When Utilitarianism Designs a Healthcare System…
Ezekiel Emanuel, the architect of President Obama’s signature health care legislation, has penned a provocative piece published in The Atlantic and entitled Why I Hope to Die at 75. In this essay he argues that people over the age of 75 are a drain on society and it would serve the common good if they would just die sooner rather than later. He is very clear that he is not advocating for euthanasia or assisted suicide. But what he is doing is laying the groundwork for age-based rationing of health care.
It must be understood that Dr. Emanuel is a utilitarianist. He believes that the value of a person lies in his contribution to the economic structure of a society. Non-contributors are worth less than those who are economically productive and are therefore entitled to less of the community resources, including health care.
Emanuel argues that age associated declines in mental-processing speed and creativity make older individuals a burden. He notes that most great scientists, writers, composers, and artists have made their most significant contributions by the time they are in their late forties or early fifties. He declares that it is a rare individual who still has the intellectual capacity to produce great work past the age of 75, so we should stop striving for longevity at that point and refuse all life-prolonging medical care.
It is quite disturbing to read his cold assessment of those with even the most minor disabilities associated with age. He has no respect for the elderly enjoying their golden years and pursuing avocations instead of professional excellence:
The American immortal, once a vital figure in his or her profession and community, is happy to cultivate avocational interests, to take up bird watching, bicycle riding, pottery, and the like. And then, as walking becomes harder and the pain of arthritis limits the fingers’ mobility, life comes to center around sitting in the den reading or listening to books on tape and doing crossword puzzles. And then …
Of course, many of us would counter his arguments with a discussion of the non-economic benefits the elderly provide. I have had the good fortune to know several centenarians in my lifetime. They provided a window to the past that could not be captured in any history textbook. I think of my relationships with several of my grandparents and great-grandparents who lived well past the age of 75 and know that my life was immeasurably enriched by these encounters with my elders, even when they were challenged by infirmities and disabilities. I hope to similarly influence my own grandchildren.
Ezekiel Emanuel discounts any value to familial relationships. In fact he states, “Our living too long places real emotional weights on our progeny…there is much less pressure to conform to parental expectations and demands after they are gone.” His further explanation of this reveals a prideful, self-centered motivation. He is concerned that if he lives past the age of 75, he will be remembered as a burden instead of as someone who was vibrant and a joy to be around.
After laying out his arguments for why life after age 75 is just not worth living, Emanuel goes on to outline the health care policy implications of his position. After the age of 75 he advocates for virtually no health care. No screening tests, no treatment for cancer, no flu shots, no antibiotics. Palliative care to keep the elderly comfortable is all that he sees as reasonable.
Here is where Emanuel errs most dramatically. He is judging the patient as to his worthiness for treatment, instead of judging the treatment as to its worthiness for the patient. There is no question that there are many medical tests and treatments that are not appropriate for patients over the age of 75. Following cholesterol levels, screening mammograms in asymptomatic women, screening colonoscopies for colon cancer are all tests that can be discontinued by this age. However, the reason is not that patients over the age of 75 are not valuable enough to receive this medical care. It is that the burden these tests impose on the elderly is not justified by the expected benefit of these tests. Decisions about the appropriateness of any medical test or intervention need to be made on an individual basis, taking into account the specific burden to benefit analysis for a given treatment in a given patient. Arbitrarily declaring that all those over the age of 75 are unworthy of anything but palliative medical care is unjust ageism.
Caring for an elderly relative can present physical, emotional, and financial challenges. But facing these challenges is an opportunity for great spiritual growth. We are better people and create a better society when we generously love and care for those with infirmities and disabilities. Through their lives, the elderly generously offer us the opportunity to cultivate virtue. As Pope Francis said, “A population that does not take care of the elderly and of children and the young has no future, because it abuses both its memory and its promise.”
Emanuel explicitly rejects such thinking as existential nonsense:
Many of us have suppressed, actively or passively, thinking about God, heaven and hell, and whether we return to the worms. We are agnostics or atheists, or just don’t think about whether there is a God and why she should care at all about mere mortals. We also avoid constantly thinking about the purpose of our lives and the mark we will leave. Is making money, chasing the dream, all worth it? Indeed, most of us have found a way to live our lives comfortably without acknowledging, much less answering, these big questions on a regular basis. We have gotten into a productive routine that helps us ignore them.
I actually feel sorry for Ezekiel Emanuel that he cannot see the value of human life in any terms other than economic productivity. How sad that he does not cherish the rich dimensions the elderly add to our lives. We learn from their experiences, their faith, and, yes, even their suffering. The question before us in American health care policy is whether or not we will value each human life from the moment of conception to the moment of natural death and treat each individual according to his individual needs. Or, will we follow the utilitarian approach and declare whole classes of the population as economically unproductive and therefore unworthy of medical care?