Sacrifice in an Aging Society:

The Reality and Implications of Limited Health Care Resources

Written by Francesca Doriss

March 12, 2003

Honor Code Upheld

Introduction

Our society is currently suffering from a severely limited supply of health care resources. In his State of the Union address this past January, President Bush announced that he intends to commit an additional 400 billion dollars of the budget over the next decade to reform and strengthen Medicare. Currently, Medicare provides coverage to 40 million elderly; by the year 2031, that number is expected to reach 77 million. [1] As it is, the government allocates 21.6% of its annual budget to meeting health care needs; [2] unbelievably, due to the present nature of the system, even this huge proportion of the budget is not sufficient to meet the requirements of this growing, and aging, population. Today, our society is experiencing an extreme increase in both the numbers and the proportion of the population over the age of 65; as the number of elderly increases, so does the amount of federal health care funding allocated to them. The demographic realities, along with the fact of the finitude of our financial resources, provoke the question of how to appropriately allocate these resources; however, what initially begins as a material matter quickly expands into a number of other realms.

A host of social and ethical problems and implications are raised by the facts that not only are our resources limited, they are also unjustly distributed. In his book, Setting Limits, Daniel Callahan deals with this very issue, investigating the moral maturity of a society that bestows six times more in federal health care expenditures upon its elderly than upon its children. [3] Callahan explores the underlying social beliefs and values that have brought us to this point, suggests new perspectives and possibilities, and implores us as a society in general and the elderly as a segment of that society in particular to consider a re-allocation of our health care resources. From his point of view, an age-based rationing of our resources is the only way we can effectively manage this situation. In effect, he is calling for an ethically based self-sacrifice on the part of the elderly.

In this paper, I shall analyze Callahan’s proposal. Using as my final framework the lens and language of sacrifice, I intend to demonstrate not only the efficacy but also the ultimate necessity of Callahan’s proposal. I believe Callahan’s proposal is the only just solution, and even though in its practical application it will have difficult implications at first, in the long run it will be much better for society at large, not only financially but also socially and interpersonally.

The Problem Unfolds

A financial and economic dilemma sets the stage and poses the question: How will we address the issue of allocating this country’s limited health care resources? Were there enough funding for all persons to receive all the health care they needed throughout their entire lives, perhaps this issue would never even arise. But the reality is that we live in a land of limited resources, and this question requires serious investigation and consideration, now more than ever.

Why now? What is occurring now in the world of health care resource allocation that so desperately demands our attention? A look at some statistics will reveal the staggering reality of the situation and expose the vast discrepancies that exist in the ways that these resources are distributed throughout the population. First of all, between 1900 and 1987, there was an eightfold increase in the number of those over the age of 65, and almost a tripling of their proportion of the population. [4] It has been estimated that the number of Americans 65 and older is projected to rise from about 30 million in 1988 (12.5% of the total population), to 39.2 million in 2010 (13.8%), and 64.6 million in 2030 (21.2%). [5] As the system stands, as the number of elderly increases, so does the percentage of the national budget devoted to their care. By 2040 the elderly will constitute approximately 21% of the population and their care will consume 45% of the budget. [6] Clearly, this is an unjust distribution of resources; one fifth of the population should not be receiving almost half of the available resources.

The situation is made only more unjust when we realize that children, the most vulnerable segment of the entire population, are the ones suffering most from this disproportionate allocation of resources. It is quite interesting to note that in 1935, at the advent of the Social Security system, the elderly were one of the poorest of all social groups. Over the next few decades, the system led to a remarkable change in the situation of the elderly. However, nothing comparable was developed for another needy group, that of children living in poverty. Especially during the 1980s, as the situation of the elderly improved, social support for health and other forms of care for the young actually declined. Indeed, in 1970, poverty among children under 14 was 37% less than poverty among the elderly. By 1982, poverty among children had increased to 56% greater than poverty among the elderly. Sadly, and somewhat unbelievably, children receive one sixth as much in federal expenditures as do the elderly. [7] It is certainly a strange state of affairs to be living in a time and place in which the elderly actively compete with their own grandchildren for societal resources.

