peopl Duy fool 1 shly--and 11blrtar1 ans tend to believe t111t tndividU1li know better than IQOM 1111 hoW thly can 111Xtatz1 tneir welfare with their resources--the pr1nc1p11s of 11ber1., ts preserved. Individuals are trNted with respect ai 1Utonaraau1, dlc1s1on-king agents. MDreover, 11Dertar1ans art prepared to put 1n place I systla of chart~ that wlll -t the needs of the elderly wllO do not have the resources to r.111t critical 11111th care needs. Saal caaantators (eg. Chrl11 Fried (1976]) ccx.mine the libertarian approach to health care with I proviso that everyone sllOuld be entitled to 1 decent atnillllil. Tnt President's Coawission for tlle Stu~ of Ethical ProbllUI in t41d1cine and Biouedical ana Behavioral RtsNrch (1983, p. 4) appears to favor I similar two-tier approach saying that aquttlble access to health care requires that all citizens be able to secure an adequate level of care without excessive Durdens. Whether SUCh two-tier approaches have strong libertarian traplications w111 depend upon how low the c11l tng is on t111 adequate level. Fried gives the impression that his c1ecent ~in1muu 1s quite aintmal making him often sound 1ssentta1ly 1 ibertar11n.
PAGE 25
,: n _, '-, .. -....... -19-2. Ut111tar1ans TIie tapltcatton of ut111tlr1an1m 1s s1r.a111rly cowplex. A prelia1nary analysts suggests tht the elderly re p1rt1cu11rly vulnerable to ut111tar1an cons1derat1ons. wtaethtr benefits are constdeNd tn term of the health benefits to tht elderly th1111elves or a. social benefits of the contr1~ui1on of the health cart rec1p1ent to Ult socie,ey1 tnvestmnts 1n health care for the elderly would appear to have ca11p1rattv1ly low payoffs. 1111 ftrst app11cat1ons of the value of 11fe analyses tn the 1960s rt~l how cost-Mnef1t analysts and other techniques rooted in uttlttar11n pl'llil1Hs pose special problfor the elderly. Rtce and Cooper (1967) caeveloped the baste athodology of datel'r.lintng the economic value of llulaln life for purposes of 111k1ng policy Judgrants tnvolv1ng chotces IIIOfl9 1lt11rn1ttve health cart 1nvestants (as well as other uses 1n lltgllWly safe~ 111d insurance coeapens1tton). Thay detera1ned the econGlil1C value of 11fe by_. calculattng tbl 1 tfetfra earnings of persons at various ages. By use of their figures policy analysts can estt111te tne contrtbutton to the GNP of alternative health care investments. Rtce 111d Cooper (1967, p. 1960) calculated that the present value of (future) ltfatta earnings varied by 191 (11 wall as sex and color). They pelted during the third decide of ltfe and tapered gradually to very low v1lu111 dropping prectpttously at about nonal rettrer.aent age. For eX111pl1, using thetr 1967 figures the present value of 1 ffett earnings of Wllftl ls age 20-24 was $131,416 while those age 65--69 was $13,530. F-..le earnings decline raore gr1dUc1lly since Rtce and Cooper chose to aonetfze aOlillst1c laoor, wntcn continued for r.10re waan into rtt1r1111nt years. The fr.1pltcatfon1 however, ts clear. If future
PAGE 26
.. .. .... J .: .J. ,
PAGE 27
-21- '? ., \., .. -i.. u only I few years of 11fe expectancy. The cost per year of 11fe IKpletancY ._ ts_ ny tims greater for the elaerly person even 1ssuratng that that person is just as easy to treat as the younger person (an 1sllllipt1on thlt is often not re11tst1c Dtcause older persons are actually birder to treat raking the benefit/cost ratio of treatatnt of the elderly even lower). No ratter how sophisticated the calculus of benefits--whether tt takes into account morDidity as well 11 mrtality, psycholo_g1ca1 11 well as physical benefits, etc.--the benefits are likely to be greater when the health care services go to younger persons. Only by coap11cating the utility calculus 1l1110st btyonca usefulness can we begin to even out the benefit/cost ratios. we might, for 1xU1ple, consider the harus that would accrue to other flll'lly _.ers tf we treated younger persons out not older ones. F1111l ies would have to watch their elderly L18Glbers d1e untre1ted--potent111ly a devastating psycnolog1cal trauua. Uoreover, each of us would have to anti.cipate that we would one day be 1n the category of the elderly who would not be treated. That would count as a hana 1n a sophisit1cated cost-benefit analysts of treatment or non-tre~trant of the elderly. It is conceivable thlt tnese suDtle, psychologtcal factors would provide enough hanas to countlrb1l1nce the more obvious benefits of limiting health care to younger persons. Such as subtle analysts would also have to take into account the social costs of losing persons who have long years of training and experience. In 111 likelihood, however, on balance the elderly would not fare well with ut11itar1an approaches to health care resource allocation.
PAGE 28
. -22r.. f ~--' J ~-.,: -l '"X 3. Mlxfmin Mlx1a1n theory poses an intrigufng_and virtually unexplored probleta When health care services for the elderly are assessed. Are the elderly one of the groups who are least well off? If they are, according to 111Xtafn theorists, they deserve priority. If they are not, thin others will get the resources. Of course, according to ra11Xi111n theorists even if tllt elderly are a least well off group, they, themselves, might not get the resources. The resources might go to talented younger persons who can thereoy l>e induced to use their talents for the benefit of the el dlrly. Tne basic probl ILi, however, ts Whether tney are a 1 east well off group. Many would aryue that the elderly are long neglected as a vulnerable, deprived, suffering population group. They are often alone and abandoned. Soaetiraes they do not have adequate resources to 1 ive. They are inevitably headed for health probls. At least insofar as we are considering health care, they are a group with great need. On the other hand, rany elderly persons are quite well off. They are doing well financially. They are not troubled by psychological or physical a11mants. They are perhaps better off then ever before. Moreover, 111 the elderly have souething that those needing critical ratd1ca1 care at earlier ages do not nave. They nave the certain1.Y that they w111 live to old age and enjoy the life experiences of the full life cycle. It ts critical nere to distinguish between two ways of deterra1n1ny how well off people are. One approach--call ft the s11ce-of-tir perspect1ve--asks how well off people are at a given rJOr.Ntnt regardless of tlll Joys and sorrows, benefits and burdens at others points in their
PAGE 29
. ,. .... -23:I n ,._ t,. ,..,l \.., --~-t) lives. The second approach--call it the over-a-lifetime perspective--asks how well off people hive been sur.uing the net of tne Nntf1ts and burdens over their l tfetiras(Ye1tcn, fortheoutng). Assuw1ng that people who_ have continued to 1 ive consider 1 ffe I net benefit--an 11111a1ptton used widely in r.11ny legal and poltcy dlbates--older persons can be 11ta as a group to have had mre good. The eighty-year-old who 1s w1tll certainty dying peacefully having COl.lpleted his life projects ray be Detter off thin the twenty-year-old who has I heart condition from wich ft ts said he had one chance 1n ten of (lying within the year. From the over-1-lifetf perspective, the e1gb1.V-year-old is 1111ch better off. If the 9011 is to use a mximin strategy, the twen~ year old with heart disease would get I higher priori~. 1-llxfatn strategies will depend entirely on Wtltch groups are least wll off. That in turn wtll depend on how one deterwines what ft raeans to be least well off. If the sltce-of-tir.11 perspective ts adopted certain elderly--the s1ckest--wi11 hive high priority for health care services. Since there are more sick elderly, they are likely to cor.1a1nd treaenaous resources If. nowever, the over-1-1 ifet1r.11t perspective is used, the elderly are 11kely to get very low priority. There is 1 puzzle left frou this analysts. If the over-1-l tfetime perspective 1s used for deterrafntd who ti least well off and the elderly thereby cora out as not the least well off, that seems to imply that no resources can Just1ftably be spent on the elderly--not even for patn relief, the bastes of nursing care, and simple life-saving treatrants (pen1c1111n for pneumonia in an otherwise healthy woman), etc. Do we have to wait until the elder person 1s so raiserable that his agony in old age wipes out the pluses of an entire 11fetia 1n order to provide him an 111Jtct1on of mrphine for t11egony of a cancer? Surely not
PAGE 30
-24-' one solution ray be SOGII sort of cOL1proa1se between utilitarian and uu1a1n approaches 1n which the younger persons are given priority on re-rcll and developmnt of treataent for tncurable diseases of younger persons except When I treatment for the elderly produces great benefit inexpensively. This, however, requires the max1g1n theorist to aove outside the auiain fralillWOrk. Another solution that stays within that frllllWOrk would be to use the over-1-ltfett perspective for deterw1n1ng who ,swell off 1n cases involving research and d1velop111nt and expertantal and expensive treataents, but shifting to tbe sltce-of-tta perspective When dee1a1ng wno ts least well off when da1l tn9 wttb trtatrants that provide great benefit inexpensively. The tbeorettcal basts for dlteratning who ts least well off and Why is as yet undeveloped. 4. Eplttartans Several 1r1ters (eg. Childress [1984]) and especially tnose working within gerontology (eg. t4ooc(y [1978]) nave written with the 1sswaption that the elderly deserve to have their health care needs ,.-t exactly the way aqy other persons do without using age as a criterion. Their positions will be explored L10re later. For now, they can be cited as IXllilples of an egalttarfan approach to health care for the elderly. The egalttartan approach .is cCX1Ditted to r.aeettng needs equally. It ts now appareni that these egalitarians base their conclusions on the iraplictt use of tbe s11ce-of-tir perspective for deten.ain1ng that persons of any 191 have an equal clatm to nave their needs raet. Persons of equal need for health services are equally poorly off at the tir.ae of the need. An ep11tlr11n would conclude that equal needs deserve equal treatment. They do not appear to constder the possibility that over-1-lifeti the el __ de~ly ~"better o"f than persons 1n other 191 groups who have M lv dl.-.f ,,..,,~~.u..o., "'~'-'t~c..-
PAGE 31
,. ~:. -25-( r. ,..., ., \., .. t ,/ Like tne uax1ain theorist it would appear that the egalitarian w111 hive to dltanltne 1Nther to assess wel_l Mtng over-1-lifetta or 1t 1 -- tn tta. Thi OM potentf 11 difference betwltn eg11f t1r11ns and aui.llfn thlorfsts When tt cOlills to 11loc1tin9 health care services to the elderly wtll not N over wtlicll tfa frllillWOrk to use in deter11f ntng whO 1s 1Nst wll off. It will be over whether faproving the well Ming of the 1east well off group(elderly or otherwise) will Justify use of resources to provide s1gnff1cant incentives for those with talent to do tile work necesury to provide tlle benefits. TIie e91l1t1ri1n would want the resources to go directly to the least well of group whtle the 111Xiatn uaeortst would be content to iaprove the lot of till least well off by transferring tile resources to talented elites tncre1sin9 inequalities, if necessary. F. I11p1ct of Theories of Justice on the Use of Lffe-SUstaintng Technologies w1UI the Ten.iinally Ill Elaerly 1. The Concept of T1r11in1l Illness Before 1ddrlssin9 the i11plications of the various theories of Justice on the use of l ife-sust1inin9 tldlnologies with the terarlnally 111 elderly, 1 wrd needs to M said about the concept of teruinal 111Ns1. Sfnce 01:llr studies being done for this pro~ect address this issue tn dlta11, here ft ts only necessary to point out that tenatnal illness w111 be taken to refer to those who are on a relatively rapid tra.1ectory of dlter1orat1on that can with reasonable certainty be predfctlcl to lead to death 1n I relatively short tt. This ts basically the SIMI deffnttfon as that used by tne Hastings Center group writing on the raorali~ and econoatc of teratnal care (Bayer et 11., 1983). The
PAGE 32
'.n~ J .. -i.. 1..:, -26-t1a per10d ts arbitrary, but three to s1x aonths fs the range used for "' tb1s dtscu1ston. Even wftn thfs definition the tena teNfnal illness can be used in two very different ways. It can be lflil'lted to ttlOM who are f lNIVf tably on I trajectory of dlter1oratfon ttllt will ld to death fn I relatively short t1a regardless of ad1ca1 1ntervent1ons. It can also be used, tloWtVer, to refer to those Who will die unless treated, for exaple, by a 11fe-susta1n1ng technology. A person wtao has end stage renal d1s111e and ts refuatng_ dialysis ts terminal in thts second sense, although tnat person.ts not Q1ng tnevftaDly. In 1xuatntn9 the fapact of tlllOrfes of Justice on the use of 11fe-sustaf n~ng technologtes 1 t will be necessary to kNp these two alifngs separate. 2. The Impl tcatfons of Various TlleOrtes of Justf ce Lfbertarf1n1Slil. The crtttcal question froli1 the lfbertart1n perspective 1s who would want and be able to purchase 11fe-sustafnfng technologtes ff free arket forces and chart~ vere the only bases of access. A crucial difference would appear to be whether one has purchased insurance. Sali1e of the technologies--such as tllGIOdfalysts--are so expensive that virtually no one would be able to afford the treatant -.o had not purchased insurance for ft. Moreover, ft 1s likely that the cost of ta insurance wtth suell services fncluded would be quite high, dfssuadfng all but a very few frou even covering the costs tl'lrougn insurance. More fundlllental ts the question of whither people would buy health insurance that tnclueled these life-sustaining technologies for the taratnally 111 elderly. Sor people would not buy such insurance simply bee they do not plan ahNd. Others, however, might choose con1ctou1ly to excludl these coverages. They ll'lgllt do so for two
PAGE 33
lf r .. /' --~ ... f~' f;i~-27111gllt1y different reasons. Solill a1ght exclude sOlill life-sustaining uc:11110logte1 for till teNfnally 111 Dtcause they would not see any value tn._. Tllere are prolal-wfUI t1111 position, however. Most people would at ltast nt 11fe-susta1n1ng tldlnolog111 if thly N111Nd patn and suffering and r1111v1d ft at rel1tfv1ly low cost (as hydration and nutrition aright do). If possible. tlley would probably nt coverage that provided 11fe-susta1nfng tecllnologtes only as part of a COlilfort care Nlfn. Solill 111gllt also dlsfra to have aore a19resstve trutlllnt, but Ult ltbertarfan approach would requirt thelil to c011p1re tlll beMf1ts of taaw1ng the insurance coverage with the benefits of having the money ndld to buy Ulat coverage to spend on scathing else. It 1s likely t111t a great rany people would forego the coverage, ~specially coverage beyond 'that necessary to provide cautort. They would probably be raor1 w1111 flt to buy coverage for 11 fe-sustat nf ng tecllnol ogtes tllat were rel1t1v1ly fnexpensfve, but very few would likely buy unlfmtted coverages fncludtng, s-,, h11110df1lysts during terminal illness. Not everyone 1 s 1 ikely to hive the sar.11 response to sch11i11S to penatt persons to buy coverage for lffe-sustltnfng technologies during taratnal 111neu. The diffeNnces would reflect not only personal preferences. but also ab111t., to pay. It ts lfkely that among those who IIIDllld dlsfre lff1-sustafnfng technologtes during tel'L11na1 illness, the poor would hive auch less coverage tllln the wealthy. This would be true even for ce11fort care. b. Ut111tar11n1111. Ut111tar1an1SLI would provide a very different analysts of the use of 11fe-sustafn1ng technologies during terminal -111ness. It would ask "'4t the benefits art 1n c~r1son to tne costs
PAGE 34
i:~;s olt,"', I ii~ }_ :,), -28'I f) ..... 1w (econc111tc 111d 1oct1l ). It would tllen coapare the net benefits froa the use of tlllse tlellnologtes wtth the net benefits of other uses of the resources Qtven that saa persons consider saut uses of these ttchnologtes dllring tenrlnal illness a net n1g1t1v1, the case for tlletr use will be a d1fftcu1t ont to aake. Thi calculation will hive to involve benefits to tlll_pattent 11 well 11 benefits to s~teey. In both CINI the benefits are probl-ttc. surely tn SGI.II cases the patient w111 beneftt, tither oec1use the tr11tants wtll relieve patn 1nd suffering or bleause the patient's continutd living ts ttaought to bl dt1ir1ble lty Ult patient and/or others. Even in those c11e1, however, tllt benefits are likely to be 1a111 in coap1rt1on to the use of a. rttsources tn other ways. Earli.-1 d1st1nctton was radl between th011 lllllo IN tnevitlbly ctytng ind those who will dtt if Uley are not treated wtth a 11ft-susta1n1ng tlehnology, but could ltv1 tf treated. A dtstinctton t11s also been mde bltwttn l_ffe-sustainfng ttct1nologt1s tlllt are used on a one-tf basts to aet acute r111dl and those tlllt mst be used Chrontcally. Botll of tnese v1rtlbles have direct bearing on the anttctpated Hftefit from the UN of a technol091. Thus, for the ut1lttarf111, wllo ts 1spec1a11y concerned IDOUt anttctpated benefit, the cl1111ftcat1on of ttte patient (Whether hi or stle ts 1nevttlbly tng) ana Ute tre1tr.11nt (Wtlltner 1t 1s used acutely or chron1ca11y) w111 oe very fapor'tlnt. At ltast for the 1nev1taD1y dying, the benefits will be short-lived. For the use of technologies that ire not used chronically, Such as CPR and antibfottcs, the saaa 1nvestr.11nt of resources 1n sOG1eone l1lllo 11 not cl,fng wfll prodUce much greater payoffs r.wasured in years of ,:,
PAGE 35
" ', -29-() -~-, ---. ,--..,, -4. life added. Even for tllON elderly who are terafnal, but not fnevftably UIVlnal NCauN Ille 11fe-1111utnin9 iecttnology could reverse the ._11111 trlJectory, Ula Denefits of tlle use of till tedlnolou w111 be relatively brief tn ccmparison with tile use of Ula 111.11 tedlnol09tes for you,.... patients. On the ou.r hand, tf years of fe added ts the criterion of 1 ut11ttartan analysts and the lffe-sustatning iecttnology fn question ts o Ulat aust be applied continually (such as dialysis or chronic na10-911tr1c fNdtng) then the benefit f.-. applying tilts tedlnolog to tile terllf nally 111 1111 be 11 gNlt 11 tt wuld be fn applying tt to younger, non-terafnal pattents. Di11yzfng one tllou11nd tenai1111ly 111 elderly patients for one WIik Heh produces the 11111 ...-.r of 1 ffe-years addlcl 11 di1lyzing one non-tefflfnal for1;'/ year old for one thousand WIiks. Tne crttfcal issue here ts whether ltfe-y11rs added can be taken 11 the encl potnt of I uttlftarian calculus or whether 1d_just111nts would De adl DY the ut11ttar11n for the qualf~ of the 1rs ltved. A good case could be trait the thousand weeks DOugllt dtalyztng tlle non-tenl1na1 for~ y11r old UQ be of hfghar qualtty thin the seven days of Hen of one tllOUsand elderly fng patients. A consistent ut111t1rf111 IIIDllld want to lllke such adjustants for quality. Policy analysts such as Rtdlarcl ZICkhauser and Donald Shepard (1976) have proposed conducting cost-benefit analyses usfng units of qual 11;1 1c1Justed life years (QALYs) 11 a way of kfng such 1djus:t111nts. Thi only uttltt1rt1n arguant 191in1t use of saathfng like QALYs ts that the dJustrants would be too ca111p11cated and too controverstal to k such that their costs exceeded tllefr benefit.
