ration bookWe had a number of guests to dinner for the Fourth of July celebration yesterday. One of our guests, an older, retired man, had had a lung transplant. He reported how well his new lungs worked and how marvelous it was that medicine could give him such a new lease on life.

His story got me to wondering about the issue of limiting treatment options due to considerations such as age, productivity, ROI, etc. I found a related article by Andre & Velasquez (1990) that began with a quote by Euripides from about 500 B.C.E.

I hate the men who would prolong their lives
By foods and drinks and charms of magic art
Perverting nature’s course to keep off death
They ought, when they no longer serve the land
To quit this life, and clear the way for youth.

It often surfaces that in order to provide affordable care for everyone perhaps the options need to be limited, or given finite resources, choices must be made as to who gets what’s available. This is of course a very sticky wicket.

Ethicist Daniel Callahan wrote a book, Setting Limits, about limiting health care for people over 70 based on the premise that they had lived long enough and it was best to provide for palliative care but not expensive, life prolonging procedures. This position has been very controversial to say the least.

Callahan has focused on the cost of care, citing ever more expensive health care options that provide ever smaller increments of increased life span. Recently, he was quoted as saying, “Our whole health care system is based on a witch’s brew of sacrosanct doctor-patient autonomy, a fear of threats to innovation, corporate and (sometimes) physician profit-making, and a belief that, because life is of infinite value, it is morally obnoxious to put a price tag on it… Cost is a symptom of a deeper problem. We have an ‘infinite progress’ model. Nothing is ever good enough. The standard of care is raised higher and higher – but death always wins.” (Baker, 2009)

Callahan is nearly 80 now and has not voluntarily passed up expensive medical help with his personal health issues and this is not surprising. The issue of “affording health care” is based on a notion of lack, that there is not enough to go around and that somehow we must ration it, lest we run out. I don’t think this is the case.

On Wednesday, we can discuss this area and I excerpted a few quotes from Andre & Velasquez (1990) that appear to be good discussion starters:

“If our aim is to use costly resources more effectively, then we ought to deny treatment to all patients whose prognosis indicates a short life span, chronic illness, or little likely improvement in the quality of life, rather than denying treatment simply on the basis of age.”

It is argued that… “providing benefits to one group means unfairly taking them away from members of the other group. But, this is mistaken. We don’t claim that it is unjust to spend more educational dollars on children than on adults. Similarly, it is not unjust to spend more medical dollars on the aged than on the young, so long as every individual has the same access to medical care over a lifetime.”

“To claim that the elderly’s right to health care must be restricted because they have achieved a “natural life span” — that they have no life goals or possibilities — is simply erroneous. In fact, their major life achievements may still be ahead of them.”


  1. Andre, C & Velasquez, M. Aged-Based Health Care Rationing. Issues in Ethics, Vol 3, Num 3, Summer 1990, Markkula Center for Applied Ethics, Santa Clara University, http://www.scu.edu/ethics/publications/iie/v3n3/age.html.
  2. Baker, B. Ethicist Callahan: ‘Set Limits’ On Health Care. Kaiser Health News, 12-10-2009, http://www.kaiserhealthnews.org/checking-in-with/daniel-callahan-limits-on-health-care.aspx.
  3. Callahan, D. Setting Limits: Medical Goals in an Aging Society. New York: Simon and Schuster, 1987 (http://books.google.com/books/about/Setting_Limits.html?id=NH1T-sVvEw4C).

Join us for a real-time discussion about questions raised by this essay on Wednesday from 12:00 p.m. to 12:45 p.m. See Discussion and SL tabs above for details. Link to the virtual meeting room: http://tinyurl.com/cjfx9ag.

Image Source: Identity and Ration Books. Image licensed under Creative Commons by Wolfiewolf on Flickr