The current distribution of resources is also made extremely troublesome by the fact that there are currently 44 million American citizens without any health care coverage and another 30 million who are significantly underinsured. Personally, I cannot help but wonder what we are doing enriching the benefits of the singular group already insured with federal money when so many people have no care at all. [8]

Although the issue initially arises from the seemingly straightforward mathematical dilemma of too many people and not enough resources, it would be naïve to believe that the economic realities tell the whole story. In and of themselves, the hard facts of our current dilemma are not isolated social truths; rather, they stem from and are indicative of powerful underlying beliefs and values that we as a society hold and defend. In this sense, the above statistics have much to offer us, much to teach us about ourselves, if only we are willing to listen. These facts and statistics reveal some profound insights into what we as a society understand both the ends of medicine and the ends of aging to be.

Misconceptions I: Contemporary Understandings of Medicine

In this century in particular, this society has experienced an interesting, and potentially devastating, shift in the manner in which it views and understands medicine. For the vast majority of the history of human civilization, nothing changed in the way we either conceived of health or treated disease. [9] This is because, as Callahan explains, for most of its history, medicine was relatively powerless to do much about illness, disease, and death. Efficacious cures did not often fall within medicine’s scope; for the most part, medicine could really only offer comfort and palliation. That situation began to change by the middle of the eighteenth century, primarily because of better diets and sanitation. By the nineteenth century, scientific method was coming to be applied to illness and disease. Systematic biomedical research first appeared, and soon, by the early twentieth century, medicine began to offer real cures.

With the advent of immunizations, antibiotics, and high-technology devices and methods, the purpose along with the possibilities of medicine came to be seen in a whole new light. [10] Instead of being solely care-oriented, as it had been for so much of history, medicine started to become cure-oriented. The combination of public health, vaccination, and antibiotics allowed the average life span to increase from around thirty years at the beginning of the twentieth century to over seventy as we enter the twenty-first century. [11] Clearly, this had extraordinarily positive implications for the modern world. As science and medicine met with success after incredible success, the sentiment in favor of biomedical research and finding cures became widespread.

Clearly, medicine’s newfound power and ambition did much to raise standards of human health and happiness and, in this sense, offered much good to human civilization. However, the oft-overlooked downside to this new role of medicine was that the newly emerging paradigm was haphazard, unrealistic, and unsustainable. As Callahan points out, in the overwhelming ambition of this new paradigm, very little thought has been given to medicine’s ultimate ends. There has been neither a unified vision of nor a cohesive approach to medicine. In this sense, it is more like an ensemble of piecework than the creation of an integrated tapestry. Researchers go where their interests carry them, or where the money for research can be found. [12] The newly emerging paradigm was unrealistic because medical progress, by pushing forward the frontiers of health, began to invite and seduce us to set an ever-higher standard of what should count as “good health” and an acceptable life span. It has encouraged and allowed us to reject fatalism and previously held beliefs about the limitations and natural decay of the body. The message from medicine about our health is clear enough: it is no longer by luck or chance that some live and some die, but simply by a failure of science yet to succeed in conquering or managing those illnesses which remain. [13] We have been moved by the impulse to transform death into an externalized enemy upon whom it is both possible to wage war and win. [14] Medicine now seems to deny, it its assault on disease, an acceptance of any cause of death as fitting or natural. [15] This is exciting, to be sure, but also completely unsustainable, for as our present experience demonstrates, the logic of a medical progress set to conquer all disease – in combination with a growing proportion of elderly people – guarantees an ever-rising budget and ever more ways of spending the money. [16]

Furthermore, and I believe this to be a very important point, medicine’s current focus seems to be on ever extending the lives of the elderly, but no one is stopping to ask at what cost. We push and push for quantity of life, but the elderly are suffering for sometimes excruciatingly long periods of time from chronic ailments and afflictions (such as dementia and osteoporosis, to name a few). The elderly are living longer, to be sure, but these are not necessarily “good” lives. Our culture seems to be less concerned with improving what life we have left and more concerned with simply getting more life.