PAGE 36
n '< "' ., J ,.., ,v -30-' Uttlturf analysts would also require taking into account the net Mllf1tl to socte~ of tlle UH of tllaH tldlnologtes and alternative uses of tile funds. Tlle1r use atght bl supported on grounds of ~octal benefits tn rare cases "'91re the terldnally 111 elderly person could still lllke 1 sstanttal soctal contribution, but that ts likely to be rare. WIien ca11p1red vlth the use of the resources tn other ways, the soctal benefits are likely to be llillll. TIie soc111 benefit tnat a are 1opnt1ttcatld ut1ltt1rt1n ts ltkely to 1e1enttfy 11 1M benefit for ftly .... ,. _, will 91t postttve value out of tng a loved one ltve I btt longer. In SOIII cases these benefits could be sub1tant111 such 1s when I rel1ttv1 ts traveling fraa out of 1:NI and desires to s the ter1.1tn11ly 111 person OM last ti ... A 'tllorougll uttl ttarfan would tnstst that ttllN benefits be tncludld in the calculation. Tnese social benefits are ex'trllally subJect1ve and hard to quantify, however. Moreover, ttae1r 1nclus1on has 11111 strange 111pltcattons. A ter1111111ly 111 elderly person w11:h no relatives or frtencls would llavt no cl1ta baled on these social benefits to the treltDlnt. This could lead to unlikely policies of ustng ltfe-sustatntng tacllnologtes for tlll teftilt1111ly 111 only in cases where there are re11ttve1. NDN unlfktly, tlletr use really ought to be reserved for those cases where relatives w111 be 111d1 happy by the Qing one's continued ltvtng. TIier 1s one final issue raised by a ut111tar1an calculation. Different 11f1-sust11n1ng teehnologtes aay have different subjective 111p1cts on the pop1111tton. In soae cases tne decision to prohtDit their use ts likely to N very distressing to the sense and sens1biltt1es of IClal of the population. In other cases, the deeis1on not to use the
PAGE 37
< ,"'-,J, ... ,_ t; -?: -31n .. ~. ~ ,J ~ ,...., ":_) tecllnology-, produce ltttle df1tr11s at 111. For example, the level of psycll0109tca1 dt1tre11 at tile dle1ston not to provtdl baste nutrttton and llydrat10II 11 probably ach greatlr Ulan tllat of dlctdtng not to tmpl1nt an arttf1cta1 tlelrt tn I person 11111G Will 1nevttao1y d1t without one. In fact scae persons appear to fetl real d1streu at tlle 1rttf1c11l heart's use. TIiey see tt as pla,tng God, 11 tuapertng wttll areas best left untouched. How should 1 11ttlftarf1n respond to these different sUbjecttve fN11np on the part of wrs of the society? Should tllly be constdlred 11 benefits and ha,.. of tile treatlllnt dletsfon? It-odd to clletde Nhether naso-gastrtc tulle fNd1ng on tlll basts of lllllether 111ke1 01:ller people uncGllfortable not to provide such fNding. we norrally do not tllt'* should dltermt111 wtltch treatantl should be provided by dltlnrlntng whither cft1zens art upset by lack of tts provtston. A ut111tlr1an approach to 1lloc1tfn9 11fe-1111iatntng tedlnologfes wtll nave to dltlrlltne Whither these subjective benefits 1nd hlNS of provtdtng 11fe-susta1ntn.g tldlnologtes are relevant or Wllltlllr aore objective ... ,ures such as ye1r1 of ltfe added or QALYs added should be used instead. c. Muiain and Eplttart1n ApprNCtles. In contrast to the uttlitar1an Uleortsts, 111Xtatn theorist 1nd e911tt1rtans would be 1111ch 1111 concerned lbOUt he cl1sstffcatton of the patient (Dased on whether or not hi or slle ts tnevttloly ~fng) and tlll treatment (based on whether 1 t 1 s an acute or chront c 1 ntervent1on). Thf s 1 s because for thera proJectton of aggregate beneft t 1 s not crf ti cal as ft 1 S' for the ut1lttart1n.
PAGE 38
.t-:, .. ,, ~. r '-' .J .. -, 6i: -32-TIie cr1t1ca1 question for both ttle IIIXfmtn and 191lft1rf1n analyses ts .._.., Ille tlrlltna11y 111 elderly are 1 111st well off group and, ff 10, 1N1:lllr tlle tadlnolog1es provtde uy beneft~. Tlle,teratnally 111 eldlrly llfgllt wll N COlllfdtred I lNSt wll off group. Froa the iltce-of-tt perspective, they IN fn very bad shape. Yet fraa the over-1-11fett perspective they are plausibly better off than persons 11M are tlrllfnal and young. If Ille teratnally 111 elderly art viewed 11 1 lNst off group, a.y Nft c111us to Ute resources tt11t would benefit thlll 1ccordtng to axtatn 111d 1911ftar1an tNOr1es. In tlle case_.,.. tile 1tfe-susta1ntng .. treatlllnt 1s perceived as befleftctal, thin rautll1n and e91ltt1rt1n tlle0r1sts mo concludl the t1r11tn111y 111 eldarly are I lNst well off group would support tre1t111nt even tf benefits VIN afnor. Tllere 1s racm for dispute aang these tlleortsts 1b0Ut WIit should happen lllhln tlll patient perceives tt11t the treatant would be beneftctal, but there -.~ very good reason to bl111ve that ft would not be. Whit should happen, for exaple, when 1 ng elderly pattent fnsfsts that an anttbtottc be used for an fnftctton Mlln the consensus of dtcal optn1on 11 t111t the ant1btotic ts extrlrally unlikely ta overcoa the fnfection 111d ts very likely to produce 11ndesir1ble side effects. W1thholdfn9 the ant1btot1c 11 ltkely to produce dtstNss for the patient, but supplying ft 1s ltkely to produce harr.aful sfde effects. Muimtn and epl itartan analysts will nNcl to decide whether their theories require provtdtng SUl,Ject1ve benefit from the patient's perspective or only benefits aasured fn S01i11 aore ~bjective manner. If a. teratnally 111 elderly are viewed as a group that 1s not 1Hst well off, different set of issues arise. PreslllillDly rax1lil1n
PAGE 39
-33tlllOrtstl and egalftlrtans would reach tbe ~onclus1on that the ltfe-susutntng tec111ol09tes stlOUld be wfUlheld on grounds of Justice. cons1dlr I dt1ly~f1 patient who Ills I few days to ~1ve and thOn days will bl ltvecl fn I state of 1t-con1c1ou1 stupor. It uy be tr19tc to b1ve to withhold d11lysfs or CPR fl'OII such patients on tesource 11locatfon grounds, but if. by hypothesis, others are fn greater need, tllln t111t 11 the decision I li1IX1m1n theorist or e9111t1rfan would support. TIiey atgtat for example, favor I new DRG for the 1rreve~s1bly vegetative patient and advocate assigning I very low reflilburseant wighting to tt. For 11fe-sustlin1ng tecbnolog11s that also provide coafort and do so relatively inexpensively the probla ts.,,. coaplu tf thl terminally 111 elcllrly are not a lust off group. Consider a tfttnally 111 elderly patient llllloM ltfe will be sustained through hydration and 111so-911trfc tube fHdfng. Ylat should happen ff w1tlldraw1ng those trutants prodUces dfsc111fort for the patient. Thi logic of the 1911ttari1n or autain 1n1ly1ts ts that, ff these are not least well off patients, ft a1ght bl argued that they have no claim to the resource even 1f the suffering prevented ts quite great and the cost of the treatwent ts quite -11. For I terra11111ly 111 elderly person who has previously hid I good ltfe. 1:tle burden would proDlily hlvt to be severe tn order to outweigh till 1 tfetta of well Ming. Even are absurd, for another t1n1t1111ly 111 elderly patient needs food 1ne1 fluids for comfort, but wo has bad a aiser1tale existence throughout hfs 11fe, his claim for benefit wuld be much greater. It 1s for these reasons that same egaltartans are arguing tbat for provfdfng the basics of COlalfort care, 1:111 slice-of-ti perspective mst be used even ff for more cogplex
PAGE 40
-34-dlcisfons pertaining to res11rch, developmnt, and exper1a~tal and high tec11nolot, trea1:lllnt the over-a-11fetia perspact1ve 1s appropriate. G. TIie lntarfac1 bltwlen tne Ethics and Econaatcs of Distributive Justice ,,_ llllllt has bHn said thus far, 1t should be cl11r that tne ethical issues raised by the use of 11fe-sustafning technologies for the elderly art cloHly related to the economics of tnefr use. In fact lilUCh of the dtscusston has drawn upon wrftfngs fn tbt field of economics and policy : science. Econmics, however, can only tell us certain things about the UM of 11fe-sustafning tlebnologfes for tbl elderly. It can give us data about the dollar costs per untt of benefit. It can, by extension, give 111 cllta about the others costs well, the social, psychological, and cultural costs. What ft cannot do ts tell us how those aata ought to be aSHSSld. Each of the theories of distributive justjce has a set of ethical presuppositions unc1erl1fn9 ft. One euphas1zes 11Dtr1.Y and the rights 'that accrue wf th ownersh1 p of pr1 v1t1 property i another 11.1phas 1 zes the goal of mu1111izf ng aggregate net benefit, rauimiz1ng the posftion of the lust well off groups, or striving for greater equality. Thus even ff we had caraplete agr-nt on the relative costs and benefits of alternative policy options, we IIIOUld not necessarily know Which policy to adopt. Econaa1sts and policy analysts have becor.ae very proficient at generating and processing data for complex policy issues of tne kind being addressed here. However, fror.a within their own d1scipline they cannot determine Which kinds of analysis are going to be decisive for dlefdfng about the 1lloc1tfon of life-sustaining technologies. For txuaple, different cODputer programs would have to be written for policy analysts depending on which theory of Justice was adopted. A traditional
PAGE 41
,~.f,.:(,~-.. .. ~.---"""'""'---....... -... ... .... ... ...... -..... -~-..... -... }t' ~::. .. ;~ -35- cost-beneftt analysis would requi're a cputer prograa designed to calculate the ratio of aggregate benefits to aggre~te harus of alternative po~icy options. A ut111t1ri1n would be very interested in that result. But a muim1n theorist would not. He or she would be much aore interested in a more differentiated analysis tn which net benefits were calculated separately for each group w1thparticular interest being gtven to tne figures for the least well off group. Ega11tar1ans on the other hand would prograw their co,aputers_to calculate the standard deviation of tbe 1nd1v1dual net benefits for persons effected by alternative policies. The egalitarian would opt for the policy that has the sllest standard deviation of benefits. Finally, the libtrtlrian _,ld not be terribly interested at 111 1n the economic and other data except insofar as it helped indivtauals rake better cho~c1s about how to buy hfflth care and invest in insurance. It ts possible that some policy dec1s1ons could be mde drawing on the ethics of terra1nal and critical care without looking at econm1cs at all. Under li10St systems, persons ought to be permitted to refuse care that they do not find benefictal prov1Cled t111t the refusal does not yenerate extra costs for society (and normally tt would not). Probably only tbe uttlitarian tneory could easily justify forciny care tn such a cast and then only when tht benefits to others of keeping the patient alfve outweighed 'Che hana to the patient. Increasingly, however, the critical ethical proolems 1n health care w111 N distributive Justice pro~ler~s. The life-sustaining technologies that are the focus of this stuqy are often technologies that, from the patient's own assessnt offer ra11rgin1l benefit, but at great costs to tll1rd parties (tnsurers, hospitals, and goverRG11nts). In that case the
PAGE 42
;-.. ,, ........... -........... ,. -.J .. ... ......... ____ .............. -. .. ............. -' ... .... ....... ~--------..... lo.----'"""' .... -.... ;. r, .. j (' ~j .J ... f.1 (J, -36" cost of care beca111s a critical ethical proDl. Only by choosing a tneory of distributive justice and integrating that theory into the calculattons and analyses done to c0r.1parw policy alternat1ves will we be Ible to decide how to respond to these cases _,.re care is 111rginally beneficial and very expensive, but those costs are borne by third parties. H. SUmaary of Imp11cat1ons for Life-sustaining Technologies. It appears that whether one adopts libertarian, ut111tarfan, MXia1n, or 1galitartan perspectives there are reasons for and against the use of lffe-sus~intng technologies that are the focus of this stucl,. The 11bertar1an will favor the use of thOst technologies that _can be purchased by the wealthy and those that other persons would buy pr1111rtly though an advance deci_sion to buy insurance. These are 1 fkely to be only those uses that provide comfort care. Different persons wftb different economic 1e11ans will buy different levels of insurance cov1r191. For soae wtlO have limited raans. even COfilfort care 11fe-sustaining technologies are likely to be foregone. For uti11tarians, any life-extending technology for the terminally 111 1ld1rly is likely to have low pay-off 1n comparison to the uses of the resources for other purposes. The benefits to tne patient wf 11 be non-1xtstent or low, especially for those who are inevitably dying. The benefits to society are also likely to oe low. In rare cases where the dying could still provide signif1cant benefit to society, life-sustaining technologies w111 be Justified. In other cases, the societal benefits are likely to be quite subjective. Fam111es Olly benefit from prolonging the 11ft of the elderly person, but tt 1s debatable whether ut111tar1an analysis should include subjective oenef1ts of that sort.
