Leading Bioethicists Do Not Believe that the Elderly Have Equal Rights in the U.S. Medical Care System


Dave Kingsley

Nursing Homes & COVID:  200,000 Fatalities in One Institutionalized Population

Last week, the U.S. officially recognized a COVID death toll of one million U.S. residents.  An estimated 200,000 or 20 percent of those deaths have occurred in nursing homes. At any given time, individuals in long-term care/skilled nursing institutions comprise approximately three-tenths of one percent of the U.S. population.  One would think that an investigation would be under way to determine how such a tragedy could occur in one institutionalized population and who is accountable.

There is no doubt that a huge proportion of these deaths were preventable.  However, due to neglect and greed of corporate providers, paid by taxpayers to care for patients in LTC/SKN facilities, and lax government regulation, COVID was allowed to sweep through institutions housing frail elderly and disabled Americans. This resulted in the largest mass fatality of an institutionalized population in the history of the United States.   

Appallingly, interest in accountability for this human rights atrocity on the part of politicians, the media, the medical professions, government agencies, or any other relevant interest group is nonexistent.  Even two commissions on nursing homes – one specifically charged with investigating COVID in LTC/SKN institutions and one under the auspices of the National Academies Science Engineering & Medicine (NASEM released a report barely a month ago) – ignored the issue of industry culpability.

The industry is culpable.  It was well-known that a novel virus was likely to make its way to the United States eventually.  For decades, scientists have been sounding alarms.  Asian countries learned from the SARS pandemic and issued guideline for protecting patients from raging viral pandemics.  Those guidelines were ignored by the U.S. nursing home industry.

Indifference to an unnecessary mass fatality event is occurring in a context of long-developing denigration of the worthiness and value of elderly and disabled Americans.  Religions and their leaders have been absent from and seemingly uninterested in the plight of institutionalized people needing nursing care. Indeed, many deplorable facilities are affiliated with major religious organizations.

And then there is the question of bioethics and decline of Enlightenment and Judeo-Christian ethics as they pertain to persons needing medical care.  Indeed, the current dominant bioethics movement supports withholding beneficial medical care from the elderly for the sake of the market economy and what they erroneously see as federal budgetary constraints.

The Elderly & Human Rights in a Neoliberal Capitalist Society

As a highly visible extremist Catholic majority on the nine member U.S. Supreme Court “legislates” on human rights for a population of 340 million citizens, a small group of America’s most prominent and powerful bioethicists are engaged behind the scenes in a chilling, ageist movement – mostly in academic journals. Few Americans are aware of the proposals for “rationing” medical care concocted by Daniel Callahan of the prestigious Hasting Center on Bioethics, celebrity physician Zeke Emmanuel, and other well-known bioethicists.[1]

The underlying philosophical/ethical, foundation of these physicians’-academicians’ rationale is a toxic, perverse, combination of utilitarianism and neoliberal economics rather than a profound and humane theoretical framework calling for reinforcement of universal human rights based on Enlightenment values and ethics.  The essence of their reasoning is that the U.S. cannot afford all the medical care needed by the U.S. population, therefore some needed care should be directed away from the elderly to young populations who are of more value to society, i.e., from the less productive to the more productive.

A review of the literature clearly exposes two unexamined and flawed premises of this horrifying philosophical/ethical position: (1) the U.S. economic system cannot absorb the cost of needed medical care for all citizens, and (2) the elderly are not as worthy as younger cohorts.  Proponents argue from these premises to the conclusion that it is OK to shorten the lives of elderly Americans for the sake of reducing costs.

Integral to their position is the concept of a “decent minimum level of medical care.”[2]  Schneiderman defines a decent level of medical care as:

“…a level of medical care that enables a person to acquire an education, seek or hold a job, or raise a family.  Or, if the person, because of impaired health, is unable to meet any of these goals, to attain a reasonable level of function within the person’s limits and respectful of the person’s dignity, as well as a reasonable level of comfort, whether it be from pain or other forms of suffering.”[3]

This statement clearly expresses an opinion contrary to humanistic ethics that grew out of the Enlightenment and formed the philosophical underpinnings of liberal democracy. The bioethicists in this movement have a perspective of human beings through the lens of bioethical utilitarianism in which their right to medical care is reduced to their worth in a radical free-market economic system.  As Schneiderman states: “Without the support of society, the individual would not prosper; in return, I argue, the individual has a duty to recognize society’s needs for productive citizenry.”[4]  He proceeds to claim that “The success of the society depends on the productivity and contributions of its individual members.”[5]

The Context of Rationing Bioethics

As prior quotes suggest, a powerful group of bioethicists are valuing humans for the purposes of medical care based on their value to the economic system.  Without operationalizing “productivity” and “contribution,” they presuppose a declining value of aging human beings because of less engagement in and usefulness to the economic sector of society. Wisdom, life experience, leadership ability, and other contributions needed by an enlightened, democratic society are not only discounted, but given no worth whatsoever. 

As Zeke Emmanuel, the most famous bioethicist in the U.S., wrote in the Atlantic, it is best to die by 75 because life is not worth living past that age and all productivity and contributions cease.[6] Dr. Emmanuel equates “living too long” with living beyond our 75th birthday.  He claims that longevity “robs us of our creativity and ability to contribute to work, society, the world.”  That it “transforms how people experience us, relate to us, and most importantly remember us.  Dr. Emmanuel believes we are, after age 75, “no longer remembered as vibrant and engaged but as feeble, ineffectual, even pathetic.

Culling the Herd:  Let the Old Die

At some point in U.S. history, elders were no longer seen as important to the survival of the family, community, and nation.  That sociology and history – the history of transformation of valued elders to useless, dependent old people – has been covered elsewhere.  In radical free market economic systems, individuals not needed are vulnerable.  Public policy tends to reflect the power of industrialists and the economic values guiding politicians.

It has not been uncommon for media personalities to suggest that people dying in nursing homes were probably near death anyway.  So, not a big loss.  As Bill O’Reilly on FOX put it, “they had one foot in the grave any way.”  Some suggested that diseases “cull the herd,” and who better to go than old people. 

In a country as wealthy and advanced as the United States, there is absolutely no reason to deny health care to citizens and other residents based on their worthiness as human beings.  There should be no place in a humane society for “deserving” and “undeserving” people in need of medical care.  Medical ethics require nothing less than deference to physician-patient decisions about needed, beneficial, care.  Unfortunately, in the privatized system now dominating U.S. medicine, the needs of shareholders and executives take precedence over people with medical needs.

[1] See e.g., Daniel Callahan (2009) Taming the Beloved Beast.  Princeton University Press; Lawrence J. Schneiderman (2011) “Rationing Just Medical Care,” American Journal of Bioethics, Volume 11, Number 7, 7-14.; Norman Daniels (2013) “Global Aging and the Allocation of Health Care Across the Life Span” American Journal of Bioethics, American Journal of Bioethics, Volume 13, 2013, 1-2.

[2] Schneiderman, ibid, page 8.

[3] Schneiderman, ibid, page 8.

[4] Schneiderman, Ibid, page 8.

[5] Schneiderman, Ibid, page 8.

[6] Ezekiel J. Emmanuel (2014) “Why I Hope to Die at 75,” The Atlantic, October,2014 Issue. https://www.theatlantic.com/magazine/archive/2014/10/why-i-hope-to-die-at-75/379329/.