By:
Dave Kingsley
Yes We Can Afford to Care for Babies and the Elderly
A mere thirty years ago, babies born at 24 weeks weighing 750 grams rarely survived. Today, 70% of these children survive, thrive, and go home to continue their development as healthy human beings.[1] That is the wonderful side of medical technology. Keeping pre-term babies alive is expensive – these are the rare multi-million-dollar hospital cases. No doubt, the 0- to 5-year age category includes a large proportion of the highest cost acute care patients.[2] But I believe it is fantastic that medical technology can accomplish that. I also believe that it is the moral and medically ethical thing to do.
The 65 to 70 age cohort is the other group with the most expensive hospital charges. Most of the exceedingly high charges for this age-group are related to heart disease. Charges drop precipitously for patients past the age of 70. I discovered this phenomenon while doing research and teaching at Kansas University Medical School and discussed it with famed cardiologist Caldwell Esselstyne at the Cleveland Clinic. Dr. Esselstyne explained that we were seeing the natural history of a disease – namely atherosclerosis. Autopsies on soldiers during the Korean War revealed that this disease was well developed in a large number of young adults, which was a revelation to the U.S. medical profession. Typically, it progresses untreated and results in a crisis by a person’s mid to late 60s. [3]
The question that has arisen in treating patients with costly medical care is “should we provide or withhold care based on age?” Treating complicated diseases with advanced medical technologies is expensive, but the United States with the most abundant financial resources in the world can easily afford to save pre-term babies and 65- to 70-year-old patients with heart disease. If provided with necessary information regarding the realities of public finance and medical necessity and outcomes, the American people, would, I believe, want to spend whatever is possible, reasonable, and feasible to save and extend life regardless of disease and age.
The Dominant Bioethicist View in Scholarly Debate about Healthcare Justice: Depriving the Elderly of Beneficial Care is Justified
In the past few decades, a consensus has formed among the most influential American bioethicists that the escalating cost of healthcare in the United States is unsustainable and, therefore, bioethics demands rationing of beneficial medical care. Rationing of medical care could, in their view, be justified primarily by an individual’s years of future economic productivity and contributions to society. This is a chilling and horrifying mantra within a constricted context of neoliberal economics, erroneous conventional wisdom about public finance, and medical-industrial (Wall Street) narratives.
Not surprisingly, in the grand theories and scheme of the poohbahs of bioethics, the elderly and Medicare are primarily blamed for running up the cost of cost of medical care. In an article titled “Rationing Just Medical Care,” [4] Lawrence Schneiderman, a proponent of medical care rationing, has incorporated and summarized the rationale of the rationing movement. Schneiderman states that a “decent minimum of care” would be at a level that “enables a person to acquire an education, seek or hold a job, or raise a family.” [5]
In Schneiderman’s proposed system, age and productivity are criteria for providing or withholding care rather than individual medical diagnoses and prognoses. The nature of care for persons with impaired health, unable to meet the three goals for qualifying for expensive, lifesaving, life extending care should, in his view, include “a reasonable level of comfort, whether it be from pain or other forms of suffering.”[6] A person not acquiring an education, seeking or holding a job, or raising a family would be accorded just enough health to ensure “a reasonable level of function within the person’s limits that is respectful of the person’s dignity, as well as a reasonable level of comfort, whether it be from pain or other forms of suffering.[7]
Schneiderman is speaking for America’s preeminent bioethicists such as Peter Singer, Daniel Callahan, Zeke Emmanuel, and Norman Daniels – to name the top few. Their utilitarian philosophy is compatible with neoliberal economics and Wall Street claims that Medicare plus an aging population is a major threat to the economic wellbeing of the United States. Utilitarian ethicists consider individuals and their treatment in the medical system as “means to an end” – a perceived economic “greatest good for the greatest number” – rather than ends in themselves. This philosophical position is illustrated by the quote Schneiderman borrows from economist Paul Krugman:
“America has a long-run budget problem. Dealing with this problem will require, first and foremost, a real effort to bring healthcare costs under control – without that, nothing will work.”[8]
This is an accurate quote, but one taken out of context. Krugman also emphasized a flawed tax code, which has become even more obscenely tilted in favor of the wealthy and against the working classes since 2010 when he wrote the opinion piece in the New York Times. He also refrained from blaming Medicare and the elderly for excessive healthcare spending. If Krugman were engaged in a serious budget discussion today, he would probably agree that waste, fraud, and inefficiencies in privatized healthcare, defense, and other government programs turned over to industrial complexes are major contributors to federal deficits and debt.