PAGE 43
' ., ~'~,! '"""' :-._ .._,, .'\!-;_.>. _. O'~, I l '* .. ,oo. .., -37. J (\ .. r;.,1 v Maxtatn :theorists and ega11tar1ans w111 have to determine whether tlll ttn1f11111y 111 elderly are I le11t well off group. If they are, then 11fe-sustatntng technologies wtll be used whenever they produce benefit. Wllltller the beNf1t ts sured by patient preference or by mre o&,Ject~ve criteria will have to be determined. If the termtnally 111 elderly are not a least well off group, then tt will be harder to justify tile use of 11fe-susta1n1ng technologies. At least hydration and nutrft1on mfgbt be Justified in those cases Where they provide comfort provided the s11ce-of-t11i11 perspective ts adopted for dltena1n1ng who 1s least well off. CONSIDERATION fE AGE AS A CRITERION IN TIE ALLOCATION (F TECHNOLOGICAL RESOURCES A. Age 1s a Direct and Indirect r41asure If 191 ts to be used 1s-1 criterion for 1lloc1ttn9 technological resources, ft 1s iaportant to distinguish between two different ways thit age can function. Age can be the criterion 1n a direct way. In such cases ft would be believed tnat age per se, independent of any of the usual correlates of age, 1s the legitfGllte basis for allocating care. More camon and probaoly lilDl'I plausible 1s the UH of age as an 1ndtrect -ur of soae other variable that 1s thought to be the 1eg1t1mte basis for allocating care. Age can be an indirect measure of any different variables. The ltlOSt oov1ous his been the use of age 1s a predictor of ad1ca1 benefit. It has been conaon to use age as a oasis for excluding patients for such procedures as heart transplants. Very old or very young patients were believed to be poor mdical risks. People hive believed the procedure 1s not likely to be successful with
PAGE 44
r 'I ., f\ .:.... .... ., ---., -38~ttelltl .of. a certain age. It is not that the very young or the very old were tntr1ns1ca11y unworthy. Rather the principle fs that patients slloUldnot get Ult procedure tf it will not work on thera, and age has been tlloUght to predict wnether it will work. Exclusion frara d1.lysts on ttle basts of 191 has SOLWtias Deen grounded in a belief that dialysis would not work well for older patients. These, of course, are empirical arguments resting on evidence about whether age really correlates with expected outcOIII. There 1s increasing doubt that young or old age nece111rfly predicts poor outcOlill fr heart transplants. To Ule extent that 191 ts being used only 1s an indirect aasure of expected outcGIII, 1ts use as an allocation criterion "111 depend on the aaptrical evidence. The re~soning here 1s sorattas utilitarian fn character. The 9011 ts to use rs011rc1s efficiently. If machines and skilled professionals are scarce, they should not be used 1n cases where the radical benefit ts low. TIie concept of adtcal oenefft ts mre ubtguous than ft IIIY appear, however. The r.11dtc1l benefit cr1ter1on for selection 1s attractive bec1u$e it appears objective. It seeas that ff two people are candidates for I transplant and one w111 live lilOre years thin the otner, then the one Who w111 live longer 1s the correct chotce. That 1111 well be the case, but if tt 1s, it ts not without evaluative judgmnt. Consider the following hypothetical case. Suppose there are two cand1aates for a transplant and only one organ 1s av1111bl1. SUppose further that 1t 1s predicted tnat each will live ten years w1tll the transplanted organ and that they are in 111 respects equal except that one patient is twenty years old and the other 1s tigb~. They 1>oth have predicted benefits of ten years, but do they bot11 hive the SIIII amunt of benefit. If one says they do, one 1s assuming
PAGE 45
,., .. :L ;J, __ ("";''t'\"' -' ._., .-~--. -... --........ -. ---~ ...... .... .. .. -'-.. ... .. -39-~. n _. f~ ., ,, 1., .-t., ..:i.. tlllt Mft froll twenty to ttairty is I benefit equal to that of 1 ffe from etgll to nine~. They 11111 in fact be equal, bUt ft ts not 11 objective fact tlllt they are. So111one mght argue that age is to be revered and iltlt till ninth cllcadl is r.JUch IIDN important to respect thin the third. .,,.. likely tn the current youth-ortenttd culture, one say argue that tht third dtc1dl ts GIUCh CION creative, exciting, productive, etc. and therefore aore iuportlnt. It takes a certain lup of i1119in1tion to equate years of 11 ft added to Mneft t. Thi notion of 1111d1ca1 Mnefit often tncludls not only years of 1untv1l but tbt lfke11ho0d of coapltc1ttons, the UIOUnt of effort necessary to 111ke tne procedure successful, the ltk111hood of success, and 111,-, other factors. The caapl1x coabin1tton of these thlt leadS to UNI conclusion that one patient can benefit mre than 1n0Uler ts highly sllbJectt v1. All ts an tndfrect a1sure not only of adtcal benefit, but a n1Der of other factors thlt are stgntficant tn various theories of Justice. TIit aost Obvious ts that age ts an tndtrtct predictor of years of 1 ffe added by I ltf1-sust1tnt119 tntl"entton. This ts true espect11ly for the 0111-tt acute interventions such 1s 1ntibtottcs. Otner things being 1q1111 tlll seventy-year-old can be expected to get aore years of 11fe fr-om 11 anttbtottc for pn...,nta than -an eighty-year-old. If one's pol fey was to allocate to the person who would get the mst 1 ife years froa the treatlllnt, then 191 would be an taportant factor in deciding who gets the tru'l:lllnt. Closely relatld, aye is also an 1nd1rect sure of tne llilDUnt of 11111-betng one has nad over I lffe tt. For those Who work wfth an ov1r-1-ltfet1 concept of equali1.,, other tntngs being equal age 1s an _t ~ t 1~dtctor of haw ell 11111-oetna his bNn 1cc11111lated.
PAGE 46
if~:~-='" ,,.., .. -... .. ---....... r:~(: -.. -...... .:.. --~~'.j .. i n ry "! ( .. J ',__# ... u l"'-4 -40-TIii probl, of course, ts that other things art not always equal. A .. 11 a pNCltctor of dtcal success, y11r1 of 1 ff added, or c11111l1tec1 11e1ng~ but ft ts an tuperfect predictor. So even ff o accepts the undlr1y1ng v1rtlbl111 a legft1Mte basts for 111ocat1ng tldlnolog1es, tt does not follow that 191 can be used 11 1 1>1111 for 111ocat1ng. a. Arpuants tn support of t11e U11 of Ap 111 Crtttrton At 111st four rYll'l'ntl appear fn 'the ltterature tn dlf1n11 of tlll u11 of 191 11 1 criterion tn 1lloc1tt111 resources. TIiiy can be explored tn turn. 1. The Ap-DllllndS-Rtspect Arpuant It ts 1trtktn1 that tn tr1dttfo111l 1octetf1s 191 ws wttllout question 11 l19ttf111te basts for al1oc1ttng certain resources. TIit 11dlrly COClillnded I special place 11 Ille ones dllllndtng respect. In certafn. 11111 there are vesttges tn our society. Older persons are st111 occasionally given courtesies of title. They st111 saaettre11s expect btgher s1l1rt1s for work statlar to tnat of I younger person. Perhaps tn part tt r1flecttc1 the conv1ctton that age brought wtsdaa. I once referred to tllts vtaw 1s tt11 older-ts-better pos1t1on(Y11tc11. 1979). In the 1r1 of ortentatton to youttl, ft ts taportant to r11ltze that tf 191 ts usld as a crtterton for 11loc1tton, tt does not necessarily man Ulat the tlcllrly wf 11 be less 1 tkely to rec1tv1 1 tfe-sustatntng technologtes. In particular, tf there were I chotce between person tn the 191 group now referred to as the young-old, say SOlillOnt about stxt,-ftve, and a neworn infant, saa people might opt for the elderly person on the grounds that I person whose character ts fully develope-i dlrlUdl respect over the unformd infant.
PAGE 47
ft~"--~-. ... __ .... ,,,,, -......... ,,.-. _.,........ ...... ... ... .., ..... t>'. :r:',' .. {zf:/~ ,1,.,-~ :1~~?: -41' z. Ap II I Predictor of Utt119 A IICOlld lrglllllnt for tlle USI of age II I criterion ts.,.. 11ktly co 1Hd to dlc1stons 1 tattt111 1cc11s to 1 tfe-sustatntng tecllnologt11 on tlll bats of 11~ Ttlts second aryunt ss 199 as I predictor of the benefit t111t will 1ccru1 fraa tnterventton. TIit btneftt includes the acltcal factors constdlred but 11 so. 1spect111y for one-tta 1 nterventf ons, tlll years of 11 fe added, thl useful contribution of the tndfvtdull to the soct.1~ tn tile future, etc. Tbts 1rg11111nt, of course. 11 gtounclld 1n 1:111 ut111tar11n tlltory of Justtc1 and appeals only to 1:llose lllllo are open to ut11ttartan rNsontng 11 at last I partial account of Wlllt k1s poltctes right. Uttltt1rt1n1 llf9"t offer I defense of tne us, of 191 1v1n tf it ts only an f aperftct pNdt ctor of uttl 11.1 TIii uttl 1 tartan, dr1 ven to uutatze the net benefit, would conctde that tt would be best to use 11fe-susut ntng resources tn the way tlllt rautatzts tilt benefit. TIiiy 111111d concede tllat occ1sto11111y older people get great benefit out of ltfe-susutntng tldlnologt11, that they aight continue to 11vt and contribute I great deal tf Uley w.-1 used. Tney also conctdl that sora you1119r people ought to be dfsqualtfted ff usefulness to tht p1tt1nt and to socte1., wre tlle crtterton. Thty might argue, however. that there would be grtat d1sut111~ tn setting up coraplex procedures for dtt'tlnrfntng wtltch elderly persons of I particular age were the exceptions tlllt justtftlCI special constderatton. TIit labor and psychological stresses tnvolved afgbt make tt such that the lilOSt efftctent way to raxtll'lze ut1111.Y was s1aply to include or exclude 111 persons of a P1rttcul1r age fgnortng the fact that occasto1111ly persons would thereby be wong1y c1111tfted.
PAGE 48
;r: __ .,_._., __ ___ ,_ ----------;#\-:.: ,, i.:. -4i-Constcler Mrs. B, a WOiiin who 1s etgll~-ftve, wllo has diabetes, 1111funct1on1n9 lltp, 1aa1 stgns of sentltty and coronary artery df-se wno Cllstres by-pass sur91ry vltn tlll llope a.at ft ray extent tier 11fe sltglltly and ray '11kt lier wore caafortable IVtn tf 1t dais not extend her 11ft. Ass11G11ng surgeon ts Vlll tny to perfona ttae operation, slloul d Mlcl1 CIN pol 1 cy perat t the surgery wt tll tlld1 CIN ~turs .. nt? surely tt would for ftf--ffve year old 1tutl1rly situated, even tf tilt ftf--ftve-year-old had psychtatr1c problCGIIPlrlble to tllts patient's senn t~. one reason 11111y ~lldt care 111 gttt oppose the reflilburslfillnt ts tlllt the expected beneffts--tn IIIDllnt and dur1tton--ar1 quite 111111 tn cOlilplrt son to tllt costs. 3. TIie Argtllillnt for OV1r-1-Ltf1tf1i11 W.11-Betng L fr. r! f '-' V ,.; U ':t A 1:htrd 1rg11111nt for Ula use of 119 1s I crtterton l11c1S to a statlar coacluaton, but on very different yroundS. nste1d of accepting utflttartu pl'llltses 1t wor1s froa tlle raxtatn or 19111tar11n tllffry of ~u1ttce Mlktng use of the ov1r-1-ltfetta perspective for detera1n1ny WIG ts lt off. Froa that perspective f-trs. a. might well be qutttt wall off. At lust we have no basis for assuming she 1s among the worst off. Slit ts currently suffering soae probleas, but froa whit we can till. 1111 1111 111d very ny good years. The egalttartan wtlO 1s working fra111:lle over-1-lffett perspect1ie would have to face the problm of
PAGE 49
-43, n o e--_ ,j J ..: --u tJ 111111:llw lie can presura that Mrs. a. has really done well tn her earlier yNrS_allCI ..___. 111111NN1ld be aort ent~tled to ttle by~ss surgery if she bid .... a1Nrlb1 t of her 11fe. TIie ast oovtcius rtsponH ts stat11r to tlNt one gtven above. It ti Nlsonlble to 1111111 tlllt 1 tfe 1n general has bNn I plus. After111, ~a.ts sttll 111,e. The pre11111ptton of postttve value on ltf ts the only prtsumptton we can lllke. Moreover, 1tt111pttn9 to 1111s1 tndtvtdu1l vart1ttons tn ltfett well-being for tw persons of stlll'll1r 199 would be 1 ove.,..latngly caapltcated task. For poltcy purposes, so the defenders of a.ts 1r9111111nt 111DUld cl1ta, tt 11 better to hive I crude, staple blsts for dlctston tlllt w111 provtdl at lNst 1n 1pproxttton of-caaul1tld .-Ntng. If tnts posttton ts doptld, tile older I person ts, 1:111 less cl1ta be or she has to resources. Dts11ses of infancy vould PPHr to get very h1gtl prtortty, then d1H11es of ClltldNn, etc. Tllose 11111G hive lived to old 191 would perhaps have I clt to tlll bastes of care--s1f1, st11pl11 tre1ment1 of baste problms, caafort care, and standard lilldtctne, but not 1xpenstv11 llfgll tlebnology, and 1xpertant1l tre1a11nts. Instead of dlltvertng these coaplex, expensive treatlllnts to thl elderly, .,. work should N done for those .tao otherwise wtll never have tlle opportunt~ to old 199. That ts the baste posttfon of t110s1 Wllca offer a.ts 1r9111111nt. 4. The Arpant frm Contract Nonlll Danttls (1982; 1983) offers I final 1rgurant t111t 1111 lead to tile conclusion tlllt age can 1egtt1111tely be I cr1terton for 1lloc1ttng lllaltll care. It c1r1ws on certain egalttar11n preutses, but also incorporates any of Ula tdt1s of those coa1tted ta tncl1vtdua1 liberty. Dlntels ts struggltng wtth the probl of whit constitutes I fatr
PAGE 50
lf./1;"~'>'-:~--~~-----.. --.,:,,\r. -44-trus(ar of re1ourc11 for health care from.the younger generation who IIIYe tlle 11~ to pay for care to 1:111 ol generation.-have great IINd for care. HI su9ge1t1 tlllt we thtnk of till probl 11 aore an tntrapersonal probl rather than ~n tnt1rp1r1onal 0111. Then the probleu NCaas one of bow 1111cn of the resourc111v1tlabl1 to thl younger llflll'ltton would prudently bl saveca for health care tn old age. HI 1ryua1 that rational persons would 11loc1te fundl tn I ranner atat dells not nec1111rtly provtdl the llli1I hlalth car 111'Vtc11 at 111 IH dllrtng tlletr 1 tv.11. TIii population INS no,..1 opportunt~ ranges tut vary fraa one a91 to anot:blr. *t ts noraal functton1119 for one 191 ts not for 1not111r. Dlntels 1r9111s that prudlnc1 dictates tblt persons wuld allot their t111lth care d01l1r1 with an 111 to those relattvtzld opportunf~ r1n911.(p. 531) TIii result would be different patterns of health care for different..-groups, but coap1r1bl1 _levels of 11tt1f1ctton of tlll age relattvtzld opportunity r1n91 at till diff1rent 1911. Justice requires that we 1llocat1111111:11 car tn 1 ..,...,. that assures 1nc11vtdU1l1 a fatr chance at enJoyfng thl nor111l opportunity range, and prudence suggasts 1:hlt tt ts aqually important to protlct 1nd1Y1dul1 opportunity ranga for 1adl staga of life (p. 536). In arcllr to 91t to 1:1111 concluston, D1nt1l11111st suppl-nt hfs aodll of till prudlnt saver w11:b I concept of Justice so that each person bis I fatr portion of health care over 11ifet1 (even though 1t may vary througtloUt hf s or her 11 fetia) He opts for a strategy heavt ly 1 nf1 uencld by John Rawl s. It 1 s I hypotbetf Cl 1 contract di 1 1 n which persons fraa behind R1wls1s vetl of ignorance apportion their health care prudently. TIii result ts protlcting the nonal opportunt~ range at Hell stage of their ltves (p. 529), but using such Judglillnts as I basts
PAGE 51
-454 rl '~ ,.., J ~-oJ I for generatt 119 1 Ilea 1 tll care p 1 an that would dtterra1 ne everyone Is enttt1-nt to care. Thts would rain thlt 111 persons at I gtven 191 wuld b.e trNted 1fatl1rly even tbOugh persons at d1ffertnt 1911 would be trNtld d1ffere,.tly. Dlntels 1111 providlel tbe fr11i1NM"k for an 19111tar1a basts for using 191111 crtttrton for 111ocat1ng care. People of different 1911 would be entitled to care geared to different opportunity ranges, but 111 persons of I given 191 would hive s1a11ar entttl-nt. Once 1911n over-1-ltf1tt persons would be treatld 1q1111ly, bUt 191 would still bl 1 1e9ttt111te criterion for 11loc1tton. The over-1-1tfet1 perspective ..... to taply that the younger 1 person ts, tlll 9rt1ter the clata to soctetll resources. Al I practical poltcy Mtter that could create IOI.II serious probl--IIY of dloostng Ntwean I tlltrty-tbree-year-old and I tlltrty-four-yur-old on the basts of age. Stnce Ult prtry area of controversy ts over the use of expensive, 111r91n111y D1n1ftct1l resources for thOse wllo hive coapleted a.tr 11ft plans, ft 11 possible that sea cut off point would bl adopted 1n usfng 191 as I crtterton. Here use ratgnt bl lilldl of the tncre111ngly fraportant dtsttnctton bttwetn the young-old (say, ages 65-75),thl old-old (1911 75-85), and the very old (1911 over 85). It 1s poss1Dle thlt an 191 crttarton could bl usee1 for 11loc1ttn1 certain 1tfe-sust1fntn9 ttdlnolog11~ only for thl older subgroups. It ts also possible that tf 191 crtter1a are generally adopted, different sets would be adopted for d1ffeNnt subgroups of the elderly. D1nt1ls could explain tnts by arguing that there are aifferent age-relat1vtzed nonal activity ranges for 1:111 different subgroups. a. Arl!!nts Against the Use of Age 1s a Crtterton
PAGE 52
~~;~.--.. ......... --. --. -... -ft,'':-'. f~- ~-; :, t' -46-. TIii 1rg11111nts favoring the use of age as a criterion are clearly dlpencllnt llpOII tlle theory of Justice one adopts. The argunt that ush1g 191 11 exc1111ton cr'lterfon tends to uu1a1ze ut111ty depends on utllttartan pNll1N1. Thi arg11D1nt that higher 191 1apltes lower prtort~ bec1uH peGpl1 dlse" 1qu1l we11-b11ng and ov1r-1-11fettae elderly persons hav1 hid yre1ter well oeing dlpends on one v1rs1on of the 1111Xtatn and ega11tar11n positions. The hypothetical contract modll tha~ ~tls believes 1Ndl to the conclusion that paopl1 should have equal opportun11., to fulfill tt11tr 191-rel1ttvtzld opportunity ranges 1110 ltandl tn the e911itar11n tradition. TIie counwr1r.-nts 11111 1110 follow the patterns establtsned tn Ult U110rte1 of Justtc1 Cllb1te. Any arguant 191tn1t the pNlltses of tnt particular theory of Justice will turn out to be I reason to oppose the use of age 111 crtterton. For 1xarapl1. anyone who rljacts ut11ttar1an1a w111 likawtse reJect the ut111tarf1n reasons Wflly 191 atght be usld 1 crtter1on. Moving to spectftcs, five lillin 1rguL11nts '!!f111st tht UM of 191111 cr1t.r1on -to _,ge. 1. Eplttart1nt wttll tne Sltce-of-tt P1rspecttve Perhlp1 the lilDSt coiaon 1rg11111nt tn the 11ter1tur1 on ettller stde of tllt dlNte ovr a. u11 of 1911s crtterton tn 11loc1ttn9 resourc1s ts tlll a.at people should be trNtad aqually and that t111t ans equal flleCII should hive an equal ch1nc1 of being ,at regardless of aye. Childress (1984), MDo (1978), and St1gl1r (1984) all make use of tt. Clltl dress and JtooclJ appear to reflect the broad Judeo-Chrt stt an egalttart1ntsu. They casatne ft, however, with the s11ce-of-t11i11 parspacttve for deteN1n1ng how ft ts that people should be treatea equally. People equally sick at I given point 1n time have an equal clata, so Ula ar.-nt .... to be.
