1 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.”

3 Why We Talk About This Nearly 30% of Medicare spending is in the last year of life Over 10% of Medicare spending is 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

5 Core Ethical Principles: a primer Beneficence Non-maleficence Justice Autonomy

6 Beneficence Roots in the Hippocratic Oath Foster patient well-being Moral obligation to promote goodness Reduce pain and suffering

7 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

11 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

12 DNR in the Operating Room Can a patient with an active DNR have surgery?

13 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

14 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

15 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