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Health Care Rationing in the Aged

Ethical and Clinical Perspectives

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Abstract

This article provides an ethical analysis of the question of whether aged patients’ access to health care should be less than, the same or greater than, the access younger patients enjoy, when economic resources are limited. This topic is being urgently considered in the US because managed care is becoming more common and brings with it new challenges to traditional medical ethics, and because the prevalence of the aged is increasing as is the number of patients with Alzheimer’s disease (AD). It is also critical throughout the world because new findings suggest that the progression of AD may be retarded or even reversed by providing patients with enriched interpersonal environments. If these findings are valid, it would be inhumane to not consider providing these resources to patients with AD, since these gains would be so meaningful and substantial.

Deontological and consequential values influencing this question are presented and evaluated. The theories of Veatch, Callahan and Daniels in regard to allocating health care to the aged are discussed. It is argued that 2 subgroups of aged patients, the isolated and demented, are among the patients worst off because the capacity to enjoy meaningful relationships with others supercedes all others and both groups of patients have lost this capacity. We assert that, on the basis of the principle of justice according to need, these 2 groups of patients’ exceptional needs should be prioritised.

We then raise the question of whether the majority of the population would be willing to provide these isolated and demented aged patients this care if the new findings proved valid. We conclude that, in light of many people’s fear of growing old and dying, and some peoples bias against the aged (particularly in the US), willingness to provide the necessary resources is open to debate.

Finally, we provide specific examples of the kinds of interventions which might be optimal for each group of patients. For patients who are cognitively unimpaired, this might be providing home care so that they could remain closer to and in contact with their loved ones. For patients who are cognitively impaired, this might be providing interpersonal support when these patients begin to lose control, rather than applying restraints or using psychotropic medication.

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References

  1. Lanken PN. Critical care medicine at a new crossroads: the intersection of economics and ethics in the intensive care unit. Am J Respir Crit Care Med 1994; 149: 3–5

    PubMed  CAS  Google Scholar 

  2. Ruskin A. Capitation: the legal implications of using capitation to affect physician decision-making processes. J Contemp Health Law Policy 1997; 13: 391–21

    PubMed  CAS  Google Scholar 

  3. King G. Health care reform and the Medicare program. Health Aff 1994; 3: 39–45

    Article  Google Scholar 

  4. Lubitz J, Beech J, Baker C. Longevity and Medicare expenditures. N Engl J Med 1995; 332: 999–1003

    Article  PubMed  CAS  Google Scholar 

  5. Evans DA, Funkenstein HH, Albert MS, et al. Prevalence of Alzheimer’s disease in a community population of older persons: higher than previously reported. JAMA 1989; 262: 2551–6

    Article  PubMed  CAS  Google Scholar 

  6. Snow C. Medicare HMOs develop plan for future of Alzheimer’s programming. Mod Healthc 1996; 23: 66–70

    Google Scholar 

  7. Ernst RL, Hay JW. The US economic and social costs of Alzheimer’s disease revisited. Am J Public Health 1994; 84: 1261–4

    Article  PubMed  CAS  Google Scholar 

  8. Karlsson I, Mandahl N, Brane G, et al. Effects of environmental stimulation on biochemical and psychological variables in dementia. Acta Psychiatr Scand 1988; 77 (2): 207–13

    Article  PubMed  CAS  Google Scholar 

  9. Kempermann HG, Kuhn HG, Gage FH. More hippocampal neurons in adult mice living in an enriched environment. Nature 1997; 356: 493–5

    Article  Google Scholar 

  10. Knopman D, Schneider L, Davis K, et al. Long-term tacrine (Cognex) treatment: effects on nursing home placement and mortality. Neurology 1996; 47: 166–77

    Article  PubMed  CAS  Google Scholar 

  11. Karlawish JHT, Whitehouse PJ. Is the placebo obsolete in a world after donepezil and vitamin E? Arch Neurol 1998; 55: 1420–4