PAGE 53
;:-t. -47To aw knowlea91 none of the e9111tlr11n crfttcs of the use of 1911s 1 crtter1on llas dealt 1xpl tcitly wttb either Ula ov1r-1-l ffetia v1i~s1on of 191lttarfant or Dlntels bypothlt1ca1 contract prudent saver lilOdll, lOtn of llllltch tr.eat people equally over I ltf1tt, but 1110 pan1tt, 1n fact require, that people of different 1191 bl treated differently. The posstbtlt~ that there can be 191litari1n as well 1s ~ti11t1rt1n grounds for ustng 191111 crtterton has really not bltn confronted by the 19111tar11n critics. 2. Ltbertari1nfsa A second argument against the use of 191111 crtterton for 11loc1ti119 11fe-susta1ning ttch1101ogtes ts qufte different. Rootacl tn the ltbertari1n theory of dtstrtbutton, ft llilplllstzts that lffe-sustatntng technologtes, ltke other goods and s1rvtc11, should be 1v1tl1Dle to tnose who want to purchase tbH or to those Ntlo are the rectptents of gtft or exchange fraa others who control these services. UIICllr tnts vtew 11110111 Wtlo has the rttsources (tither direct fundl or insurance coverage) should have access r1prdl1s1 of 191. Age atght enter tnto 1ndtv1dual choices about Wllther to rake use of 11fe-susta1n1ng teclmolog1es. SoGII elderly people ratght reason that they wuld rather a.at their resources bl used for other purposes. Age Y'lght also tnfluence tlll distrtbutton of resources thereby deteratntng who has ttae funds to purchase ltfe-sustltntng technologies. But 191 par se would not, according to the libertarian perspective, determine who should have access to any resource including 1tfe-sustatn1ng technologtes. If sora people are unable to gain access because of lack of resources that ts unfortunate, bUt not unfatr.
PAGE 54
1~r:>:~r-~, '. Si 1 .~ ~f-~_ l',',. : .. ':' :{," r .. t[;, r -48-('\ 3. The Rule Ut111S, Arpumnt Against Using Ape as a Criterion Uttlttarfans w111 approach the probl of the use of age as 1 crtttr1on fn I very different 11111ner. WI hive alNlf.W SNn that S01i11 uttl 1 tart ans mi gilt argue that us1 nt age cutoffs for care 1 s I good way to autllfn tile 111Nt1te good done by ah11lth care poltcy. They would argue tlllt stnce 191 1s an indirect 1nd1cator of other factors that. correl~te highly with the IIIOU~t of benefit produced by 1 tfe-susta1ning tldlno109tes--f1ctors such as predicted liildical success, years of 1 ife 1dded, and social usef~lness of the life saved--tt ts most efftctent to operate under SOlill yener1l rules that allocate df 11ys1s and other tlcllnologfes strictly on the basis of 19e. Otller uti11tlr11ns wight push this reasoning one step further. They alght be concerned about the d1sut11 it1es of tlavtng sa111 persons 1n the soctety receive 1ife-sustain1ng tedlnologies wlltle others--equ1lly sick 111d equally at rtsk--do not. They uight fear the psychological stresses and social unrest created by such I pol icy. They might go so far as to argue that 1n order to atniatu the social friction created by age cutoffs, everyone, regardless of age, should have the saa access to ltfe-sustltning technologtes. That rule, even with the ineff1c1enc1es that result fl'Cllll_deltvering care to elderly who are likely to gain very little benefit and add very little to socie~. 11111 end up producing raore -good 'tllan trying to tnstitut1ona11ze an age-based dtscrfmination. The utflftarfans 11111 have an additional case against the use of age as I criterion for allocating 11fe-susta1n1ng technologies. If age 1s an fncatrect IIINSUrt of future life-expectancy or future usefulness, 1t 1s at oest an 1nd1rect aasure. Two people of equal chronological age may nave very different phys1olog1cal ages, different life expectancies, and
PAGE 55
-49. .,, 0 ,~ ., J _.:_ ':t i different future productiveness. There might, therefore, be a sense of unfatrN11 result1ng_frOII the use of chronological age as criterion resulting 1n discontent and further d1sut11ity. Tbts raises the question of whether developing fnd1ces of pbys1ologica1 191n9 would nave an irapact on the decision to use 191 as 1 criterion. If an index of physiological aging were developed that accurately predicted future life expectancy or future productiveness, then these ut11itarian objections to the use of age as I criterion would disappear. An index of physfolog1cal age would be preferred by uttlft1r11ns to dlronologfcal age. By contrast the developuent of an ~ndex of phystologfcal age would probably have no sfgnfficance for over-a-11fet1 e9111tar11ns and aufmtn theorists. They are interested in age, not as a marker of future ltfe, bUt as an indicator of cumulated 1 ffet1m well-being. Chronological age would probably be I more appropriate aasure than physiological age frOIII this point of vfew. 4. TIie Life-ts-sacred Arguant St111 another arguant against the use of age as a criterion 1s specific to life-sustaining technologies. Sora people 1n some religious and cultural trad1tions--sOIII Orthodox Jews, for example (Bleich, 1979)--belteve ihlt 11fe ts sacred. They hold that ltfe should be never N shortened by the witharaval or w1thhold1ng of n11dic1l technologies under 1,-y c1rc1111stances. They consistently oppose withholding of respirators, the writing of DNR (do not resuscitate) orders, and the refusal of any other life-sustaining tre1tants. It goes without saying they oppose w1thhold1ng of hydration, nutrition, and ant1b1ot1cs. Anyone tiling this position would necessarily oppose the use of age as a
PAGE 56
-50-:. n .: "" I. ./ '-~ : criterion for detenain1ng who should get 11fe-sustain1ng technologies. Thase'persons cou~d consistently support the use of age as a criterion for otlllr resource allocation dte1sions--th0se that are not utters of 11ft and a.th--but they w111 oppose age as a criterion for 11fe-susta1ning technology allocation. They w111 do so for reasons that are not fntrfnstc to the age criterion probl. s. TheUse-of-Soc1ologfcal Categories Argument '-.... :C:fV A ffn11 1rg11111nt ~inst the use of 191 as a criterion draws on e1rlt1r parallel debates frou the civil rights and waaens rights aoveants. In the early ph1s11 of those debates s0111 who would defend d1scr11111nation on the basts of age or sex did so using the argumnt that soctologtcal categorfes (such 11 race or sex) can be used to predict perforauct or success in the work place and other uttfngs. A former dNn of Harvard Law School defended ttie exclusion of wan for the school on the grounds that there was good evidence that, on 1v1r19e, a woman trained fn law spent fewer years working in her profession than her ,ale counterparts. Similar arguf.llnts were offered that race was a predictor of perfonance. Unless there was som way of differentiating Which women or blacks would under-perforu, some argued that they were justified in d1scrtlilfnat1ng on 1:111 basts of accurate pfrical generalizations using socio1og1c:a1 categories. This generated substantial argument. Melabers of minority groups, espec1a11y those who had reason to believe they would not follow tne Pltterns attributed to tne~ on the basts of soctolog1ca1 categories, took strong exception. They argued that 1t was unfaf r to assume that they, as 1nd1v1duals, would perfon.a poorly, that tiley would follow the soc1olog1ca1 patterns. They further argued that sex or race ts an
PAGE 57
-51J. n:,.~.-, ~.. ) .... ) .. 'i: "-' 1scr1bld category over which they had no control. Ascribed categories. they M1ntl1ned, could not fairly M us1c:f 1s I Das1s for allocating socf-11 goods suc:11 as Jobs, .sct1ol1rst11ps. or places 1n school. They Sllollld.,. 1v1l111tedas fndfvfduals independent of the ascribed categories and the perfof'r.Jlnct of others in those cate~r1es. The critics of the use of ascribed 1oc1ological categories have now largely won the debate regarding sex and race. Only 1n very special cfrcUGIStances where sex or race in 1nhirently 1 fnked to a job, may these factors be used as selection criteria. TIie iap11cations for the use of 191 as a selection crfter1on should be apparent. Age, we have 1ndtcated, is almst always used as an fnclirect. imperfect f ncl1cator for saae other factor. thought to be relevant in selection. It predicts lfk~lfhood of radical success, years of life added, future benefit to society, or net well being accuaulated over I lffetiae, but ft predicts each vif these 1.aperfectly. Furtheraore. age is an ascribed category. There 1s nothing af\Yone can do by hard work to change ft anygore than one can (with very special exceptions) change race or sex. If race and sex cannot be used for allocation without being unfair, does ft not follow, so -these critics argue, that age likewise cannot be used. Th1 s 1 eads to tne conclusion tnat anyone who wants to exclude on the basis of raed1ca1 benefit, ut11i1.Y calculations, or 1ccU111l1ted well-being over a 11fetfme would need to 1.aount direct evidence that these fa~tors justify exclusion fn the particular patient. Age per se could not be used as a sociological short cut to these factors. c. Mixed Argusaents Regarding Age as a Criterion It 1s possible to accept the useof age as a criterion in certain
PAGE 58
-52~. n t .J .... "): -.:. c1rc11111'Clnc1s and reJect 1t in others. We have al ready seen that a s1w11r po11q has -rged regarding the use of sex and race as selection e.r1ter1a. Only 1n those cases When the socfologtcal c1ttg0ry was 1n111Nnt1y linked to the position could that category be used tn H11Ct1on. It ts hard to conceive of situations lffltre 191 per se fs directly relevant to the medical consequences of life-sustainfng technologies at least regarding the elderly. There may be situations fn neonatology where a treatment must be de11verad before the infant is I certain age or 1t ts certain to fatl. Age 11 are nor1111ly, however, an indirect 1nd1cator of scra other v1r11Dl1. We have s11n, however, that SOIII 1galttart1ns (see Veatch, forthcOli11ng) are experiaenting wi~ 1 differentiated approach whereby 191 is legit1mtely used 1n 11locattn9 res11rch and aevelopuent funclS, exper1antal treatlillnts, expensive treatrants, and those wfttl low ltkelthood of success while everyone would have equal access on the basis of need to inexpensive, safe, and effective treatments and to coafort care regardless of age. Daniels prudent saver, contractual scneme could easily 1Nd to the Sllill result. Prudent planners of 1 11fe-t1a of expenditures would reasonably buy insurance for inexpensive, safe, and efftetfve treatants and comfort care regardless of age, but, when constdlr1ng thetr old age, they well might forego insurance for experfntal or expensive treatments and those with a low probab11 iey of success. Other formulas for ~1xed po11c1es where age ts somet1raes used as a criterion and other t1raes 1s not are likely to lli18rge 1n the future.
PAGE 59
-53J n ; ,-, r.--,_I J ;.: -,t it; D~ Saving Lives Versus Saving Life-Years lilt have sn that, especially with _consequence-oriented (uttlttartu) tlleorfes of Justice, it will rake I great deal of difference exactly wt11t Ula goals of I h11lth poltcy are. In f)lrticular ft wtll lllke 1 difference in any cases to Ule eldlrly Wle'ther the goal of I policy 1s to save 1 ives or add expected 11fe-ye1rs. This difference ts particularly critical for those tldlnologits that overcoa a life-threatening iituation with I single set of applications. Ant1Df ottcs and CPR are exuples of such technologies within tllt fraawork of this study. Other t1Cllnologie1 thlt are one-t1 rather Ulan continuous are organ transplants, INlrn tre1t111nt, bypass surgery, and tile tre11:111nt of acute toxic reactions. These contrast wtth trel1:lillnts that nd to be applied continually such 11 chronic n110-911tr1c feeding, chronic hydration, di1ly1ts, u well 11 insulin therapy, blood pressure regulation, 1nd treatrant of hypothyroid1sra. For 'tlle acute, ont-tia inte"entions that overcoa 1 tfe-tnreatening situation the benefit is the sa regardless of age, if one takes saving lives as the goal (ignoring the differences in success rates that ray be related to 191). If, tlOWever, the goal 1s adding expacts life-yea", tllen the benefit 1s inversely proportion to aye. The second goal 1 s IIIICII uore contrary to the 1 nterests of the elderly. E. Inttrpnerational Responsib11 ities and Confl 1cts Considering the use of age as a criterion for allocating 1 tfe-sustain1ng tldlnologies poses the probler.a of intergenerational respons1bi111.Y 111d conflict 1110ng the generations. Thinking of the use of ltfe-sustatntny technologies for the teratnally 111 elderly, many indfvtdu1l1 have COIII to the conclusion tblt such uses, even tf they are
PAGE 60
-54-dl111'ICI, cons ... large mounts of personal resources that could better De UHCI by Ofll1S cll11dNn 1ne1 grand dl11dren. On that basis soaa 1nc1tvtdull1 forqo Ula use of life-sustatning technologies ring i.ratnal illness. If ildivfdulls k such dac:isions with tt11tr 0\111 resources, the question arises "'8tber at the societal level policies can be adopted that presll'Ye the socie1.Y1s resources so tlley are not used excessively for Ult older generation. If 111111 people constdtr the benefits of such uses Slllll or even non-extstent, utfltt1ri1n1 would reasonably support prese"1tton of the resources for futun generations. In fact, ft ts not cl11r that these constderations would be liufted to existing generations. Is the calculatton of. benefits and taanas to tnclude 111 future persons, wether presently ltving or not? If so, since the nuraers involNCI are 1xtrera1ly large in coupar1son to the nuraer wao are teratn11ly 111 1ne1 needing 11fe-sustatning ticllnologtes at any given tfa, the 199re91t1 benefit of using the resources for future 91ner1ttons (through resrch and developant of t111 causes and cures for the underlying condttfons) w111 be very great. Goldtng (1972) 1Dng others has argued tt11t those mre than wo ~r tllrN genar1tton1 in the future w111 be so different fraa us that tt w111 be virtually tmposstble to predict thetr interests and tnat therefore they do not need to be taken into account. Others, such as Daniel Clllahan (1971), are not as convinced of the radical dtscont1nu1ty between our generation and future ones. At 1 east When it coa11s to the dlstre of future generations to avoid end stage kidney dts11se1 tnfac:tions, dellydratton, nutrttton1l deftctt, and sudden cardta~ or re1ptr1tory arrest, ft SNlill reasonable thlt those tn the f~ture are
PAGE 61
l?,:,,~:',,. :~~~' >' l:\ .... ... ,'f!',,' '.~{ :~-., -55-. n ., .-.t e_: J :: -~ I lttely to dlstre to hive these probl1111 solved. Ut111tlr11ns thus mst face till,,_,. of llow a,w expenditures on tre1tant of the present 91_.1tton of tile elderly can &>e just1f1td. Stull~ pro&,1of 1ntergener1tton1l responst~111~ 1r111 for au1111n tllaertsts and 191lttart1ns. They 1111st dltlrlltne whetlltr the pNHnt tenr11111ly 111 elderly ire 1110n9 the vorst off groups taking into account Ule 1111ttng younger 91ner1tton 1nd possibly future gen1r1ttons a well. Rawls (1971, p. 284-93) 11 11111 11 otllen in plltlosopby and econaatcs t1av1 worrted-1 grNt dNl 1boUt Just1c Ntwttn gener1tton1. Since fn Rawls' bypattllt1ca1 contract t110C1olog, for generatfng tht prfnctplts for u. baste tnst1tuttons of soct11., no one knows tnto Wlich generatt hi wtll be born, tllt result w111 be Wllat Rawls (1971, p. 289) calls tllt .iust savings prtncfple tn llllltch tlllre ts an underltlndtng b1twaen guerat1ons to carry thetr f1tr shire of till burdln of rea11z1ng 111d pre..-vtng a Just soct1~. Each generation trt1s to ptec1 together a Just 11,tnp schedule by bal1nctn1 how 111ch at each stage they would be wtll tng to 11,1 for tM1r traldtate descendants against wlllt they would entttlld to clata of t111tr 1-d11t1 predecessors (p. 281). Dan1t11 (1982, 1983) ss the tnter91neratton1l respons1b111~ probl u cr1t1ca1 for for tits hypothetical contract prudent s1v1r I.IMlll. He r1glltly ss ne1lt11 coverage for the elderly as es11ntt1lly 1 ICMlill WIINly each older 91nr1t1on ts the bln1ftc11ry of the resources of 1:lle younger yenerat1on. If I plan prov1d1ng a91-rel1ttvtz1d opportuntttts for he1ltn 1s once tn place, even tf the elderly did not get the 11r.11 levels of coverage for 11fe-sustaintng tecbnologtes, everyone wuld be treated fairly. They would at lNst 1f every 91neratton were of Ute Slli1I stze and hid the 11a level of resources to
PAGE 62
f')t r ~::,, ,~ -56-() ,. lo. .. -..:: contr11N1tl. TIii tnter91ner1ttonal transfers would cancel out with each ,. youger ..,..ration contributing, as 1t pri11ntly dots in Mldtcar1, to the support of tie O1c11r generation. Two probl-IN fdenttfted by D1nf1l1, however. First during the start-up plllse certain generations w111 bl trllted differently. If, for eX111pl11 1a111 of tlle ltfe-susta1ntny tecbnolo9t1s now available to the elderly were 1111i11nated, a transitional 91n1r1tton would have pafd, t11rou9'1 Nldtcart or SGDI successor in1ur1nc1 sctlera, for htgh levels of servtces 111d yet not rec1tv1 tllllil. On the other hand, tf soa serv1c1 IIICII a bo1ptc1 care or bypass surgery were suddenly tncludt4 tn the -plan, IOIII tr1nsitton1l generation thlt dtd not pq for such care would be the r1ctpt1nts. In ettlltr case, problof fairness would arts that would be of concern to tllOse working tn a theory of df strfbutfon that 1s patterned. Daniels also points out tilat 111 91ner1ttons 1111 not be equally equipped to Pl1 for care for tlll 1laerly. Saa paying generations WIY M qutte -11 y1t h1v1 to pay for care for 1n elderly generation that is large. Other g1n1r1ttons way fact the opposite delilograpntcs. Solill .. aenar1tfons say face long pertodl where econtc concaittons rake 1t dtfftcult to pey for care for tile older gen1r1tton. Daniels argues that fl'OII tile potnt of vtew of I dtstrtbutton syst-.a lllphas1z1ng equal tty, there would b1v1 to be adjustments so that the ratio of burdens to benefits was evened out. In any case, 1f a plan using age 1s I cr1ter1on for 11loc1tfng 11fe-susta1n1ng tectlnolog1es were suddenly instttuttonaltzecl, 1c1Justants IIIOUld have to be 1.11de to deal with tntergenerat1ona1 responsib111t1es during the transition generations and be'Cwlen g1111r1tton1 that t11d unequal ab111ti1s to support healtb care.
