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HOW OLD IS TOO OLD?

How old is too old?

How sick is too sick?

(How young is too young?)

2

Daniel Callahan

“The very quest to overcome our biological limits is destructive of health care systems.”

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Why We Talk About This

• Nearly 30% of Medicare spendingis in the last year of life

• Over 10% of Medicare spendingis in the last 2 months of life

• Medicare will be insolvent in X years

• ~65% of health consumption is by 20% of people, viz. the elderly

4

Rationing Medical Care

• Already occurring

• Directly: denial or restriction of services

• Indirectly: financial tactics to influence behaviors (co-pays, deductibles)

• Covertly: unwritten agreements(e.g. Brits NHS post-WWII)

-Daniel Callahan

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Core Ethical Principles: a primer

• Beneficence

• Non-maleficence

• Justice

• Autonomy

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Beneficence

• Roots in the Hippocratic Oath

• Foster patient well-being

• Moral obligation to promote goodness

• Reduce pain and suffering

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Non-maleficence

• Ethical obligation not to harm

• Embedded in the Hippocratic doctrine:

“primum non nocere”

• More strict requirement than beneficence

8

Justice

• Personal: respect and fairness

• Social justice (common good): - access - resource allocation - dovetails with medical futility

9

Autonomy

• Capacity • Substituted judgment

• Informed consent • Best interest argument

• Self-determination • Paternalism

• Surrogate decisions • Resuscitation status

10

Positive and Negative Rights

• “Negative” right: legitimate- Choose among, or refuse, procedures- Based on autonomy, informed consent- Supported by constitutional rights:

privacy, liberty- Common law protection against battery

• “Positive” right: not legitimate- To demand a treatment- Limited by clinical judgment

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Palliative Care

• Procedures that are not desired “as life prolonging procedures” are all permissible if used for proper palliative purposes.

• “There is no realistic hope of significant recovery”--intended to allow a rational flexibility

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DNR in the Operating Room

Can a patient with an

active

DNR have surgery?

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• Full resuscitation

• Limited resuscitation: procedure-directed

• Limited: goal-directed #1(temporary & reversible events)

• Limited: goal-directed #2(statement of patient desires)

DNR in the OR: ASA Guidelines

Goal-directed approach:Prioritize outcomes, not procedures

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Sociology and Ethics

• Health care providers are human beings

• Patients and families are human beings

• Societies are imperfect and unpredictable

• Health care occurs in a society

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Conclusion: Rationing

• It already is here

• A sociopolitical issue

• Physicians’ obligations are to provide care

• Policy decisions cannot be made by individuals- Too much variability- Physician biases- Not enough transparency

• Policy must be fair, reasoned and compelling

• There must be an appeals process