    Article  PubMed  CAS  Google Scholar 

  12. Knapp M, Wilkinson D, Wigglesworth R. The economic consequences of Alzheimer’s disease in the context of new drug developments. Int J Geriatr Psychiatry 1998; 13: 531–43

    Article  PubMed  CAS  Google Scholar 

  13. Kitwood T, Bredin K. Towards a theory of dementia care: personhood and well-being. Ageing Soc 1992; 12: 269–87

    Article  PubMed  Google Scholar 

  14. Sapolsky RM, Uno H, Rebert CS, et al. Hippocampal damage associated with prolonged glucocorticoid exposure in primates. J Neurosci 1990; 10 (9): 2897–902

    PubMed  CAS  Google Scholar 

  15. Damasio AR. Alzheimer’s disease and related dementias. In: Wyngaarden JB, Smith Jr LH, Bennett JC, editors. Cecil textbook of medicine. 19th ed. Philadelphia: Saunders, 1992: 2075–9

    Google Scholar 

  16. Kitwood T. Toward a theory of dementia care: ethics and interaction. J Clin Ethics 1998; 9: 23–34

    PubMed  CAS  Google Scholar 

  17. Feil N. The validation breakthrough. Baltimore (MD): Health Professions Press, Inc., 1993

    Google Scholar 

  18. Shaw AB. In defence of ageism. J Med Ethics 1994; 20: 188–91

    Article  PubMed  CAS  Google Scholar 

  19. Hunt R. A critique of using age to ration care. J Med Ethics 1993; 19 (1): 19–23

    Article  PubMed  CAS  Google Scholar 

  20. Sulmasy DP. Physicians, cost control, and ethics. Ann Intern Med 1992; 116 (11): 920–6

    PubMed  CAS  Google Scholar 

  21. Veatch R. Justice and the economics of terminal illness. Hastings Cent Rep 1988; 18 (4): 34–40

    Article  PubMed  CAS  Google Scholar 

  22. Kilner JF. Age as a basis for allocating life-saving medical resources: an ethical analysis. J Health Polit Policy Law 1988; 13 (3): 405–23

    Article  PubMed  CAS  Google Scholar 

  23. Callahan D. Setting limits. New York: Simon and Schuster, 1987

    Google Scholar 

  24. Daniels N. Am I my parents keeper? An essay on justice between the young and old. New York: Oxford University Press, 1988

    Google Scholar 

  25. Daniels N. A lifespan approach to health care. In: Jecker N, editor. Aging and health care. Clifton (NJ): Humana Press, 1991: 227–246

    Google Scholar 

  26. Colombo M, Vitali S, Molla G, et al. The home environment modification program in the care of demented elderly: some examples. Arch Gerontol Geriatr 1998; Suppl. 6: 83–90

    Google Scholar 

  27. Post SG, Whitehouse PJ. Emerging antidementia drugs: a preliminary ethical view. J Am Geriatr Soc 1998; 46: 784–7

    PubMed  CAS  Google Scholar 

  28. Bell NK. What setting limits may mean: a feminist critique of Daniel Callahan’s setting limits. Hypatia 1989; 4 (2): 168–78

    Article  Google Scholar 

  29. Jecker NS. Age-based rationing and women. JAMA 1991; 266 (21): 3012–5

    Article  PubMed  CAS  Google Scholar 

  30. Bennett JC. Special reports/inclusion of women in clinical trials: policies for population subgroups. N Engl J Med 1993; 329: 288–92

    Article  PubMed  CAS  Google Scholar 

  31. Levinsky NG. Age as a criterion for rationing health care. N Engl J Med 1990; 322 (25): 1813–5

    Article  PubMed  CAS  Google Scholar 

  32. Brock DW. Justice and the severely demented. J Med Philos 1988; 13 (1): 73–99

    Article  PubMed  CAS  Google Scholar 

  33. Kumar V, Cantillon M. Update on the development of medication for memory and cognition in Alzheimer’s disease. Psychiatr Ann 1996; 26 (5): 280–8