PAGE 63
t:c \/\ f.: .. '. ?. -57L o. .,f n \. .J ... -z tJ TIii d1 scu11ton1 of Rawls and Dante 1 s 111kt cl Nr that one of tt1e key ,,..1_ of tnttr91..,.ttonal re1pon1tb1lt~ ts thl extent to Wlltcb Cll11dNII ...., r.esponstbtlt~ for tlletr parents tn I direct -,. Both rteognt11 tlllt Ula parental 1111r1tton tr1n1ftr1 resources to younger 11watton during rly 1n and that SCIIII reciprocal respon11bt11ty ts b 111 by clltldren for tllttr parents durtng tnttr old age. At tile saa tta botll place substanttal ltatts on tlle Obltgatton of tlle younger generation for thl "ldar. Rawls puts tn tn ter111 of the OD11gatton of Mell .. ,..atton to save for tts i .. dt1t1 Cllsclfldlnts. Dlnfels puts it 11 una of way I prudent saver would allocate I lif111 rtsourc11. In botll CINI tt ts clNr tnat ltatts extst on 1llhlt muld be transferred ,,_ Ula younger yaneratton to Ula older. Cl111111n, taking I samwt11t different perspective, s govr,..nt progrto .... t Ule needs of the elderly 111 llflY of 1111119 tensions N'CIMetl 91111r1tton1, 1 tension that IINlld ot11erwt11 result tf tlle younger gener1tton dtd not bear 1 responstbtlt~ for provtdtng care for the older, but nevertheless 1'11111necl 1n contact wtUI tlla through f1111ly ttes. TIE HEALTH CARE RESOURCES THAT CAN IE DISTRIBUTED Eidt theory of dtstrtbutton w111 hive iapltcattou ior the health care NIOUl'CII 1:0 bl dtstrtbuted. In order 1:0 1Xllllne tbos t11pltcattons, tt ts necessary to hive I catalogue ~, tbe the health care resources that cu N distrtDUteca. It ts ftrst necessary to recognize that different goodS aay need to be dtstrtbutecl on different D1ss. In fact, d1str1but1ng one thing on o buts-, bt tdenttcal to distributing 1notner thing on sae other b111s. For ~1, d1str1Duttng health equally (to tile extent wa could) would sure require distributing healtll care very unequally.
PAGE 64
..... t~;r 1!i' '~._, -58-. -1 n ,-0 'Solll of Ult 11ter1tur1 on tbe 1lloc1tton of t1e1lth c1r1 r1sourc1s .... flllpOrtant d1st1nct1on betw11n d1str1but1ng h11lth and health care. Wlltlt 1aa1 lttrature (Blackstont, 1971; Sparer. 1176; YNtch, Just, 111,; D1nt111. 1179; Prestdlnt's Caratsston for tllt Stuel, of Etlltca1 Probl-tn Mldtct and 810llld1ca1 and Bltlavtoral ResNrch, Slcur1ng, 1983) explores the concept of a right to health, tt ts now c-..onplace to potnt out that I rtgtat to health doas not ~1st as a legal r1gllt. Nlrlover, health 11 not sa111t11tng tlllt can be I r1gtlt bteau11, 1n 1aa1 caM11 tt ts taposstblt to aak1 people hlaltlly. For tllese reasons tt ts _, generally constdlred aore appropriate to speak of a right to hNltll care. MDreover, SOCII coa11ntator1 (Nicklin, 197&; President's CG1111111ioa, Slcuring, 1983, p. 32) prefer not to speak of rights at 111, but rather to address tlle undlrlytng tssue of tllt proper distrtbutton of care. Thus this stu and mst caraantltors working tn till,,.. nov 1p11k of 1:lle 1lloc1tton of health care rattler than health. A. TIit D1sttnct1on Between Ht_. and Low Ttdlnolop One of tlle lilOSt avtou1 ways of dtv1d1ng tht health care resources ts betwlen those that are htgt1 tldlnologies and those that 1r1 ov. Uncllr tilts clustftcatton dtaly111 uach1nes. ventilators, resusc11:lt1on equtpant. and HIii dtcations lllgbt be constcaereca high, wtltle skin care. tollellfng,turntng,_sOlill form of nutr1t1on and hydration, and CGlillllltcatton could be considered low. The d1stinct1on ts obviously arltttrary. More stgntftcantly, accord1ng to mst theories of d1str1but1on and lilDSt otlltr 1t11tc1l and ph11osopb1c1l analysts, tile difference betwaen hfgll and law technology 1s not terribly tmportlnt. TIier was I tt~ espacially 111Dn9 cltn1c11ns, when thts d1st1nct1on was believed to bl
PAGE 65
-59iapo,Unt. It was related to tht language of ordin1ry and u-craordtnary ... 11. Ml,w cltnic11ns believed (sa111 still De11eve) .. t tile tttgtllr t111 tec11nolo0--aan1ng prtsuauly ttll aore coraplex--ttae _.. exlraorcl1nary. It 11 traportant to realize that the plltlo1oph1ca1, ttleolog1ca1, and 19111 CCU11ntator1 (President's Comtssion for the Stu of Et111ca1 Probltn Mlcl1cine and Bioadical 111d Behavtoral ResHrcll, FoNgo, 1183; Pope Pius XII, 1158; Congregation for the Doctrine of The Faith, 1980; Rwy, 19701 Veatch, Death, 1176) never intended that a tre1t111nt be cla111f1ed as utraordtnary on tilt basts of how coapltx or how unusual tt Rattler a treatlllnt was called extraordtnary tf 1t involved a grave burden for the patient or 111s useless for the patient. SOllltts (Congregation for the Doctrine of TIii Faith, 1980) now tt ts 1t111ply said tllat tnl burdens are d1sproport1ona1 to the benefits of the treatant. Nevertheless to the extent that 10-c1lhtd high technologies are parttcularly expensive, exper11.11ntal. or possessing I low probab111~ of success, UNI libel of t11g11 technology ray be relevant for holdlf'S of various theories of dtstr1oution. To the extant that a nigh tecllnology 1111 111 gll cost and 1 ow proa,111111 of success, 1 ut111 tart an is 1111 likely to ftnd tile benfits of thl tre1ta1nt proportional to the burdens. 1'11111 a 111111 tacnnology for ut111tar11ns 111'19'1t be a suspect tldlnolot,. Nevertheless SOGII tligh tedlnologtes can offer very stgntftcant benefits for SGlill patients including SOI.II elderly patients. The teuporary UN of a respirator as part of CPR for an elderly patient Who ts suffering an 1sthallttc attack, but wtao ts otherwise healthy ts surely a li11n1 fnvestant with I very ntgn 11ke11hood of adding "1 1rs of high quality ltfe to ttle patient. The fact that it ts a htgt1
PAGE 66
l{f?)~: '' .Jf:_.: .. t-;,,' ;~ -60-r, : C.' .. --., ~' ~J tlCIUIOlotJ 11 noi terribly relevant for utfltt1ri1ns or holders of otner IIIIOrt of dtstrtbutton. ,or 1111111, rusons the dtst1nctton between high and low technology ,ay N faportant to the group of egalttar11n1 wllo, ustng an over-a-ltf1t1 perspective, are wtlltng to u11 age 11 1 criterion for tntervent1ons that are expensive, 1xpertntal. or w1ttl low probabtl tty of 1t1ec111, but 1ns1st on equal access re91rdl11s of age for those 1ntervlnt1ons 1:t11t _are rel1ttve1, safe, inexpensive, and wtth I tatgh ,,._111~ of success. To till extent that the label g11 signals that tlll ucnnolo., ts in till fo,_r c1iegory. tt1t1 wuld 1aportant for holders of such I position. It ts taportant to r11ltn that the label 1s only 1 1191111 t111t tllt tldlnolot, way fall tnto the cate90ry wnere ~ is a relevant d1strtbuttona1 criterion. It ts not I final dtvts1on of tbe tldlnologtes. a. Sptc11ltz1d Setttnps In addttton to d1strilNlttng resources bttwetn htgtl and low tldlnologtes, we can also speak of dtstrtbuttons aaong different health Clrt settings. Sora settings correlate wtth the use of tht higher tldlnologtes. ICUs would be 1n extrea exuaple. Hospitals would tend in 'CIiia direction 11 well. On till other hand nursing howes and espec:11lly t1o1ptc11 offer IIDN baste cre of the sort thought of as low tecnnology. When they do tbetr JObs well, they provide comfort.. pain control, and tne basics of nurst ng care. They are ltlcely to provide few of the life-sustatntng technologies tnat are tne focus of tbts stu(bt. Ant11ottc1, for exllilple, would not 11on.111ly be used tn hospices. The 1&1111 true for d1alys1s and CPR. Tn1 only exceptions would be for caufort cart. They are mre likely to be providing hydration or
PAGE 67
~: -61n ,: r : t J ".. V ''--; nutrition, bllt f ncre111ng11 ft 1~ being argued (In the Mitter of Claire c. Conroy, 1983; Lynn and Childress, 1983~ President's Coaatssfon on the siuc-, of Ea.teal Praltl .. tn Mld1ctne and Btoadtcal and Behavioral RelelrCh, Forego, 1983; Lynn, _fortllcowf ng) that tlNtse are expendable just 11 IW o'tller tN1t111nt 1s when they serve no useful purpose or when the, are gravely burdensC1i11. The only exception to tllf pa~ttrn ts tne recant lower cOt&rt deefs1on fn the Brophy case 1n Mlss1ct1us1tt11 which was cleciCIICI very recently and ts_ certain to bl 1pp111ec,. It would appear that bOUI ut111tar1an and tM over-1-ltfetia ega11tar11n ttteort11 of dfstrflMltfon would be are 1upporttv1 of the l f fe-sustainf ng tldlnologfes tbat are provided in nursing haas and llo~p1ces than tt1o11 tnat are higher technologfes.used in ICUs and hospitals. There is no theory of dtstrtbutfon that would systaaatically exclude 111 ltfe-sustafnfng technology for the elderly simply on the Dasis of the setting fn whfch ft fs d1ltv1red. c. Hnlth C1r1 Providers Likevtse, one ray 1xui111 Ult way the various theories of distrfbution would treat alternatfve health care providers. It ts fraportant to re111z1 that there 1r1 reasons other tllan those of theories of dfstrflNltfve justice w11y certain providers aay De preferred. Nurses, for 11111ple,-, operate under different pllilosophical 1nd ethical caaitanu than physic11ns 1nd may eaphasize different kinds of care. Saal patients choose nurse a1.,ives for child birth while others prefer obstetrtcfans. This may have nothing to do with the ethics of d1strtbutton of resources. Different theories of d1str1outfon will place different son different providers, however. L1bertar11ns are 1 ikely to favor I policy
PAGE 68
. 0 .., .. -'-i -ti2' of pen1ttt1ng persons to k deals wfttl wllltever providers they choose. provt_dlcl only that the prov1 ders are wn 11 ng to cooperate. Extrea 11taertar11ns 1vtn oppose restrictions such 11 those imposed by ltcensure Uttlttarians will ask whit the raost efficient mix of providers 1s wttll efforts being 111cle to assure that overly trained professionals are not providing services that can be provided at least as well by those t less prolonged training. They w111 even prefer lay providen and self-can when tllat ts reasonable. Mlx1atn tblortsts and e9111tar11ns differ sharply on the question of w.tllttr tt ts acceptable to divert resources to elites such as hf ghlY ir11n1e1 professionals in order to benfft the least well off. Mlx1m1n theortsts provide the intellectual underpinnings for a tric&le down 1pproadl that justifies high salaries for physicians and other skilled professionals when necessary 1n order to benefit the less well off. If the elderly are I least well off group then raxfmfn theorists would in principle support increasing funds for research and development to iaprove tt11 conditions of tt11 elderly as well as higher salaries for marstng hCli1I personNl 1n order to improve the quality of the care offertcl. Egalttartans, on the other hand. are aach raore skeptical of such moves. TIiey would favor such 1rr1n91m1nts only as I compromise when the 1111 well off approved of tne inequalities and even then they would constdlr I sacrifice of justice in order to benefit the less well off. Mlxtain theorists and egalitarians who take the over-a-lifetime approach to detena1n1ng who 1s least well off, but the s11ce-of-t1 approacll for dec1d1ng wllo should get ttll basics of c01.1fort care and
PAGE 69
i. -~tr.-: -1.: .J ... : q) ~1 -63. staple, routtne, 1ffect1ve trNtmnts. would reasonlbly favor ~pec1a1 pr_1or1t1es for nursh19 ho,a.s and ho1pfc11 for the elderly. but may want to restrict ,aore intense. expenstve care. Ega11tartans would be reluctant, however, to iuprove nursing hoa and hospice care by offering large financial incentives to staff. Rather they would support .other Kinds of faprovllillnts such 1s more lower paid staff and are direct expendftllres on the patients th ... lves. D. support s,ysts such 1s Furflfes, Coaunit1es1 R19tons Care w111 also nd to be allocated to support syst for fua11ies, ccaunttfes, and regions. Each theory of df strfbutfon will havt its cbaractertsttc approach to thfs allocation: 11bertar11ns relying on prtvata resources and cb1r11.ilettfng support systlal develop where they 1111, ut111tar1ans looking for raxtlillm aggregate benefits, mutain theorists attlllpting to improve the position of the least well off. and e91lft1rt1ns strfvtng for greater equality. Planners will need to d1stingu1sh between support systs that are designed to benefit the patient through providing support for tht faa11y and support systems tblt are designed to benefit the fua11y or cOli1illln1ty itself. In SOUi cases tlle posftton of tne patient 1n the systlril and that of tlle fllltly may be qufte different. A severely afflicted patient may have I f111fly that ts reasonably well off econ01i1ca11y, psychologically, and socially. Support sy,tas would probably fit into the category of low technology services, tne kind that w111 be favored by utilitarian and e91lft1rf1n approaches. POSSIBLE BASES OF MACROALLOCATION When con~eaplating I public policy for the racroa11ocat1on of resources 1n the he1lt11 care sphere, 1 nlllilber of bases of d1str1bution
PAGE 70
'. .. ,. : I. : n ,.... c I. -f!J J -64-nave bltn proposed. TIiey hive very different imp11cat1ons for the dlr1y. In tbts section of tne report~ 1 general cl1s1if1c1t1on of po11tbl1 basts of distribution will De pres~nted followed ~Yan extended eX111plt frau the DRG syst A. TenPossiDle Bases of Distribution 1 Egua 11 t,Y S.. social goods are thought properly d1stributld when they are dtstrtbutect equally, that is with each person getting the-1110Unt. Votes 1n I dtlilOcracy are distributed this-,. _R1wl1ians believe liberty should be distributed tllts way. Libertarians would agree. Egalitarians would strive to catstrtDute health this way recognizing that fn same cases tlle goal would be tapossiole to fulfill because SOCII people cannot be restored to health regardless of the r.10st 1110st heroic efforts. It ts unlfkely that developers of I health care plan would want health care distributed tn1s way. There was a national health insurance plan proposed in the 1970s which sought to gtve every cft1zen I lifetime $50,000 worth of health care. such a schlr.le was driven by this notion of d1str1out1on on the basis of equali~. 2. Proportionality Saa goods are thought properly distributed 1n proportion to some obJecttvt _,ure. Votes among share holders are distributed 1n proportion to the number of shares owned, for instance. In the health care sphere a general anesthetic might be thought to be distributed 1n proportion to the weight of patients. In add1t1on to these two r.aore obJective bases for distribution, a nuraer of sch11111 have been proposed that take into account various talents, needs. psychological attitudes, and relationships with society.
PAGE 71
-65-(\ ..... ,., ~. J :-~ JI .J ... -u Figure 1 reveals eight of these bases of distribution, generated by three '\ different two-way variables. 3. NNd Egalttartans and max1u1n theorists are oriented to need--an object1vt .. sure of individual deprivation. They approach allocation on the basis of need differently. Egalitarians d1str1Dute resources directly to the one in need. Mlximin theorists ay distribute resources to elites such as physicians or aGainistrators as an incentive to get these elites to benefit the persons with greatest need. The result, in et'Cber case, is that resources are assigned wt'th need as the reference pot nt. Uttl 1 tari ans 11111 take need f nto account insofar as they include benefits to the 1nd1vidual 1n their ut111ty calculus. The impact on the elderly of distribution on the basis of need will depend on whether the elderly are judged to be a particularly nee group. 4. Desire The subjective correlate of need fs desire. While health care would not normally be distributed on the basis of desire, desire would COIie into play at least insofar as a policy respected individual liberty to the point that persons could refuse care even if they needed ft. Libertarilft theories of distribution rake greater use of desire as a basts for distribution when they permit 1nd1v1duals to trade freely tn orcaer to purchase what they desire and are able to buy 1n the rketplace. Pareto optiralfty (the optimality that exists when persons are peraittea to trade unt11 no one ts able to improve h1s position by making exchanges with others also willing to trade) fs a concept in econou1cs that ts grounded in libertarian theories of distribution 1n which desire dominates.
