Prioritized lives

We can never be allowed to hear good news about our health. The government won’t allow it. “Such is the strength of cultural miserabilism today that even the most smile-inducing good news stories can swiftly be turned into doom-laden tales about the terrible future humanity faces,” wrote Brendan O’Neill, editor of Spiked.

Reporting on the latest U.S. Census Bureau report, finding that advances in science, safe food production, healthcare and prosperity have allowed people, worldwide, to live longer, healthier and wealthier lives, Brendan’s article had a much deeper message. It examined our prejudices, our compassion for others and how our society is coming to view the value of human life.

His thought-provoking article, titled “Older people are more than food for worms,” was about aging, but could just as easily have been about fat people, handicapped people and everyone deserving of our kindness. It was a reminder of our shared humanness and the need for ethical behavior.

As he wrote, rather than being seen as good news, the Census Bureau’s report was treated as worrying, if not bad news:

The growth of the older population will have ‘formidable consequences’ and pose ‘widespread challenges’, we were told. There was talk of an ageing ‘tipping point’, ‘burdens’ on social services, and the need to ‘sound the alarm’ about how the presence on Earth of all these old folks might provoke ‘intergenerational conflict’. In one fell swoop, we went from the revelation that mankind has successfully extended life beyond birth-work-death to warnings of burdensome old people sucking up all of our health and social resources and possibly launching a war of attrition against the young. Nothing better captures the downbeat nature of public life today... The new fear of the old springs from today’s tendency to treat social policy challenges, which an ageing population no doubt is, as insurmountable demographic nightmares – and more fundamentally from our inability to give meaning to human life and see it as something more than a bovine, biological thing.

An ageing population is an unadulterated good thing. Throughout history we have sought to extend human life in order that people – and humanity more broadly – might realise their potential…

But when we do enjoy longer life expectancies, suddenly success is treated as a sign of doom and older people as little more than burdens.

They’re no longer thought of as wise people whose experience of life counts for something important but as individuals with ‘outdated and irrelevant’ views: they’re grumpy, a bit racist, hell they don’t even believe in global warming. The treatment of older people as burdensome and irrelevant speaks to Western society’s increasing estrangement from, and its fear and suspicion of, the ageing process…

Our fetishisation of youth is a way of erecting a barrier against the future, keeping everything in an innocent childish state in order to avoid having a grown-up debate about our potentially grown-up futures. Today’s ambivalent or outright hostile attitude towards the ageing process really reveals our inability to give meaning to human existence today.

Rather than seeing older people as an integral part of some social fabric… we see them as a drain on society’s apparently limited resources. Rather than seeing older people as individuals with hopes and aspirations like the rest of us, we see them increasingly as little more than bovine creatures with a long list of burdensome medical needs. Many now ask: ‘Who wants to live to be old when you’ll only be sick and slow and incapacitated?’ – revealing our inability to see the profounder side to life behind any health problems individuals might have to endure.

“Quality of life” as seen through the eyes of a youth-oriented society does not mean the lives of older people are any less meaningful. When older lives are no longer valued by society, at what age do they become “too old” to get medical care and use public healthcare resources that could go to healthier, younger people?

If you’re too old, no care for you

This week, news in Sweden reported a woman had been left to endure incredible pain due to a treatable condition for four years from the age of 79; then had to wait more than a year to see a specialist in the public healthcare system before being told she was too old to get a surgery she needed. She was given pain pills and turned away. ‘I can understand that the county feels it is expensive to 'fix' us elderly, there more and more of us,” she told Östgöta Correspondente, “but in general, I am healthy. We end up paying for healthcare for younger people, but we don’t get anything ourselves.”

That happened in Sweden’s government-managed healthcare, but could never happen here… could it? Readers deserve to know about Dr. Ezekiel Emanuel, M.D., Ph.D., who serves as the director of the Clinical Bioethics Department at the U.S. National Institutes of Health. He's a key creator of Obama’s healthcare reform plan and his bioethics advisor. He’s also the brother of White House Chief of Staff Rahm Emanuel.

Dr. Emanuel has been appointed to two key positions by the Administration: health-policy adviser at the Office of Management and Budget and a lead member of the Federal Council on Comparative Effectiveness Research, deciding how healthcare resources will be rationed. [After reading this, what comparative effectiveness research is really doing and its resulting spending priorities, covered here, may be clearer.]

His ex-wife, Linda Emanuel, by the way, headed the American Medical Association’s Institute for Ethics, launched in 1997, focused on assisted suicide, terminal care, genetics and managed care. One of its initial projects, was to educate doctors and medical students on end of life care, funded by Robert Wood Johnson Foundation with $1.5 million to start and which went on to fund it ($6.4 million between 2000-2003, alone). RWJF's "Education for Physicians on End-of-Life Care" (EPEC) project was directed by Linda Emanuel. Many of their end-of-life projects focused on addressing minorities, Blacks, Latinos and Native Americans. Its real purpose and disconcerting messages help to explain why the AMA’s promotion of a new medical ethics, which replaced the Hippocratic Oath, has resulted in widespread rejection among practicing doctors of the AMA. Its new ethics includes socialized medicine for "health equity," under the guise of government-managed care. She spoke at an aging conference at RWJF two months ago, on May 21^st, on reducing healthcare costs “without causing a panic by introducing explicit rationing of care.”

The Journal of the American Medical Association published a paper funded by Robert Wood Johnson Foundation and Blue Shield of California Foundation on June 18, 2008. Dr. Emanuel and co-author Victor Fuchs, Ph.D. of Stanford University, examined “overutilization” of healthcare and increases in the costs. They attributed four factors to doctors:

First, there is the matter of physician culture. Medical school education and postgraduate training emphasize thoroughness. When evaluating a patient, students, interns, and residents are trained to identify and praised for and graded on enumerating all possible diagnoses and tests that would confirm or exclude them… In medical training, meticulousness, not effectiveness, is rewarded.