    Google Scholar 

  34. Kitwood T. The dialectics of dementia: with particular reference to Alzheimer’s disease. Ageing Soc 1990; 10: 177–96

    Article  Google Scholar 

  35. Barnes T, Sack J, Shore J. Guidelines to treatment approaches. Gerontologist 1973; 13: 513–27

    Article  Google Scholar 

  36. Folsom JC. Reality orientation. In: Reisberg B, editor. Alzheimer’s disease. New York: The Free Press, 1983: 449–54

    Google Scholar 

  37. Butler RN, Lewis MI. Aging and mental health. 3rd ed. St Louis: Mosby Company, 1982: 366

    Google Scholar 

  38. Evans LK, Strumpf NE. Tying down the elderly. J Am Geriatr Soc 1989; 37: 65–74

    PubMed  CAS  Google Scholar 

  39. Beardsley RS, Larson DB, Burns BJ, et al. Prescribing of psychotropics in elderly nursing home patients. J Am Geriatr Soc 1989; 37: 327–30

    PubMed  CAS  Google Scholar 

  40. Svarstad BL, Mount JK. Nursing home resources and tranquillizer use among the institutionalized elderly. J Am Geriatr Soc 1991; 39: 869–75

    PubMed  CAS  Google Scholar 

  41. Garrard J, Makris L, Dunham T, et al. Evaluation of neuroleptic drug use by nursing home elderly under proposed medicare and medicaid regulations. JAMA 1991; 265: 463–7

    Article  PubMed  CAS  Google Scholar 

  42. Sloane PD, Matthew LJ, Scarborough M, et al. Physical and pharmacological restraint of nursing home patients with dementia: impact of specialized unit. JAMA 1991; 265: 1278–82

    Article  PubMed  CAS  Google Scholar 

  43. Beers M, Avorn J, Scarborough M, et al. Psychoactive medication use in intermediate-care facility residents. JAMA 1988; 260: 3016–20

    Article  PubMed  CAS  Google Scholar 

  44. Rango N. The nursing home resident with dementia. Ann Intern Med 1985; 102: 835–41

    PubMed  CAS  Google Scholar 

  45. Kitwood T. Brain, mind and dementia: with particular reference to Alzheimer’s disease. Ageing Soc 1989; 9: 1–15

    Article  Google Scholar 

  46. Avorn J. Benefit and cost analysis in geriatric care: turning age discrimination into health policy. N Engl J Med 1984; 310 (20): 1294–301

    Article  PubMed  CAS  Google Scholar 

  47. Sackett DC, Torrance GW. The utility of different health states as perceived by the general public. J Chronic Dis 1978; 31: 697–704

    Article  PubMed  CAS  Google Scholar 

  48. Becker E. The denial of death. New York: The Free Press, 1973

    Google Scholar 

  49. Jecker N, Schneiderman L. Is dying young worse than dying old? Gerontologist 1994; 34 (1): 66–73

    Article  PubMed  CAS  Google Scholar 

  50. Post S. Technology and the aging society: ethics and public policy. In: Blank RH, Mills MK, editors. Biomedical technology and public policy. New York: Greenwood Press, 1989: 201–22

    Google Scholar 

  51. Zweibel N, Cassel C, Karrison T. Public attitudes about the use of chronological age as a criterion for allocating health care resources. Gerontologist 1993; 33 (1): 74–80

    Article  PubMed  CAS  Google Scholar 

  52. Jecker N. The role of intimate others in medical decision making. In: Jecker N, editor. Aging and ethics. Clifton (NJ): Humana Press, 1991: 199–216

    Google Scholar 

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Authors and Affiliations

  1. Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland, 20814, USA

    Edmund G. Howe & Christopher J. Lettieri

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  1. Edmund G. Howe
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  2. Christopher J. Lettieri
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Correspondence to Edmund G. Howe.

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Howe, E.G., Lettieri, C.J. Health Care Rationing in the Aged. Drugs & Aging 15, 37–47 (1999). https://doi.org/10.2165/00002512-199915010-00004

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