Misconceptions II: Contemporary Understandings of Aging, Dying, and Death

Hand in hand with the shift in our understanding of the proper role, goals, and ends of medicine has come a comparable shift in the way we as a society view and understand the entire process of aging, dying, and death. As Callahan explains, whatever deeper and wider reasons, whether religious or biological, we might find to support the value of death, it is also part of our natural endowment that we want to live and not to die. It is, as he says, a sign of our greatest vitality. [17] I agree with this, for clearly a healthy will to live is essential for the continuation and flourishing of any human life. However, we have a serious problem if our societal understanding of a “healthy will to live” is a desire for limitless life and perfect health. Simply put, it seems that the fundamental misconception we currently hold about aging and dying is that they are “bad,” and to be avoided, and that if we simply put our minds to it and are willing to pay for it [18] , we can have life everlasting. Certainly, upon being questioned, the average individual will respond (in vague and general terms) that of course we will all die. Of course, they will insist, they know that aging and dying are inevitable. However, as a society, this is not the premise from which we operate. We do not behave in a manner that reveals our understanding and acceptance of the inevitability of death. Death has become a failure, an embarrassment. Death is a subject that is evaded, ignored, and denied by our youth-worshipping, progress-oriented society. [19]

In fact, death itself is usually referred to only euphemistically in major segments of our society, and children are shielded from knowledge of it, as if it were some unnatural and immoral act. [20] Elisabeth Kubler-Ross points out that in the U.S., we have long been known as a death-denying society, a people who even deny the aging process itself. [21] That is not hard to believe, considering the absolutely ridiculous market that exists in our country for anti-aging or “age-defying” products. We are so afraid of looking (not to mention growing!) old, a fear which marketing executives in the so-called “beauty industry” masterfully capitalize on and reinforce by presenting us with irresistible products that promise not only to keep us looking young indefinitely but also to make us happy to boot!

Another interesting point to note is the increase in numbers of the elderly living in convalescent homes or assisted living facilities. [22] As time passes, more and more old people live in these facilities. I recognize that a number of different factors (economic, sociological, historical) influence and cause this trend, but for my purposes, what is relevant is that this trend seems to reflect our tendency as a society to hide death out of view. We do not want to see or have to deal with the dying.

I think I have made it fairly clear how these two skewed perspectives on medicine’s role and aging’s place mutually negatively reinforce each other. Because we fear and are disconnected from aging and death, and view them not as an acceptable part of a normal life cycle, and we see medicine’s job as being to beat back whatever ails us, we set up the societal context for this relentless pursuit of and support for health care for the elderly.

A New View: The Potential of a Paradigm Shift

There is decidedly nothing inherently “right” about our current paradigm that necessitates its continuation. Thus, in light of the obvious detrimental consequences of this paradigm, perhaps a reformation of it is in order. What would a new paradigm look like? First of all, it would require that we re-envision both the proper and appropriate ends and goals of medicine as well as what it means to age, to be old, to die. How much is reasonable to expect of medicine? How will the elderly fit into society? How will we view dying and death? These are some of the questions that Callahan attempts to answer.

As for a proper understanding of medicine, Callahan proposes quite simply that medicine should be used not for the further extension of the life of the aged, but only for the full achievement of a natural and fitting life span and thereafter for the relief of suffering. [23] In other words, in this new paradigm, medicine’s function would be to avert premature death, which he vaguely defines as death before the fulfillment of a “natural life span,” and to alleviate suffering after that point. He says that an improvement of active life expectancy, not life expectancy in itself, would be medicine’s purpose. [24] As far as high-technology methods and devices go, Callahan points out that just because technologies exist which could extend the lives of the elderly (who have already fulfilled a “natural life span”) does not mean that those technologies should or must be used. Rather, the uses of technology are to be subordinated to the appropriate ends of medicine; otherwise, we will be slaves to the powers of technology, and it will be they, not we, that determine our end. [25] He believes that no technology should be developed or applied to the elderly that does not promise great and inexpensive improvement in the quality of their lives, no matter how promising for life extension. Incremental gains achieved at high costs, he says, should be considered unacceptable. [26]