This culture is further reinforced by a unique understanding of professional obligations, specifically, the Hippocratic Oath’s admonition to “use my power to help the sick to the best of my ability and judgment”…

The Hippocratic Oath, the very foundation of medical ethics and the one that the Nazi doctors abandoned, is seen as a problem because it raises healthcare costs. To contain costs, Dr. Emanuel and Fuchs recommended “many more experiments [of] pay for performance, bundled payments, partial capitation, value-based payment or other payment methods that promote prudent use of resources.”

Specifically, how medical care is planned to be allocated (rationed) in the United States was described in the January 31^st issue of the journal Lancet in “Principles for allocation of scarce medical interventions” by Dr. Emanuel and colleagues. In making rationing decisions, they recommend an alternative triage system they called “the complete lives system, which prioritizes younger people who have not yet lived a complete life.” Their ‘complete life’ principle also purportedly includes prognosis, lottery and instrumental value principles.

They first rejected caring for the sickest people first, writing:

Preferential allocation of a scarce liver to an acutely ill person unjustly ignores a currently healthier person with progressive liver disease, who might be worse off when he or she later suffers liver failure… [However], when interventions are persistently scarce, saving the progressively ill person later will always involve depriving others.

What is instrumental value? It “prioritizes specific individuals to enable or encourage future usefulness,” they wrote. “Responsibility-based allocation—eg, allocation to people who agree to improve their health and thus use fewer resources—also represents instrumental value allocation.”

Youngest first, they explained, directs resources to those who’ve had “less of something supremely valuable—life-years.” Their proposed ‘complete lives’ principle modifies the youngest-first principle, they wrote, by prioritizing adolescents and young adults over infants. “Adolescents have received substantial education and parental care, investments that will be wasted without a complete life. Infants, by contrast, have not yet received these investments.” They supplied an age graph, showing how healthcare resources will be prioritized:

The ‘complete lives’ system also considers prognosis, since its aim is to achieve complete lives. “A young person with a poor prognosis has had few life-years but lacks the potential to live a complete life… When the worst-off can benefit only slightly while better-off people could benefit greatly, allocating to the better-off is often justifiable,” they wrote. In conclusion:

When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance, whereas the youngest and oldest people get chances that are attenuated… the complete lives system justifies preference to younger people… Age can be established quickly and accurately from identity documents.

Remember, in the United States, the government now forces every citizen at retirement age into government managed care, Medicare. The only way to opt out of Medicare is to relinquish all of the social security benefits you’ve paid into your entire life. But even this option was later eliminated: Nowhere in the entire country can individuals purchase a self-managed PPO plan after age 65, only Medicare plans are available to individuals. The first proposal from the administration to “save healthcare costs” was to cut $313 billion from Medicare, which cares for seniors and disabled people. Didn’t anyone wonder how they really proposed to do that?*

The government, our government, is already working on deciding what lives are more valuable based on their usefulness and burden on the state, how long we will be allowed to live, and which of us will die.

Sixty-eight years ago, the appeals for compassion and ethical principles, and public condemnation of what was happening, sounded somewhat like O’Neill’s article, but with considerable more urgency. What is deeply disturbing is that the words spoken by Clemens von Galen at Münster Cathedral on August 3, 1941 in an effort to stop the Final Solution (ordered that fall) feel so imperative for us today:

[T]he doctrine is being followed, according to which one may destroy so-called “worthless life”… because, in the opinion of some department, on the testimony of some commission, they have become 'worthless life' because according to this testimony they are 'unproductive national comrades.' … of no further value for the nation and the state…

[W]e are dealing with human beings, our fellow human beings, our brothers and sisters. With poor people, sick people, if you like unproductive people. But have they for that reason forfeited the right to life? Have you, have I the right to live only so long as we are productive, so long as we are recognized by others as productive? ... then woe betide us all when we become old and frail!... then woe betide the invalids who have used up, sacrificed and lost their health and strength in the productive process… then woe betide loyal soldiers who return to the homeland seriously disabled, as cripples, as invalids. If it is once accepted that people have the right to kill 'unproductive' fellow humans—and even if initially it only affects the poor defenseless mentally ill—then as a matter of principle murder is permitted for all unproductive people, in other words for the incurably sick, the people who have become invalids through labor and war, for us all when we become old, frail and therefore unproductive.

Then, it is only necessary for some secret edict to order that the method developed for the mentally ill should be extended to other 'unproductive' people, that it should be applied to those suffering from incurable lung disease, to the elderly who are frail or invalids, to the severely disabled soldiers. Then none of our lives will be safe any more. Some commission can put us on the list of the 'unproductive,' who in their opinion have become worthless life. And no police force will protect us and no court will investigate our murder and give the murderer the punishment he deserves.

Who will be able to trust his doctor any more? He may report his patient as 'unproductive' and receive instructions to kill him. It is impossible to imagine the degree of moral depravity, of general mistrust that would then spread even through families if this dreadful doctrine is tolerated, accepted and followed.

© 2009 Szwarc

* That’s also why, in part, it was important to understand economics and the facts of who the uninsured really are in this country. Instead of finding a way to help the 7% of Americans who actually need our help and rather than caring for seniors at the time in their lives when they most need medical care, healthcare reform will have taxpayers pay for managed care for 18 million generally healthy young adults, 9.5 million illegal aliens, and 17 million with incomes over $50,000.