Health care and science resources should be conservatively allocated to our aging population, focusing on providing quality to the aging years without draining assets in a reckless attempt to extend life.
Outline:
I. Introduction
to an increasing aging population: components of the discussion.
A. Current and projected
numbers.
B. Economic and medical
resource consumption.
C. Social effects of the
increase.
D. Health concerns.
E. The importance of
meaning and fulfillment.
F. Thesis paragraph.
II. Scientific research
to extend life.
A. Aging theories.
B. Telomere research.
C. Anti-aging therapies.
III. Health care allocation.
A. Medicare.
B. The market-based
system.
C. Treatment objectives:
acute vs. chronic care.
D. Long-term and
hospice care.
IV. Perspectives on
aging.
A. James Fries.
B. Daniel Callahan's.
i.
Natural Life Span.
ii.
Using age as a standard.
iii.
Changing expectations.
C. Perspectives of
other cultures/countries.
i.
Britain: good example.
ii.
Bad Examples
D. My Thoughts
i.
On Callahan.
ii.
Health care goals.
iii.
A Universal single-payer system.
Body:
The demographic projections in the United Sates are significant. Between 1982 and 2030 the median age will move from 30.6 to 40.8 years and the proportion of the population over 65 will go from 11.6 to 21.1 percent (Committee on the Aging Society, 1985). Persons over 85 are the fastest growing age group, 21 times more numerous than in 1900 (Callahan, 1995). This is also an international issue; by 2040 most developed countries will have 30 percent of their population over 60 (Hanson, 1994). These figures demand our attention on issues of aging.
Most elderly need economic assistance and are significantly dependent on lower age groups. In the 1930's most of the elderly lived below the poverty line. Social Security helped reduce this figure to 15.7 percent by 1980. 80 year-olds receive 50% percent of their yearly income from social security (Committee on the Aging Society, 1985). The rest of their income often comes from pension plans or family funds.
Elderly populations consume significantly more medical resources than other age groups. In 1984 elderly were 12% of our population, but consumed 31% of medical resources; by 2040 they are expected to consume 45 %. The Federal Government currently spends approximately $200 billion on health care for the elderly, which still only covers 67% of the expenditures. The remaining 33%, or $100 billion, must be covered by elderly and their families (Callahan, 1995).
These economic expenditures have social consequences. Many families struggle to pay for an elder parent's expenses and care (Callahan, 1995). Only five percent of elderly in the U.S are in nursing homes. Such hardships can make elderly parents feel like a burden and can lead to irritability and depression among children caregivers. Particularly affected are daughters, who have traditionally fulfilled caregiver roles. Adding adult caregiving to the responsibilities of a modern women can "drain her of her prime yearsî(Brakman, 1994, p.26). The responsibilities of younger generations must be factored into aging discussions. If not through family care, they are at least affected through tax expenditures.
The key component of aging discussions is the physical, mental, social, and spiritual health of elderly individuals. In the process of extending mortality we have also extended morbidity. 39 percent of 65-75 year-olds and 66 percent of over 85 year-olds suffer from chronic disabilities (Committee on the Aging Society, 1985). For many elderly, retirement years are far from "golden." Physical debilitation, embarrassing illnesses, and dementia leave many elderly frightened, lonely, and disengaged. Disengagement theory holds that elderly should withdraw from societal responsibilities and relax in their final years. However, this withdrawal often causes elderly to feel useless and removes responsibilities that keep their minds sharp and bodies healthy. If modern medicine provides more years, it is the responsibility of modern society to facilitate quality years (Callahan 1995).
Old age can be a fulfilling and joyful experience. The fulfillment of attaining one's life goals, the time available for travel and relaxation, the connections made with children and grandchildren, and the satisfaction of giving back to society are a few of the perks. With the extension of mortality and the decrease of impoverished elderly, the 65+ age-cohort has become the most politically active age group and the largest contributor to volunteer services. Such involvements give elderly a meaningful and significant place in society. As elderly deal with the vulnerability of confronting their limits, society must make extra accommodations to ensure meaning and significance to their last years. The attainment of meaning and significance should be the focus of public policy that confronts aging issues. If our actions do not facilitate the attainment of meaning then we must reevaluate them (Callahan, 1995).