PAGE 72
i-,. -66. effort ... lllilicy .... (cf. ffllrit) Aristotle (1). ... ...... Rou Mir wjlljftanell tlllifll of Ullfulfllll .,..,iOul totlfve blitllhlrfflld toeial harm uttliurianilffl CIDfflPIMIIOrY iustia -11111 or dltlrivMion or _, or deprivation utefulnea 1111d ut1fulneu or Mid Obieaive n: r 1.' v Figure 1. The Bases of Mlcro11loc1tton Distribution (Adapted fram YNtch, Just. 1976, p. 131).
PAGE 73
i" .,. -67-n.,.Jo t I ..: 0' s. Ab111S, lllny 111erGa11ocat1on sctllras refer to distribution on the basis of atltt.,. Both ut11ttarfans and 111Xfain thHrists aigllt 1tt1111pt to single out persons witll un tty 1n order to entice thlll into perfoN1ng se"ices tllat IN bentftcfal to society. Upon closer eXllllnatton, however, lb1111., per ts not I plausible basts for d1str1but1on tn these tlleortes. An architect wf tll great abtl 11.,. to help the elderly by desi911f119 nev nursing hotaes would not properly be the recfpfent of resources even under ut11 ttar1an and IIIIX1afn theory ff ht refused to use hfs utlft1es tn socially useful ways. It ts very unlikely that 1 terribly gifted pfantst deserves rewardS ff tblt ptantst refuses to develop her talents or to perfoN publicly. The elderly theaselves are not ltkely to fare vell t f abfl f ty f s the basts for dt stribution. &. Social Usefulness Rather it fs soctal usefulness as I basts for dfstribUtfon that people probably have tn mfnd whln they refer to 1b111~. Social usefulness ts ability caabined wtth I w1111ngness to serve society. Once 1gafn tllt elderly are not 1 tkely to fare wll ff usefulness to society 1 s the basts for distribution. Even ff subtle ut111t1es such 11 the Joys of life fn the extended ftly and thl nurturing that takes place across the genarations is taken tnto account, 1 soc11l usefulness case for giving the elderly priority 1n health care resource a11ocat1on is a d1ff1cult one to make. 7. Willingness to Serve It ts more COlilpltcated to deterr.1ine whether w1111ngness to serve per se deserves reward. Should, for exaaple, a bungling soldier whO attempts
PAGE 74
-68-a daring 11111110n but f111s be rewarded with I atal? Should health care '\ Pl'Ofe11fonal1 WIG attlllpt difficult rescue efforts, but fan N praised? surely, a cortafn degree of NWlrd for such w1111ngness to serve is faportant 1~1tr11111nt11ly. It w111 1ncour19e others wt1o li1Q not fan to try 1faf11r feats. But other tban 1nstrulillnta11y, ts there I reason to NWlrd those who are willing to sent, but lack the skill or luck nec:1111ry to succHd? Ut11itar1ans and 111Xfafn theorists probably cannot give any reasons Idly there 1hould be reward for other thin fnstruantll consfdlrat1ons. Salll persons, however, a1gilt tlkt the view that postttve lil0rl1 ttvatton per se 11 pratsworthy and deserves reward. a. Effort Just 11 wf111ngness to serve ts the subJtctfve correlate of usefulness, so lbt11~ also has a subjtct1ve correlate: effort. Effort 1s often thought to be rewarded Justly when two people of equal ab111ty exert d1fferant efforts. The one Wllo works harder dtse"es the greater .-..rd, according to SOlill tbeorfes of justice~ In the health care sphere effort enters tnto tne analysts of till voluntary component of health status. It ts 1ncre1stngly rea11zed tbat health status depends tn part on voluntary choices. If two people have opportunities to exerc1se, avotd saak1ng, avoid carcinogens, etc but one of thllil fails to do so, bow does that effect hf s 1tntttl1111nt to the health care needed to overcGlill hts d1ca1 problms? Sollll camentators (Sperling, 1978; Yeatctl, 1980) have argued that SlilOkers should be expected to pay for the costs of their free choice so that those who do not smoke are not re11de to bear the costs. Others (Crawford, 1978; Beauchamp, 1976) have argued that there ts not sufftctent evidence that smoking and other health risky behaviors are
PAGE 75
-69-C n r. J .... _v.l. truly voluntary. TIiey argue that there 1s I s1gn1f1cant social couponent tn tile cau11l cllltn. If, hoWever, there ts I IINltll risky bellavior in wtc:11 cltfferenc11 tn free dlofce alone are responsible for different ,.... for IIN1tll care, .thin dfstrfbutton on till basts of effort 11 pot111tt1lly relevant. 9. Previous Social Hara Saa ttaeor1es of Just1c incl udl "'91t ts nor1111ly referred to 1s CCIIIPlflllWry Justice. If persons have bNn wronged, 1ccord1ng to t11ts approacll, Ulere ts I du~ for the one did the wrong to lllk -ncls. TIits appltes at tlll level of tbl incltvtdual, but also at tlll lev~l of tt11 10Cte1.,. It ts an 1rguant frequently heard tn conjunct1on wt'tll ractal or sexual dtscriYtn1tion. Sollll people argue tnat blacks or waan deserve ccupensatory 1c1V1ntage to like up for prevtous d1scr1atnat1on. It ts difficult to determine whither the 1c1nt191 ts exp11ctt1y defended 1s cOG1p1n11tory. Need and uttl 1 ty are 11 so bases for dtstrtbutton. Persons who have been previously dtscrtmtnated against are lttely to have greater need. They are also likely to benefit aore froa resources. TIii question ratsed here, however, 1s whether tn addition they also deserve a special caaponent of resources as cOG1pens1t1on for past wonp. suppose that SOlill of the elderly are thought to be vict1as of previous wrongful treatlillnt by society. These elderly who have been treated wonyly 1n the past by socteey can be coq,ared wtth elderly who have equal IIHdS, but who nave not been so treated. If need 1s the basts for distribution they receive tne saaa 11JOUnts of resources frolil the soc1e~. If previous social harm ts also a relevant basts for dtstr1DUt1on, one group should get a.10re thin the other.
PAGE 76
r,-: .,, ...:-----.. -~ -70~. :"l .-~ -i.1 ,...., 10. Fltap of 111 ng H1r111d For tlll Ake of ccmpltt1on, 1 ffnal 111111 for dfstr1but1on should bt ... ,10llld 1lthougll tt ts unltk1ly that tt ts ever used. It ts the 1Ub.11Cttve corral1te of previous soc111 tiara, that 1s feelings of being harllld. It ts llard to 111191111 any resource that ts tllOught Justly d1strtbutld on tilts 01sfs. 8. The Exaap 1 e of Ap Ind DRGs These bases of dfstrtbution are likely to ba used prf111rtly at the level of croallocatfon. Constder1ttons such 11 t11111 wtll help dltarafne the bud91ts of Ule National Institute of A9tng1 research funds for Alzlletr11 dfs11se and other dts11s11 of particular concern for the tldlrly, llldchrontc care f1cilfti11 such 1s nursing horas. Mlfch cater p1rttcul1rly to the elderly. They will also be relevant to Judgments about hospital retllburs-nt, levels of Mldtcare coverage, etc. For exaapl11 the present prospecttve pay111nt syster.1 that relies on d11gnosts related groups (DRGs) for payant to hospitals (United States Dt,-rtment of Health and Hwlln Services, 1984; Office of Technology AssesSlillnt, 1984) dtff1rentf1tes lillftY diagnosis groups on the basts of 1.-. For exaaple, there ire tw separate DRG's for the diagnosis of respiratory 119111 and sy11ptaus without comp11catfons or couorbidi1.,. Tllos1 patients are divided into two groups on the basis of age. The wefghts, upon which fnd1vfdua1 hospital reiaaursements are calculated, reflect an age-related difference. DRG 99 1s for patients over age 69. The wtfght is .8035. DRG 100 1s for patients who are less than seventy years old. The weight 1s 7730. Many of the DRGs are similarly dfvfded With the older age group getting I larger re1Clburs1G11nt 1n alaost every ca
PAGE 77
' n..('n. \: .: -..: .. \,) ".:I -71-. n1s ts baled in part on the well known fact that older patients are 11w11ly _.. costly to treat in any particular diagnostic category. TIiiy NqUtre .,. 1nten care and have longer hospital stays. But as 1 tter of acroallocation policy, 1 Judgant 111st be lillde drawing on one or re of thl bases of -distribution we have analyzed. It ts not clear, for 1X1111ple, that the difference in weights is or should be exactly equal to the average difference in cost between the two age groups. The differences, which tend to be rather 111111, are tn scme CINI not sufffcient to Mke up the extra costs of treating till elderly. If one opted for a distribUtton solely on the basts of need, the weights would have to reflect tbl exact difference tn caring for thl older and younger populations. On tlla other hand, refllburs1111nt could bt the saa regardless of 191 reflecting thl notfo1 that each person with a particular dfagnosts deserves the sa1111 retlllburs .. nt regardless of the cost of treatment. Sorill DR&s, fn fact, reflect this C011i1itlllnt, the DRG for dfalysfs for exuple. It fs not clear 1metber this fs because it ts believed that 1n these cases theN ts no difference fn the cost of treatuent as a function of age or whither the planners of the DRG weights decided that even thougll older persons cost more to treat, they would not be entitled to any adcltttonal retllburs1G11nt. Still other bases of distribution would lead to policy jud,ants to asstgn different DRG weight ratios to different age groups. If one wanted to UH cost-benefit analysts using expected years of life added as crfterfon for assfgntng DRG weights, ft ts possible that younger persons would get wuch higher retlilbursewents than elderly persons. This would force on tbe local hospital an approach whereby hospital personnel
PAGE 78
-72would lllke I rud1ntary effort to treat the elderly with simple, tnupeutve procedures, .title carat ~ing thellselves to l.1IICh aore exten1tve fnterventtons for younger persons with sfatlar diagnoses. 0 _r, TIie ach1nt111 of 191-ltnked DRG categories _could easily be used to cut off care entirely for certain groups of elderly patients. If, for exuaple, we nteca to adopt I policy of no dialysis over age 69 then DRG 317 (renal failure with dialysis) could be divided into two sUbgroups wttll the exfstfng weight for tlll subgroup of patients under 70 and I new weight of zero for patients over 69. There ts no ruson why the age dtvt ding 1 ine ast be between the ages of 69 and 70. In fact, there are also 191 dtfferent11ls between 191117 and 18, but 1--, other age-line could be chosen for exuaple dfffer1ntt1tin9 between the young-old and Ula old-old. POSSIBLE BASES fE MICROALLOCATION Once the croallocatfon poltcy fs cletermfned, for example. by assfgnfng DRG weights, there ts stfll tile probl of 11loc1tfon at the local level on case by case basts. Thi DRG weights arely set a 99neral pattern for reflllburs .. nt leaving ft up to local fnstftutfonal poltctes to cleteratne exactly how much care should be given to any one Pltfent tn I particular DRG. In fact, at tile present tfa, local instttutions can cost shift frClil one DRG group to another. This would appear to defeat the allocatfonal purposes of assigning DRG weights. DR&s are (or should be) given particular weights because I soc1eta1 Jud9111nt ts Mcie that patients fn that category on average deserve the particular IIIOllnt of resources proportional to the weight assigned. If local offtci1l1 purposely take soae of those resources away fraa that
PAGE 79
f ', r.. ,-. J "; v iJ -73' group of pattelltl and 1111 tlllll for another group, they 1r1 overriding tnt social Judgllllnt uout _..t constitutes f1tr 11loc1tion. At sea point tn 1:lle future tll4t socte~ w111 111,e to face tile question of waettler local tn1tttuttons should be perultted to shift costs fraa on DR& to another. Even vftll1n I single DRG, however, local off1c11ls w111 nave to dlc1de lloW to allocate the care IIIOftl tlll patients tn that group. This ts Just ON 1xaapl1 of bow local hospitals and other fac11tt1es w111 hive to lllke atcroa1loc1tton dec1stons (or have tllOse dlc1s1ons for th by the broader public), dltlnltntng "9o ..,.. the 1v11l1bl1 patients w111 receive tile 1v1tllbl1 d111ys1s 111Cbfnes or resptraton or 11111G wt11 rtc11ve 11atted resources for 1nt1btot1c1, llyperaltntatton, and p1rtnter11 fl 111 ds. A. Mtcro11loc1t1on on the Basts of Usefulness At one point ft 11111 wtdtly 1s1111a11d that 1lloc1ttons, 1spect1lly for IIIJor technologfc1l interventions such 11 di1ly111, should bl on tlle basts of ut111~ tncludtng upltcitly the social usefulness of tne rtetptent. TIius 11loc1tton cGllltttles took 1nto account whether tbe Plt1ent had dependent dl11dNn and Wllther lie or she was engaged 1n 1 prodllctfve and useful carter. The ut111tar11n theory of d1str1but1on drove 1:tle dlctston. The elderly have routinely been excluded on these grounds. Probl-arose both at the llilp1rical level of trying to decide which of two cand1dltes would really lead I aore useful life on dtalysts and at the level of ethics. People began to doubt that future usefulness of the patient ws an ethtcally justified basts for the dec1s1on
PAGE 80
~fi:i~".rf ~(~,..: ... ,.~ '... -'"~ ,, -74-r. ., ,.' l, a. Ep11tlr1an M1~roa11ocatton In otlllr context, especially Ula allocation of kidneys for transplMt, the 1t~tlr1an Just1f1cat1on of M111ty to pay st111 today 1111 ... influence on the a1croa11ocat1on dec1s1on. For the ast part. b01MVer, both the ut111t1rt1n and the ltMrtartan Justif1cat1ons have given way to soa type of allocation crtter1a that 1tt111pt to treat persons uore equally. It ts widely held that radical nNd ts one basts for aore equitable alloc1t1on. We have 1lre1dy suggested t111t ad1ca1 need ts criterion inat does not entirely escape the utt11tar11n fr1C11wrt. The goal ts sttll to autarlz1 the good, but now the good ts ltll'lted to the ad1cal good. TIits 1s tbougllt are 1ccept1bl1, because adical good ts believed to N fnctapendent of the social and value Juclglllnts that c.-.ep tnto broader Judgants of uttltty. Whether that ts, 1n fact, the case 1s 1ncreasing11 open to question. Deciding what counts as I adfcal benefit Ind hall IIICh aedfcal l>lnefft coas froa I p1~tfcular fnte"entfon, tn fact, also requires sa111 value Jud9111nts that 1111st draw on personal patterns of preference. Does addfny ten years of 1 tfe to I twenty year old count 11 tile-lilld1ca1 benefit as 1ddtng ten years to an eighty year old? SUppose o bis tne choice of 1ddtn9 ten years of scmewhat debt 11 lated 11 fe to an 11 gb1.J year o 1 d or addt ng ft ve good years to 1 twenty yur old. Dec1d1ng which offers mre mdfcal benefit 1s I value Judg111nt pure and staple. It ts now coa10n, especially fn d1alys1s units, to opt for a two-tiered m1croallocat1on schem tn which patients are first sorted on tlle basts of whether or not they can benefit froa the tre11:lillnt and then selected on soa other basts. Those adopting this policy ire not aware
PAGE 81
-75,. : ri. .. '--u of or.ignore till fact that patients cannot bl sorted cleanly 1nto the groups Ullt can benefit and those t111t CIMot. Soae patients will hive a sltgllt dllnce of benefit or will surely benefit but by I very 111111 laDUnt. Dtctdtng whtUl~r to ~nclude or exclude a particular patient on tht inttfal llldica1 screening ts 1111ch 1.10re I judgaent call than many 11111 realize. Once the initial sorting ts done on radical criteria, soae other basts of allocation ts necessary. These include: 1. Rlndclil Selection Lotteries and otntr tnodl of ranc10r.1 selection hive the advantage of treating persons as having equal claia. It ts an 11loc1tfon thod rooted tn egalttartan preaises and ts often used when the good being dtvfdecl (such 1s dfalysts treatlillnt, an opportunity to be resuscftlted, or I course of ant1b1ot1c treatment) cannot be divided equally with each rec1p1ent getting proportional benefit. Ltfe-sustafnfng tlchnologfes are by Ultfr nature often 111 or none interventions. Gtvfng SOlillCHNt half the nNdld dtalysts w111 not solve anyone's probl. Therefore, instead of a11ocat1ng the trNtlllnt equally, soaettas 1t 1s necessary to allocate the chance of getting an adequate regtn equally. A lottery or sor.ae other rallda'I mtllod of allocation is chosen. 2. R1ttontn1 In other cases, when the good tn question can be divided in such a way that each person gets proportional benefit, a1croa11ocat1on that ts driven by more egal ttar1an considerations ts done by rationing. If three patients each needed three pints of blood to do well but only six pints were available, the proper solution according to egalitarian considerattons atght be to give each pAttent two pints hoping each will
PAGE 82
. -76-0 J':> t .... -1.J ._J 40 rNsolllbly well that way. The 1 ife-susta1n1ng technologies of this StuQ.,.. unlfkely to be rationed tn tbii 11111111r. Parenteral fluids and nutr1tton1l support atght concetvably be rationed tn the case of a t111p1r1ry local shortage. Rtsuscfut1ve efforts gbt, fn effect, be rationed ff two patients went into respiratory arrest sfaultaneously and the one 1v1111bl1 resuscitation tem d1v1ded 1ts efforts betNeen the patients For the most p1r.t, tlOwever, rationing 1s not going to be relevant to the 1tfe-sustatn1ng technologtes 1n question. 3. Geogr1p111cal Ava111b111t,y Allocation on the basts of geographical 1v1111btlt~ 1s I k1nG of hybrid. It takes the geogr1pntc1l facts 11 1 gtven and thin allocates wttllfn tlle yeographfcal regf_on. Tne 111ocat1on w1Ul1n the region could be on any of Ula bases 1lre1Q described. A11ocat1on of Ula basts of geogr1phtc1l 1v1tl1b111ty slllils to be built on the preatse that the geo9r1phtc1l distribution can be taken as I given. That, in turn, 1ssuas no geogr1phtc1l interconnectedness and respons1bflity. Certainly for Medicare and other n1t1on1lly based programs, these 1ssu1aptfons are very questionable. c. Age-based Mtcro1lloc1t1ons In addttton to tlle atcro1lloc1tton scher.ws 1lre1~ considered, ft would be pGss1Dle to base local a11ocat1on decisions explicitly on age. Apparently that ts What ts done in Br1ta1n and other countries regarding d1alys1s. Local dec1s1ons are made that are consciously age-based. If I local hospital r.ust allocate its d1alys1s ,ach1nes or its DRS-generated resources aaong pat1ants needing life-sustaining tlchnologtes or other health care services, ft could consciously select on the basts of 191 or expected life-years addld. Either syst would
PAGE 83
i. n : ,_'Ii J ,.: --vu -77leave ,thl elderly 1n I very special s1tuat1on. It 1s possible that the elderly could N given spec:111 1c1V1nta9e--perh1p1 on the grounds that a cllron1c care technology such as a d1alys1s 111chine will be tied up for~ shortar period of t1 thus giving more people a chance to benefit. They wight N given advantage on the grounds that the elderly desene 1 special respect from the society. It is more likely that on ut111tar1an or over-a-~1fetia.ega11t'1rtan grounds they w111 be given lower prtorfey for local level allocation. Whether local 1nst1tut1onal officials should be 11tl1 to Mke these kinds of policy det1r1111nat1ons without the guidance of aae broadlr socte1., ts an issue for dlbatl. It can be argued that these are the kinds of decisions that should be ade by thl broader socie1., at the national level. If that ts the case, then the local level 11icroalloc1tion pol tcy should be determined by puoltc debate, rather than b91ng 11ft to the discretion of 1nd1vidua1 health care professionals 1ne1 adll1nistrators. PUBLIC POLICY OPTIONS The baste pol tcy question to be faced 1 n conjunction wt th ttle problm of the poss1Dle use of age as a cr1ter1on for a11oc~t1ng 11fe-sustain1ng technologies ts whether to develop any conscious policy at 111 and, 1f so, how exp11c1t that policy should be. Several general poltcy options are 1,at11ble. A. General Policy Options 1. Ipore Ap as I t41tter of Pol icy First, our society could decide consciously that 1t w111 act on policy utters as if age were not a factor. This is by far the least controversial policy at least on the surface. The advantage ts that controversy is avoided or at 1 east hf dden. The d1 sac1V1nt1ge 1 s that
PAGE 84
i J () -.. ,_, -78 1111\Y off1cta1 goverrr.aent poltctes including those wtthin the health care sphere alreaQ include age as I criterion. Most obviously, Medicare 1t stlf 1s, for the most part, an age-based health care progr111. More spec1f1ca11y, we have seen that the DRGs 1n 111ny cases use age as a criterion for reilllburseant. It 1s not clear whether that 1s an attaapt to ak1. ful 1 acljustments for the fact that older patients are generally LION expensive to treat or whether the adjustaent 1s only partial so that older patients cannot, at 1ev1l of reimbursement offered, get care that w111 produce results at the ua level as for younger patients. Even setting aside extsttng policy, we have seen that many of the theories of distrfbutfon have tmpltcatfons that support the use of age as a criterion. Ut11itar11ns would probaoly deerease the levels of certain kinds of care currently available to the elderly. They would at least use age or years of lffe added as I criterion for calculating the potential benefits of 1ntervent1ons. Libertarians would permit persons to buy services taking into account their own ages when they determine whether care 1 s worth 1 t to theu. Sor.11 ega 11 tari ans and r;au tmi n theorists would even rake use of age or age-correlates. Those following Dlnte~s sch-would strive for age-relativized activity ranges, which man different kinds of health care for different ages. Those Jtriving to benefit the least well off might use over-a-lifetime well being dttena1nations and conclude that the elderly are not high priority for interventions at least for certain kinds of care. While some who hold any of these tneories of distribution may have reasons not to consider age 11 a criterion, others holding those positions would insist tnat age ought to be a factor.