However, Callahan does recognize that a denial of life-extending care cannot occur until reforms for basic health care and relief of suffering for the elderly are in place and assured of success. To this end, Callahan proposes that our major research priorities be those chronic illnesses which so burden the later years and which have accompanied the increase in longevity. Among these chronic illnesses are five primary ones: dementia, urinary incontinence, hearing impairment, osteoporosis, and osteoarthritis. [27] Researching these conditions and finding ways to ease or eliminate the suffering they cause will not extend life, but it will instead make what life is left better. Callahan emphatically concludes that nothing less than a full-blown national health insurance program, guaranteeing a minimally adequate level of health care for all, will suffice to do justice to the health needs of the elderly as well as to those of other age groups. [28] Thus would medicine be viewed and applied in the new paradigm.

As previously mentioned, the new paradigm would also involve a fresh understanding of what it means to age and die. Callahan suggests that the time has come for us to ask once again how we might creatively and honorably accept aging and death when we become old, and not always struggle to overcome them. [29] Unfortunately, too many people think that the sentence of death, rather than death itself, is an end to growth. On the contrary, it may mark the beginning of the greatest growth of a lifetime. [30] This is certainly the view of death held by proponents of the hospice movement. Death is recognized as the inevitable end for us all and, as such, is neither to be feared nor avoided. The primary focus of a hospice is to provide care, comfort, and attention to terminally ill people in their final months. Fortunately, the hospice movement is becoming more widespread in our country; advocates are slowly but surely raising awareness of the possibility of dying well – dying with maximum peace and ease.

Additional Reformations of the Current Paradigm

While this reworking of our understanding of medicine’s proper role and dying’s proper place in society allows for a great shift in our thinking, the new paradigm is not yet complete. In order for the new paradigm to work, there are two more aspects of our current framework that still need our attention. The first issue is that there is within our society a severe ambiguity regarding social roles and obligations. Because of this ambiguity, the elderly are left with very little societal purpose as an aged people. [31] There is at present no meaning for the aged unless they can supply it for themselves, [32] which has the dangerous potential to encourage people to withdraw into themselves and limit their concern to their own individual welfare. Common sense tells us that a society cannot survive for very long if its members subscribe to and perpetuate such self-centered mentalities. It is essential that we reintegrate an understanding of life stages into our way of thinking. From this perspective, for each stage of life that one is in, there are corresponding social roles and obligations. Each member is seen as part of the whole, and at each “stage” of life, every member “owes” something back to the whole of which it is inextricably a part. For the young (children and young adults), that social role and obligation involve education and preparation for the future. Mature adults (those in their “second stage” of life) have the responsibility to procreate and rear the next generation and to manage the present society. For the elderly, their social role and obligation is indispensable: they are to serve as the moral conservators of that which has been and the most active proponents of that which will be after they are gone. In this sense, the primary aspiration of the elderly, Callahan suggests, should be to serve the young and the future. After all, just as the elderly were once the heirs of a society built by others, who passed on to them what they needed to know to keep it going, so are they likewise obliged to do the same for those who will follow them. [33]

In recognition of the fact that this role is one that can only be filled by the elderly, and that such a role is indispensable to the society, Callahan seems to allude to the fulfillment of this role as a sign of  “moral maturity” on the part of the elderly. A willingness to give up some of their own interests for the sake of the society as a whole would reveal a maturity that Callahan seems to believe is currently lacking in our elderly (as determined by the continued – and growing – claims that the elderly make on our society’s health care resources). In other words, by sacrificing themselves for younger generations, the elderly would be fulfilling a unique and indispensable societal role that only they could fill and, in this way, realizing a greater social purpose.