Cruel Capitalism and Wall Street Hegemony over the U.S. Healthcare System: The Elderly Can be Sacrificed for the Sake of Money
The bioethics enterprise is dominated by a handful of white male neoconservatives. As their theoretical framework and publications make clear, their views are compatible with the mostly wealthy male financiers on Wall Street.[9] These doyens of neoliberal economic bioethics attack Medicare and fall in line with superrich financiers’ misinformation regarding “entitlements caused” deficits and debt white at the same time they ignore the ravages of privatization on the U.S. healthcare system.
Financiers at the top of the wealth pyramid want to distract attention from an obscene tax code, which is fueling deficit spending and draining resources from public health, education, and other major institutions that enhance the quality of a society. Mainstream bioethicists are a perfect ancillary to their strategy. The real out of control costs in the U.S. healthcare system is due to the amount of the public treasure funneled into dividends, stock buybacks, and executive/board compensation. Nevertheless, this incontrovertible fact is nowhere to be found in writings of the leaders in the bioethics enterprise.
Bioethicists like Peter Singer,[10] Zeke Emmanuel,[11] Norman Daniels,[12] and Daniel Callahan [13] have shown a shocking disregard for scientific thinking and science in general. They have failed to seriously examine their basic assumptions, nor have they engaged in serious data analysis based on medical care data and public finance – they accept the Wall Street narrative at face value.
One would think that the role of ethicists is philosophical and moral rather than budgetary and macroeconomic. But that is not the role they are playing. They have joined forces with conservative deficit and debt hawks by taking up the invalid argument that Medicare is not affordable; that given the continuing growth of the elderly population and costs of medical technology, the only means of sustaining the healthcare system is rationing – essentially shortening human life for the purpose of reducing costs.
Daniels, Emanual, Singer, Callahan, and other economic-oriented bioethicists have no original scientific studies of their own to support their claim that a condition of growing elderly cohorts (65+ and 80+), advancing medical technology, and the constraints of limited U.S. wealth on government expenditures is unsustainable. They rely solely on the Wall Street generated budget busting Medicare myth to make the case that beneficial medical care should be withheld from frail older Americans. Hence, their one solution and primary proposal are buttressed through confirmation bias.
Callahan, founder of the prestigious and powerful Hastings Center on Bioethics, has stated that he believes the “only reasonable approaches are to concede the greater importance of children and younger age groups for the future than for the elderly and to make certain the economic imbalance does not increase.” [14] This arbitrary ingroup-outgroup construction typifies ordinary prejudice, stereotyping, scapegoating and discrimination that it generates. [15]
We cannot ignore the relationship between the cavalier attitude toward medical ethics in the warehousing and neglect of elderly and disabled “nursing home” patients and the ageism/physicalism of the bioethicists.
There is no scientific evidence that the elderly are responsible for causing budget deficits and debts. Conversely, considerable evidence is available to debunk the baby boomer budget busting narrative,[16] which has been ignored by policymakers, the media, and advocacy groups.