PAGE 85
-79-2. Aft as an I nforma 1 Po 11 cy ~ : .. _, ., t '--:_ .l. As I society. we could still let age play a role as a 1111tt1r of 1nfolWl1 policy. Following the example of the British we could, through public and professional discussion, reach 1n informal agrfflillnt that age should be taken into account on an ad hoc basts by individual clinicians, adli1tn1strators, or family in decidiny who should be resuscitated, who should get dialysis, etc. The advantage of this is that 1t deals with the realities of age and yet avoids a formal public debate. The disadYantage is that, 1s 1n Briu.in with dialysis, different elderly persons who are med1ca11y similar will be treated very differently depending on What institutions they happen to be in, what the whira of the individual professional is, and what the personal ability of the patient is to persuade providers to deliver the desired service. For utilitarians who believe that ability to persuade 1s a correlate of social usefulness tilts may not be I problem, but for rax1min theorists and egalftari1ns there would likely be objection to allocations on the basis of these factors. 3. Conscious Policy If nettner of t~ese 1s accepta~le, then a conscious policy would be 1n order. Policies could be adopted on a case-by-case basis such as a policy that pen.11ts no use of CPR on penJanently coraatose elderly patients or no dialysis over a certain age. A more ambitious, systematic policy might someday be in order such as the one suggested by over-a-1ifet1rae egalitarians wno would exclude all expensive, experimental, or low probability treatments over a certain age. Another approach is suggested by the contract models. Libertarians would probably support a policy whereby all health insurers offered
PAGE 86
11 ... _, ... ..... -80alternative coverages with one including and the otner excluding certain .. t1fe-susta1n1ng tedlnolog1es for the elderly. Individuals, by free dlo1ce, could then choose whither they would be covered during old.age. Unions and other 111Ployee groups could negotiate insurance plans deciding Whitner such coverages were to be included, possibly offering certain groups of life-sustaining technologies during old age only as an optional coverage. Those influenced by Daniels hypothetical egalitarian contract would strive for publtc particfpatfon fn a debate over whether various lffe-1u1t1tnfn9 technologies were part of age-relativtzed health care coverage. B. Areas of Congress f 01111 Act1 on The debate over the use of aye as I criterion for allocatfng care 1s botb new and ccmplex. The frap11cat1ons of different theories qf distrtbutive Justice are not yet well understood. Extensive, r1pfd Congressional action would probaoly be pr1111ture. On the other hand, the 1 ssues are so important to the publ fc and so controversial that ff policies are eventually adopted that would use age as a criterion for allocating lffe-sustafnfng technologfes, they should be the result of extensive public discussion and a formal pub.lie decfsion-making process. These issues are so fund1G11ntal that Congressional action should be required rather than leavf ng th to adlllfnf stratfve or professfonal decisfon-111kers whether at the n1tfon1l or local level. Nevertheless, there are several actfvitfes where faaedfate action fs possible. There are others where ft 1s appropriate to begin exploration of policy options. Finally, there sorae long-term policy alternatives that socfe~ 1s not yet ready to debate fon.11lly1 but for Which preliminary discussion and serious reflection needs to Dei1n.
PAGE 87
-81!) "".' ,, .. .. ; u 1. A~ttvtttes for Iaaediate Action Wlltle tt ts probably prllillture to adopt any fon11l po11ctes using 191 11 an uplfctt criterion for ~locating any of the 11fe-susta1n1ng technologies that are the focus of this stu~. it ts ess1ntt1l that some studies N 1nitiateel. In fact, for some of th, if they are not begun 1 .. di1t1ly it w111 be too late. _The lead-ti to develop 1 well-tbougtlt-out policy will be lost or the important data will no longer be 1v11l1bl1. 1. Identify and Stu9 Existing Age-based Allocation Policies. Several existing 191-Dased allocation policies are presently tn place in the United States and elsewhere. These need to be 1denttf1ed and studied both to determ1 ne how they work lfilP1 rt ca 1 ly and what the aora 1 underp1nn1ngs are that led to their adoption. The most relevant ts the use of age as I criterion for detenatning retmburs8lillnt tn the Medicare syst. First~ on what grounds was tt determined that elderly persons (tncludfng those who w~re not needy) had a claim on the public and on future generations for extensive adical insurance. Why was it acceptable to 1ncluele the elderly, who were the raost expensive age group to treat, but, with special exceptions. no other age groups? With the tmpl ... ntatfon of DRGs, why were SOle'II (but not all) diagnostic groups divided by 191? Was the differential in reimburseraent bJsed exclus~vely on emp1r1ca1 differences? If so, what justifies continuing to n11intain those differentials? Why are SOlile DRGs without age-based differentials? What moral Just1f1cat1ons, 1f any, are there for continuing to use age as a basts for allocation in these existing cases? Such an invest1gation need not be limited to the United States. It would be extreraely 1aaportant to know whether the d1 fferences that exist
PAGE 88
n I ,.'" --82froa one country to another over willingness to use age 1s a criterion for 111ocat1ng resources rest on dtffertnces 1n beliefs about empirical facts (such 11 whither di1ly1ts wtll De successful in elderly persons) or lllllttller they reflect differences tn aoralt~. 1n theories of dtstributive JUSt1Ct. b. A Prospective Stu9 of the Use of Age as A cri tart on in Allocating Htart Transplant Funding. These 11111 questions can be asked pnspectively as the United States begins its ftrst fonal experiant in using 191 11 an allocation criterion 1n DRG 103 (11t1rt transplants). If transplants are approved only for Mld1cart patients wtlo art no older than 55, thts wtll N the first fonal po_ltcy tn which tnere ts 1n 11>1olute profltbitton on funding solely on thl basts of age. This contrasts with tbt existing 19e-ba11d polictes lllhlrt thl lli1DUnt of r11111burs-nt 1s 1 function of 191. but not total right of access. It 1s crucial to deterll1ne why such I policy 1s adopted 1t the t1 of its adoption. Is it strictly pr1grat1c--with policy mkers reasoning that there are very few ted1c1r1 patients under 55 needing heart transplants? Is it qu11t-empiric11. with decision-kers believing that transplants for patients over 191 55 will not be successful? Is it based on the belief that thl payoffs 1 n terms of y11rs of 1 t fe added or future usefulness to the socie~ of those over 55 does not justify funding transplants? Is it because those over 55 have had long lives 11 ready so that priorittes need to be placed elsewhere? Congress could mndate a prospective study of the use of the age criterion 1n the heart transplant case as I way of anticipating probls arising if it were used for the 11fe-susta1n1ng technologies that are the focus of this study. :
PAGE 89
' n .. .. e- J -.._1 ; tJ -83-c. A coaparison of the Use of Age as I Criterion with Other Uses of Soctoroptcal C1teprfes. Sfnce age fs an ascribed sociologfc1l category, tt wuld be taportlnt to dlteraine how the use of age as I selection crtterton for 11fe-sustafning technologies COllplNS with other uses of ascrtbtd soctal categories. Age, for exalilple, ts used as I crftlrion for reti.-..nt. On tbl one hand ft ts normally constdtrecl unjust d1scr1m1nation to use an autaratfc axi1111 age for hiring and ftring dletstons. On the other nand, .~Olilpulsory rettr1111nt at a spectfitd age, though controv1rs111, is sttll wiaely accepted. How dots the use of age as ar. 1uta111tic exclusion criterion in these cases COlilplN to tts use 1n allocating 11fe-susta1ntng technologies? Also, we have a long history of the use of using thl 1scrfbed social categories of sex 1nd race as selection criteria. Do the legal and ethical 1rguants that prontbtt iw uses of sex and race as autaaltfc exclusion criteria also apply to Ult use of 191? If there are special cases llfhere sex and race can be used as legtttate crttert1, are thetr analogous cases where.age could be used? d. Deteraine the De Facto Role of Age fn Cltnfcal Choices. Although at preHnt there fs no fonal policy using age as a clfnfcal critarton of 1lloc1ttng care, ft ts widely believed that_ cltntct1ns and 1dll1ntstr1tors often consider age fn 111king Judgments. Studies need to be coraisstoned to detenaine what role age 1s really playing. For eXU1pl1, ft might be possible to learn souething about the role of age 1n various hospitals by cOLaparfng the age ratios of adaissfons to the age ratios for various procedures ~1thin a hospital. If two institutions h1v1 tdlntfcal percentages of elderly patients admitted as end stage renal patients but the percentage of dialysis patients who are elderly
PAGE 90
-84(' J '-varies cons1dlraaly, the results would be very suggestive. Also. ..,1r1cal 1tudi_11 111ght be ul1 to dltan1t111 WIY cltnictans are using age--wetller tt ts beeause of blltefs UOUt tlll adtcal outca111s or same otller reuons. z. Poltcy Options for Exploration In 1ddttton to the reSNrch issues, there are policy options for Nhich dlbate ts 1pproprtat1. Several 1ctton1 IIQ eventually be approprt1t1 for Congrass 111:IIOugh these 1111111 ire so controvers111 and so caap1tc1tec1 that t-di1te action ts problbly not appropriate. a. Ustnp DRG's 11 a wy of A11ocatinp on the Basts of Ap. A policy could bl adopted t111t DIG wetgllts should bl used as I way of conveying publtc Judg111nts about allocating of rasourc1s. If so, tt ts pl1111t1l1 that tt shOUld bl policy that the DRG weights sllould be proportional to the Just clat of patients tn various groups. Congress could consider tile question of wtletber DRGs stloUld be separatad on the buts of 191 w1ttl different retraurs .. nt wetgllts gotng to patients of dtfferant 191 and, tf so_, wbat a fatr basts of assigning weights ts. For eX111pl1, tt could bl dlteNtned tilat elderly patients should bl in separate DR&s wi ttl weights exactly proportt ona 1 to the expected additional cost to gtve the elderly p1tt1nt results cODparable to other patients. Alternatively, weights could be 1sstgned to the DRG for elderly patients that are aach less than for younger patients reflecting thl policy Judgment that elderly deserve relatively little care. Still another alternative would be to make the weight for elderly patient exactly equal to that of other patients (or alternatively collapsing the two DRG's into one group). This woula reflect the policy judgraent that all patients deserve the same amount of care regardless of the fact that ..... ,. I V
PAGE 91
-85elderly patients on 1v1r1ge require lilOre intense care to 1ccOC1pl1st1 S111111r NSUltl. fl i ."":,., J ... b. Poltcits D1ff1r1ntt1ting Optional 111d Regutred Care. Congress could also btgtn 1xplor1t1on of policy positions reprd1ng kinds of care tllat ire required for 111 persons regardless of 191. Tt11s could be on tlle presuaption of consent fraa the patient or guardian or.could conc1tv1bly bt required for 111 patients even 191tnst their consent. ADDng tllt ktndS of care that Congress atgllt nt to Mndlte for 111 patients ra91rc1les1 of 111 would bl cGllfort care, baste nursing care, patn adicatton, nutrition, and hydration. c. Extending Federal Allocation Pr1nc1p111 to Private Insurers. Congress 111gbt want to btg1n exploring the poss1bf11~ of extending its federal 111ocat1on crt tert~ regarding t111 elderly, llfllltever they 111Q be, to private insurers. Under sudl an actton Congress aigllt ndlte, for .,.,.1e Ulat no insurer, public or private, could exclude on tne basts of. 1911 c1rt1tn kindS of care fraa patients it insures. Thi kindS of care could bl stuilar to those ntioned above. d. DevelopMnt of Methods for DeteN1n1ng PUb11c Consensus. Finally, Congress atght begin exploring athods for detenaining public conseaus on 111bit care 111st be offered to patients regardless of age. Two schellls hive been reviewed that require soua thod of reading the judgaents of the population. Daniels sche1.11 of age-relat1vized opportunity ranges requires knowledge of what opportunities are typical for persons of different ages. The ega11tar1an case for using age requires deten:1ining which kinds .of care at:'9 so basic (so inexpensive, effective, and beneficial) that age should not be taken into account and wbtch might be excluded from the elderly on the grounds that
PAGE 92
r. -86-over-1-ltfetia tbl elderly are relatively well off 1n comparison to '\ oa.rs IIINing Ula resources. Both of uiese devices require I athod for detenrlning Wllicll care 11 baste. 3. Lonp-anl Policy Alter111t1ve1 All of tlll possible Ktions nttoned tllus far avotd actions by Congress tlllt would actually ban care on the basts of 191. The ftrst group 11N1Uld provide traporunt aata. TIie second group would r.10ve toward policy, bllt would not tdenttfy actual care categories to be excluded on tlle bU1s of aye. It ts also appropriate for Gongress to Ngin exploring tlll_questton of wlletller catagorfes of care could be established tlllt could N excludld on the basts of age. Several broad options tllve been nttoned in ttll public debate: 1. Develop I Pol tcy t111t No Care Be Allocated on the Basis of Age. As discussed IINWe this would avoid ua,w difficulties for Congress, but praoably ts not ra111st1c. A patient wllo ts 93-years-old, his 1111t1ple dt ... se11 and I very short ltfe-expectancy. SIie had heart problas that atght call for by-pass surgery in I younger patient. She 1111nts the surgery and a surgeon 1s willtny to provide tt. Should Medicare adopt 1 poltcy that says that her 191 should not d1squa11fy lier fre11 the surgery. If so, should Congress instruct Mldicare 1draintstr1tors to exclude suc:11191-b1sed cons1derat1ons? b. Requiring Optional Insurance for Life-Sustaining Technologies for the Elderly. Congress could require that 111 insurers, public and private, separate off certain 11fe-extend1ng tecllno1og1es and offer insurance coverage for persons over a pre-determined age on an optional basts. Thus every insured person could choose whether or not he or she wanted insurance for dialysis over the age of seventy-five and wculd have to pay an extra prer.a1 Uli1 out of pocket 1 f the coverage was des 1 red. ._.