It is particularly crucial here that we not forget the importance of intergenerational interaction and obligation. It is not just a matter of what the old “owe” the young, but also a question of what the young “owe” the old. We need to recognize that for the smooth functioning of society, there must exist some idea of mutual interdependence between the generations. The only way that the elderly can make such sacrifices on behalf of the young is if the young make a fresh commitment to the old in return. [34] To be fair, I think that the young are also suffering from a lack of maturity. The social role of the younger generations needs to extend beyond education, preparation, procreation, and the maintenance of society. Part of their obligation must be to acknowledge and cherish the wisdom and life experience of the elderly, to show them respect and gratitude, and to help create the kind of society in which aging is embraced and accepted.

The second issue that needs to be addressed is the idea of “need.” Callahan attempts to explain why age-based, rather than need-based, rationing is appropriate. He makes the case that “need” simply does not work as an allocation principle because it is too relative: medical need is not a fixed concept but a function of technological possibility and predominant social expectations. [35] Age, he points out, is a universal, meaningful category, and anyway there is not likely to be a better or any less arbitrary category for us to work with. Understandably, there is a good deal of distaste of the idea of using age as a basis for rationing, for it appears discriminatory and also seems to fail to take individual needs into account. It would be incredibly difficult to determine at exactly what age the life-extending powers of medicine would be denied to an elderly person. However, Callahan makes the rational point that no group should have an unlimited claim on medical resources in the name of medical need [36] ; it is not fair to give special dispensation to the elderly at the expense of the rest of society.

This age-based solution, then, although quite objectionable to some, strikes me as adequately reasonable. The fact of the matter, if we recall, is that we have limited resources. Callahan aptly points out that due to financial constraints, the current system cannot remain in place for long. Our resources are not inexhaustible, yet we operate as if they were. Soon, unless we first take proactive steps to alter our entire approach to allocating health care, we will be forced to recognize and begin to operate within the bounds of our finitude. Callahan argues that if limitation on health care is a defensible idea, its purpose must be to see that each age group gets what it truly needs to live a life appropriate to it, and to see that each age group gives to the others that which it alone can give. [37] His proposal, to re-envision medicine’s proper role and dying’s proper place and to allocate our resources accordingly, tries to do just that.

Through the Lens of Sacrifice: A Theoretical Model

It is certainly pleasing to imagine this new societal context, this new paradigm, but what is the reality of creating it? I am aware that the “new paradigm” presents an idealistic, utopian vision of the way our society could be, but does not necessarily address the practicality of instituting that change. This utopian vision could easily be dismissed as an impossible pipedream, but the alternative – complacently conceding to the injustice of our current system – is frightening to consider. To illustrate this point, I have come up with a theoretical model to explore the two potential paths our society could take. Both paths assume that, due to financial realities, limits on health care are going to have to be set in the relatively near future. Here, we finally arrive at the language of sacrifice. While the language of sacrifice is not traditionally used in the public debate on this matter, it offers us a new, quite applicable, lens through which to frame our investigation. The two paths within this theoretical framework are characterized by whether the sacrifice in each is voluntary or involuntary on the part of the ones being sacrificed. Depending on this distinction, the significance of the sacrifice for the larger society would differ greatly.

The first theoretical possibility is what I call the “band-aid effect.” This would be the result if we attempted to deal with the problem of limited resources without first creating a new societal context in which that change could and would naturally occur. This financially based change would be imposed from the top down; it would be an economically-driven decision made by our government rather than a ethically-based change embraced by the people based on an examination of our ideals and values. It would be an involuntary sacrifice of the elderly, and would thus amount to slaughter. The involuntary nature of this sacrifice is what would make it so negative. It would have a divisive effect upon society, for by making sacrificial victims of large numbers of unwilling elderly, much resistance, resentment, and confusion would undoubtedly ensue. Theoretically speaking, this would be the “bad” path for our society to take. Ideally, the recognition of the negative consequences of such a sacrifice would make us, as a society, take pause and then take the proactive measures to prevent this kind of sacrifice from occurring.