Right wing narratives and political strategies for reducing Medicare and Social Security benefits have been effective and harmful to the well-being of older age groups in the United States. The harm extends beyond Medicare and Social Security. It is difficult to claim that patients in so-called “nursing homes” should receive better care than the pervasive neglect, abuse, and warehousing characteristic of the current profit-oriented system when the leading bioethicists are pushing Wall Street narratives. The elderly have no powerful lobby with the mission of pushing back on the reduction of healthcare to dollars and care for the deserving.
Unfortunately, the public is led to believe that the AARP is an advocacy group for “retirees,” when in fact over $1 billion of their revenue is from royalties for selling their brand to corporations preying on the elderly while $2 hundred million is from selling memberships. They need to walk that fine line by burnishing their false image as a pro-senior organization.
Other aging enterprises such as the National Council on Aging, National Institute of Aging, Area Agencies on Aging, and a plethora of other advocacy groups and organizations spawned by the Older Americans Act have been tepid at best in the fight against excess extraction of Medicare funds by mammoth insurance corporations, medical device manufacturers, pharmaceutical companies, and a host of financial intermediaries.
Commissions and think tanks on nursing homes have shown no interest in a public discussion regarding medical ethics or the lack thereof in the outrageously poor care of patients. Instead, I see an implicit sympathy with industry financial hardship disinformation. Consequently, the elderly are vulnerable to euthanasia by neglect – not just in nursing homes but throughout the healthcare system. Indeed, the categorization of human beings as more or less worthy of medical care is eerily similar to the 1930s eugenics movement in the United States – adopted and utilized in Nazi-era Germany as justification for extermination of seriously frail and physically limited people.
[1] Sandra Lane (2015) Why are Our Babies Dying. New York: Imprint Routledge.
[2] David Kingsley (2015) “Aging & Healthcare Costs: Narrative Versus Reality,” Poverty & Public Policy, 7:1, 9-15.
[3] Jack P. Strong (1986) “Coronary Atherosclerosis in Solders: A Clue to the Natural History of Atherosclerosis in the Young.” JAMA, 256(20) 2863-2866; Young Mi Hong (2010) “Atherosclerosis Cardiovascular Disease Beginning in Childhood,” Korean Circ J 40, 1-9.It may very well be that playgrounds and “happy meals” along with double patty, cheese, bacon, hamburgers are a bigger threat to healthcare expenditures than health per se at any age.
[4] Lawrence Schneiderman (2011), “Rationing Just Medical Care,” American Journal of Bioethics, 11-7, pp. 7-14.
[5] Ibid., page 8.
[6] Ibid., page 8.
[7] Ibid., page 9.
[8] Opinion | Budget Deficits: Spend Now, Save Later – The New York Times (nytimes.com)
[9] The late Peter G. Peterson, multi-billionaire co-founder of Blackstone committed over a billion dollars to funding an anti-Medicare and anti-Social Security lobby in Washington, which includes the Concord Coalition, the Committee for a Responsible Budget, and other projects for providing disinformation and misinformation about programs for the elderly. His lobbying organizations have been effective in injecting a political narrative into the mainstream media. In his book Running on Empty (2004, New York: Picador), he states that, “whatever reforms talked about – be they more use of information technology or medical malpractice reform – we are going to have to give up some medical care that may be of some benefit,” p. xvii.
[10]Peter Singer, “Why We Must Ration Health Care” New York Times, July 19, 2009.
[11] Zeke Emmanuel, “Why I Hope to Die at 75,” The Atlantic, October 2014.
[12] Norman Daniels (2013) “Global Aging and the Allocation of Health Care Across the Life Span,” American Journal of Bioethics. 13(8): 1-2.
[13] Daniel Callahan (2009) Taming the Beloved Beast: How Medical Technology Costs are Destroying Our Health Care System. Princeton, NJ: Princeton University Press.
[14] Callahan, Ibid., p. 218.
[15] On prejudice, discrimination, & scapegoating, see: Gordon Allport (1989), The Nature of Prejudice. New York: Addison-Wesley, 243-260.
[16] Kingsley, (2015), Op. Cit.