PAGE 93
I -87, .. -.. _,_ c. Dtvel-nt of I List of Treatment not to be Funded for Elderly PtrlOll1. Ftnally, Congress could begin exploring the question of whthr Ullre .,. any catqorits of tre1t111nt that are so tapl1usible that insurers, at 1Nst governant insurers sudl 11 Mldtcare, would not cover 1:11111. 111111 1:111 proposal 111111 radical. tn fact, Mldtcare excludes ny kinds of coverage today and probably will soon exclude spactffcaliy on ttlt basts of 191. Aaong the categories Ulat could be c11D1ted re: (1) Heart Transplanu (2) Other Organ Transplants (3) Prolonged Mldlantc1l Yent111t1on for Patients in a Ptl'llllltnt Y1get1ttv1 State ( 4) CPR for patients w1 tll 1111 tllln 24 tlours 11 fe-expectancy (5) Antibiotics for patients with less thin I specified nlll8er of days of 11 fe expectancy (6) Dialysis for patients over I given age It would bl faportlnt t111t 1f sudl 1 11st were debated, tt bl tn cc,nJunctton wttb the earl fer proposals to debate categories of tre1tre11nt vllich could not be excluded on the basts of age. Otherwise, ttie discussion would sfaply be I one-sided llilphlsfs on exclusions. Ttllse IN obviously ext,...ly controversial proposals. TIie present author ts not 1dvoc1ttng any one of thew. He is suggesting, however, that 111ocat1on ts, in fact, being made on these bases 1lre1~ and that debate over the question of whether age 1s an appropriate criterion for exclusion ts so important that, if anyone is to make the pol icy fon.111. it ought to be Congress. .I \.. f u
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-88-fl c. Adegu19 of Existing Federal Programs in Achieving "I Just Allocation of Resources Detenrln1ng _..,.. existing federal progr-1dlt1ve a just allocation of resources w111 depend tn large part on tbe theory of d1str1but1on one favors. It s ... likely that holders of none of tt11 aJor positions. libertarian, ut111tar11n, raax1a1n, and ega11tar1an, w111 be coapletely happy w1tn the current sttuatton. TIiiy wHl differ over Wllet!ler the elderly are getting too aa&eh care (sOlill ut111tar11ns and 1ga11tar11ns) or tao 11ttle care (slice-of-ti e911f tar1ans) or Just having tlltir free arket choices too t1e1v1ly controlled (11bertar1ans). The IIDSt serious probl at the present t1 1111 bl inconsistency in the use of age as a cr1ter1on. It ts clNr that 111ny professionals and a,wtnst1tut1ons have di facto policies of dtscouragtng can when patients are elderly w1111, others, especially those 1n fN for se"ice 1rr1ngaants, may actu11 ly over-treat. D. Changes 1n Re111bursment Systews At the national level there needS to be a GIUCh more conscious forraulation of I policy on the role of age as I criterion 1n retamurs .. nt. No one SNlilS to be reflecting consciously on the use of age breaks tn the DRG systell. Is the goal sir.aply to provide coverage for extra costs tn treating the elderly 1n Which case the additional weight should be proportional to the extra costs or should the weights reflect a caaproa1se between the goals of equal results and mre ut111tar1an considerations of efficiency? Should the weights for certain DRGs purposely be lowered for elderly patients as a way of excluding thera fror.a care? This. 1n effect, is what is done for heart transplants. The DkG weight for heart transplants 1s zero, Which Gleans a policy has been ''
PAGE 95
, i n :.~. _, J ... lJ .I. -89adopted that tbose over six~-f1ve (at least tilose funded by Medicare) \ wt 11 not 91t heart transp 1 ants. Thi present retlllburs1G11nt raises even aore provocative questions for atcroallocatton at the local level. Once a policy bis been adopted at 1:lle national level for Medicare, it is hard to s why local officials should bl permitted to snift costs fraa one DRG to another and frcm one age group to another. Similar questions arise within DRGs. Should local officials N permitted to shift costs within I DRG fra one patient to another without having guiaeltnes for doing tt? Likewise, cost shifts betwen Mld1c1re and non-Medicare patient groups raise important policy questions. L1bertlr1ans, utilitarians, and aore egalitarian theorists would 111 have positions on the legitimacy of such shifts. Very little guidance exists at the present t1a for such judgments. Finally, should 111 payers be subject to the Sllilt standardS for re1raurs1111nt? In particular should tlle ildtrly be treated tlle Sllill way regardless of whether they are in r-tedicare. L1bertar11ns probably would see no reason why they should, but probably both utilitarians and egalitarians would. If policies are adopted using age as a criterion, it wtll be crucial to determine Nhether 111 payers should be treated sill11arly. If 191 becOlills I criterion for Medicare, but not for other payers then cost shifts and free market forces will colJbine to create soae very coaplex problms and unanticipated outcoas. CONCLUSION As long 1s hnmans had very little capacity to prolong the lives of the elderly, the policy issues were not terribly d1ff1cult. The developaent of 11fe sustaining technologies that have the capacity to
PAGE 96
; .. -90... -:..J ,'-I prolo~ the ltves of many elderly patients poses policy choices that are bo1:11 un1qua and coaplex. Thi cOllb1ned costs of the use of the tldlnolog1es under consideration for tn1s stuQ ts several b1111ons of dollars per year 1n the United States alone. If the moral reflection were expanded to include consideration of the responsiDilit;y of t;1e hun c0111Unt1., for 111 citizens of the world, the costs would be even more staggering. If these technologies guaranteed continued life at what everyone 19rHd was high qu11t~. the controversy would not be 1s g.-.at (or at lNst would not be ttle saa). The fact is that 1a11ny (but not 111) are convinced tnat SOIII uses of the technologies being reviowed fn this study offer very little benefit and do so at very high cost. In fact, SOl.ll uses are believed by soa people to actually do aore hara thin good. The analysts 1s cc,gplfcated by the fact that the elderly are disproportionate users of these technologies and that, even 1f the 11fe-sustafn1ng intervention were C"'11pletely successful. the predicted life expectancy of the recipients is still relatively short. Al 1 of this his led to I sense tnat SOIIII 11a1 u on the use of tnese tecbnologtes 11 1nevit1Dle, whether thrr111h ad hoc local decisions 1n the absence of any public debate or thro~gh lilOre public consensus fonwtion leading to either formal or infonaal polfcy. Age is alrea~ used as an explicit criterion for allocating health care and health care reilllburieaents (1n Medicare, in raany DRGs, in hospital policies for allocating dialysis, and, in all 11ke11hood, very soon for the allocation of Medicare funded heart transplants). The recognition that age is explicitly used as a tr1ter1on suggests that tne t1mt has passed when we could pretend that age was always irrelevant. The real choice seems to be between ad hoc local policies and more public ones.
PAGE 97
;,. n.; )' _, ~> _. __ u 1). -91-What tllOse policies will be will depend heavily on the theory of d1str1but1ve justice adopted. Each of the four aajor theories examined fn tllts stuQ has concrete 11i1p11cat1ons for the use of age as a criterion for allocating ltfe-sustatn1ng technologies. At times there ts a convergence so that, for exaaple, both utilitarians and over-1-lifeti,1e egalitarians aright agree on 1imit1ng expensive, low probability of success technologies for the elderly even though they would not ,gree on the reasons. Understanding how the different theories of Justice impact on the polfcy Judgants will be fG1pOrtant if our national policy 1s to be a reasonable and coapassionate one. On thing SNlilS clear. No one is advocating either of the extrea positions regarding the use of age as a criterion. No one ts arguing (at least l)llbltcly) that no care at all ts appropriate for tJle elderly. Everyone supports at least the basics of relief of pain and suffering tnd baste nursing care for cleanliness and cOf.lfort. Even the raost extreme libertarian would favor-that although SOlill raay insist that ft be provided through charity. On the other hand, no one is arguing that every elderly patient ts entitled to every use of every life-sustaining technology that 1s available. Age cut offs for heart transplants and age differentials for DRGs are alreac-, with us') Age ts an explicit criterion for allocating dialysis in otner countries and appears to be an 1nfonaal criterion at some institutions in the United States. Many people are exploring mre explicit use of age criteria for allocating life-sustaining technologies while others are very reluctant to do so. In either case, the pos1t1ons being adopted reflect the theories of Justice described in this report.
PAGE 98
G ,. ,. ,, -92J .... ) -. References Aristotle, N1chorachean Etnics, Ostwald, Martin, trans., (Indianapolis: The Bobbs-Merr111 Cor.1p111y. Inc., 19ti2). Avorn, Jerry, eenefit and cost Analysis in Geriatric Care: Turning Age Discriraination into Health Policy, New England Journal of Medicine JlO(May 17, 1984):1294-1300. Barry, Brian, on Social Justice, The Oxford Review (Tr1n1ty Teru, 1967):33-43. Barry, Brian, The Liberal Theory of Justice: A critical examination of the principal doctrines in A Theory of Justice by John Rawls, (Oxford: Clarendon Press, 1973). Bayer, Ronald, Daniel Callahan, John Fletcher, et al., The Care of the Terrainally 111: Morality and Economics. The New England Journal of Medicine 309(Decdber 15, 1983):1490-1494. Beauchamp, Dan E., public Health as Social Justice,u Inquiry 13(1976):3-14. Beauchamp, Tom L., Philosophical Ethics: An Introduction to Moral Philosophy, (New York: McGraw-Hill Book Corapany, 1982). Beauchamp, Taa L., and James F. Childress, eds., Principles of BiOGleaical Etnics, 2nd ed., (New York: Oxford University Press, 198:S). Bentham, Jerea.w, An Introduction to the Principles of ~tordls and Legislation, 1n Ethical Theories: A Book of Readings, A. I. Milden, ea (Englewood Cliffs, New Jersey: Prentice-Hall, Inc., 1967, pp. 367-390).
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I ~' () ,... ~: \.) ..; --9JBlackstune, William T., 00n Health Care as a Legal Right: Philosophical Justifications, Political activity, and Adequate Health Care,0 Georgia Law Review 10(W1nter 1976):391-418. Bleich, J. David, rhe ODligation to Heal in the Judaic Tradition: A COlilparat1ve Anal1sis, i~ Jewish Bioethics, Fred Rosner, and J. Davia Bleich, eds. (New York: Sanhedrin Press, 1979, pp. 1-44). Buchanan, Allen, Justice: A Philosophical Review, in Justice and Health Care, Earl Shelp, ed., (Dordrecht, Holland: D. Reidel Publishing COG1pany, 1981, pp. 3-21). Callahan, Daniel, what OD11gat1ons Do We Have to Future Generations?" Aatr1can Ecclesiastical Review 164(Apr11 1971):205-80. Cnildress, James, Ensuring Care, Respect, and Fairness for the Elderly, Hastings Center Report 14(No. 5, 1984):27-31. Congregation for Tne Doctrine of Tt1e Faith, Declaration On Euthanasia, (Rora: Tile Sacred Congregation for the Doctrine of the Faith, May 5, 1980). Crawford, R., s1ckness as Sin, Health Policy Advisory Center Bulletin 80(1978):10-16. Daniels, Norman, I My Parents Keeper?" Midwest Studies in Philosophy 7(1982):517-540. Daniels, Norun, I t,ty Parents Keeper? 1n President1s COllll1ss1on for the Stuc(y of Ethical Problems 1n Medicine and Biomedical and Behavioral Research. Securing Access to Health Care, vol. 2, (Washington, o.c. u.s. GovernL1ent Printing Office, 1983, pp. 265-291). Daniels, Nonaan, Rights to Health Care and Distributive Justice: Progra1&11tic Worries," Journal of Medicine and Philosophy 4(June 1979):174-191.
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-94L f: Engelhardt, H. Tristram, "Health Care Allocations: Responses to the Unjust, the Unfortunate, and the Undesirable, 11 in Justice and Health Care, Earl E. Shelp, e-d., (Dordrecht, Holland: o. Reiael, 1981, pp. 121-37). Fried, Charles, Equality .and Rights in Medical Care, Hastings Center Report &(February 1976):29-34. Golding, Martin, obligations to Future Generations, The Monist 56(January 1972):85-99. I.. \. ; l.i In the Hatter of Claire c. Conroy, Superior Court of New J,rsey, Chancery Division, Essex County, Docket No. P-19083E, Decided February i. 1983. Lynn, Joanne, The Choice to Forgo L ife-SUstaining Food and Water: Medical, Ethical, and Legal Considerations, (B1oord1ngton, Indiana: Indiana University Press, forthcoming). Lynn, Joanne, and James F. Childress, Must Patients Always be Given Food and water? Tne Hastings ~enter Report 13(0ctober 1983):17-21. Macklin, Ruth, Moral Concerns and Appeal to Rights and Duties, Hastings Center Report 6(No. 5, 1976):31-38. Moo(ly, Harry, s it Right to Allocate Healtn Care Resources on Grounds of Age? in 81oeth1cs and Huraan Rights, Bertram Bendam and Elsie Bancaan, eds., (Boston: Little, Brown, Inc., 1978, pp. 197-201). National C01&11ssion for the Protection of Human Subjects of B1oaedic1l and Behavioral Research, The Bel&10nt Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research, (Washington, D.C.: u.s. Govern,1ent Pri nt1 ng Office. 1978)
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-95-Nielsen, Kai, "Radical Egalitarian Justice: Justice as Equality, Social Theor1 and Practice 5(2):209-226. Nozick, Robert, Anarchy. State, and Utopia, (New York: Basic Books, Inc., 1974). Office of Technology AssessL1ent, "Medical Technology and Costs of the Medicare Program, Report, (Washington, o.c.: Government Printing Office, July 1984). Pope Pius XII, rhe Prolongation of Life: An Address of Pope :, ir*-1 't_1 J ~.: -,_) Pius XII to an International Congress of Anesthesiologists, The Pope Speaks 4(1958):393-398. President's COlillliss1on for the Stuay of Ethical Probls in Jtedic1ne ana Biomedical and Bet1avioral Research, Securing Access to Healtn Care, vol. 1, (Washington, o.c.: u.s. Governmnt Printing Office, J983). President's Cor.1.1iss1on for. the Stu(b' of Ethical Probleras in Ued1c1ne ~nd Bi01.aedical and Behavioral Research, Deciding to Forego Life-Sustaining Treataaent: Ethical, Medical, and Legal Issues in Trea~Jent Decisions, (Washington, o.c.: u.s. Governraent Printing Office, 19d3). Prottas, Jeffrey, Mark Segal, and Harvey M. Sapolsky, cross-National Differences in Dialysis Rates,u Health Care Financing Review 4(No. 3, March 1983):91-103. Ramsey, Paul, The Patient as Person, (New Haven, Connecticut: Yale University Press, 1970). Rawls,John, Justice as Fairness, Philosophical Review 67(1958):164-94. Rawls, John, A Theory of Justice, (Ca,.lbridge, Massachusetts: Harvard University Press, 1971). ) '1 ., ...
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/.. C ,:'.). ,, (! .. '.,, .'._) -96-Rice, Dorothy P., ana Barbara s. Cooper, "The Econora1ic Value of Huran Life, American Journal of Public Health 57(Noverimer 1967):1954-1966. Ross, w. o., The Right and the Good, (Oxford: Oxford University Press, 1939). Sade, Robert M ~led1ca1 Care as a Right: A Refutation,,!!!! England Journal of r.ted1cine 285(1971):1288-1292. S1dgw1ck, Henry, The Methods of Ethics, (New York: Dover Publications, Inc 1966 ) Siegler, Mark, should Age Be a Criterion in Health Care? Hastings Center Report 14(No. 5, 1984):24-27. Sparer, Ec:twrd v., The Legal Right to Health Care: Public Policy and equal Access, Hastings Center Report 6(0ctober 1976) :39-47. Sperling, Godfrey, Let Sraokers Pay for their Haoit, Christian Science Monitor, (January 30, 1978):7. United States Departr.lent of Health and Human Services. Health Care Financing Acain1strat1on, "r.tedicare Program: Prospective Payment for Medicare Inpatient Hospital Services. Final Rule." Feaeral Register 49(January 3, 1984):234-334. Veatch, Robert M, Ethics and the Elderly, Contetaporary Issues in Gerentolop, Davia Schnall, ed. (New York: Praeger Puo11shers, fortncoai ng) Veatch, Robert M., voluntary Risks to Health: The Ethical Issues, Journal of the Ar.ler1can Medical Association 243(January 41 1980):5U-55.
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-97I /. I\ '. ,, _._ '_) ,_; Veatch, RoDert M., "What 1s a 'Just' Health Care Del;very? Ethics and Health Policy, Robert M. Veatch and Roy Branson, eds., (Caabridge, Massachusetts: Ballinger Publishing, 1976, pp. 127-153) Veatch, Robert M., Death, Dying, and the Biological Revolution, (New Haven, Connecticut: Yale University Press, 1976). Veatch, Robert M., editor, Life Span: Values and Life-Extenaing Technologies (San Francisco: Harper and Row, Publishers, 1979). Wing, A. J., why Don't the British Tret More Patients with Kidney Failure, British fled1ca1 Journal 287(No. 6400, October 22, 1983):1157-1158. Zeckhauser, Richard, and Donald Shepard, where Now for Saving Lives? Law and Contemporary Problems 40(1976):5-45. } ; f,
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