 Instead, we would turn to the “good” path presented by this theoretical model. The “good” path would be that of real social change, which would evolve from the inner transformation of society at large. This path assumes that, as a society, we have addressed our previously held misconceptions and worked to craft a new paradigm. From the perspective of this new paradigm, the issue of health care resource allocation would become much less daunting. In this new light, the voluntary self-sacrifice of the elderly would emerge as the obviously ethical thing to do. Socially, ethically, and economically, and with a new understanding of what medicine and aging are, there would be a lot of sense in the elderly gracefully stepping aside and ceasing to compete with their own grandchildren for societal resources. In this paradigm, the elderly would be fulfilling their unique social role, and the compassion and wisdom inherent in the requirements of such a role would radiate out into the community. In this voluntary self-sacrifice, the elderly would become heroic martyrs of sorts (dying for the “cause” that is the good of society), which would have a powerful unifying, or communion, effect on society. In her essay “’A Very Special Death’: Christian Martyrdom in its Classical Context,” Carole Straw aptly explains why a voluntary sacrifice is so much more powerful and meaningful than an involuntary sacrifice: “Precisely, and paradoxically, because suffering was so contemptible when imposed against one’s will, it became all the more glorious and stunning when embraced actively with the will. In this case, the ‘charge’ or valence reverses. For, by definition, whatever one willed freely was honorable – even, and especially, degradation – because that self-abnegation was the ultimate and most solemn of sacrifices: one could give no more than the offering of one’s own life.” [38] While this slightly dramatized language originally belongs to the Christian martyrs and Roman gladiators, it definitely works here for our examination of the obligations and appropriate actions of the elderly.

The Likely Reality: A Conclusion of Sorts

 While it is interesting and informative to play with a theoretical model of possible outcomes, and it is easy to see why we “should” pick the second path, we must now turn to practical considerations. The first issue is that the old paradigm is deeply ingrained in the psyches of our people. It will be no easy task to uproot and untangle the tightly woven strands of that paradigm, not just in the minds of individuals but also in the medical community and the greater government. As for the elderly in particular, it is admittedly asking a great deal, for we are all conditioned to expect a relentless conquest of nature for our well-being, and we are all desirous of a long and healthy life. It will be difficult to convince them that this change is even a good idea; how much less can we expect them to embrace and institute the change of their own accord! [39] A second practical issue is that even if it were easy to bring about this paradigm shift, these things take time. The probability is that it would take at least a few generations before the beliefs and values presented by the new paradigm could take hold, and that is assuming we begin discussing the matter and planting the seeds now!

Sadly, this points to the glaring reality of the most likely possible outcome: we will not make a change in the way that we allocate our resources until the financial constraints make it impossible to continue otherwise. This change, thus occurring, will be economically based and governmentally imposed, and it will mean the involuntary sacrifice of countless elderly people. It is terribly unfortunate, for I visualize a better way. In my idealistic vision, there is a way to make this sacrifice honorable and blessed, and I am so disappointed that it cannot be.

 However, even though the sacrifice will thus be involuntary, I do believe that it still contains a powerful potentiality to cause meaningful social change. Indeed, it is this potential to cause good which, in the end, validates this entire argument. This sacrifice, though involuntary, will sweep the stage of our old fixed mentalities and allow for new understandings and beliefs to enter. Of course, it seems only kind and fair to offer the impacted generation of elderly some sort of compensatory benefits in order to make their losses more palatable and manageable. To simply cut them off of all health benefits “for the good of all” would be overwhelmingly unkind. Perhaps if a system of compensations were in place, the transition period between the two paradigms would be made easier, and our elderly would not have to be so dramatically “abandoned.” Then, the young could grow up not in the current matrix of unquestioned mores, but in a shifting paradigm. It would be theirs to determine the shape that this new paradigm, and indeed a new society itself, would take.

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