The increasing elderly population demands attention. The economic and social burdens that are resulting from this increase must be addressed in public policy. Large expenditures on our aging population are draining resources from younger age groups. Elderly are using a disproportionate amount of health care resources, but are still suffering from long periods of morbidity. Our current methods of allocation must be reevaluated. Health care and science resources should be conservatively allocated to our aging population, focusing on providing quality to the aging years without draining assets in a reckless attempt to extend life. Research efforts should facilitate the attainment of meaning and significance by focusing more on the social, psychological, and spiritual facets of aging. Research should also attempt to constrict morbidity by developing therapies that limit the debilitating symptoms caused by chronic illnesses.
In the past 50 years Gerontology, the study of aging, has become a rapidly expanding research field. A whole host of aging theories have been developed; many of which are connected to possible therapies. One theory suggests that free radical induced DNA damage is a major cause of aging (Bernstein, 1991). Finch (1978) suggests that brain cells which control the endocrine system are pacemakers for aging. Evolutionary Theory emphasizes that genes beneficial to young cohorts are selected for because younger individuals contribute more to population survival (Bernstein, 1991). Kirkwood (1977) suggests that aging is due to somatic deficiencies because of an imbalanced investment in reproduction. Burnet (1978) contends that genetic errors in the immune system cause aging by making individuals vulnerable to disease. Wear and tear theory focuses on the dilapidation of biological structures in combination with DNA damage. Lastly, catastrophic error theory holds that aging becomes catalyzed by a "single hit" on a somatic chromosome rending all its genes inactive (Bernstein 1991). In general, the DNA-damage hypotheses are the most widely accepted in the scientific field; however there is much debate over the key causes of this damage.
Telomere research has dominated the gerontology research field in recent years. Telomeres are caps on the ends of eukaryotic linear DNA that prevent degradation of genetic information. Telomerase is the key enzyme responsible for maintaining and extending telomeres. In most somatic cells the enzyme telomerase is absent, and telomeres gradually shorten with aging due to incomplete replication. Thus, somatic cells only have a limited number of divisions possible before their telomeres become completely degraded and DNA deletions begin. This limit is called the Hayflick limit. The implication of this research is the possibility of therapeutically introducing telomerase to somatic cells for the maintenance of telomeres. Such a therapy could extend somatic cell life spans significantly. However, so far few legitimate therapies have developed from this hypothesis (Harley 1996).
Based on this new knowledge of aging processes significant research has been dedicated to anti-aging therapies. Many like the one mentioned above try to reduce DNA damage. Dietary restrictions have been suggested that reduce oxidative free radical production. The intake of antioxidant compounds has been investigated. Researchers are also trying to increase the level and efficiency of enzymes that inactivate free radicals. Another approach is to increase the level of DNA repair. Dietary supplements, such as vanillin and cinnamaldehyde, have been proposed to reduce chromosomal aberrations. Genome manipulation is also a possibility of the future. Gene therapies that insert normal genes into persons with gene disorders are currently being researched. It has been suggested that aging is caused by dysfunctions in key gene regulators. Possibly gene therapies could replace these gene regulators with new ones as they become dysfunctional (Bernstein, 1991).
With the introduction of Medicare in 1966 there has been a change in the pattern of health services used. Hospital and physician visits increased, and long-term care greatly increased. However, the majority of Medicare expenditures are for acute care. These increases have directly correlated with increases in morbidity. Ironically private expenditures for elderly health care have increased as well, and within the last few decades private expenses have been increasing at a faster rate than public ones (Committee on the Aging Society, 1985). These increases mark a shift in attitude. First, came a shift from ìcaring services to curing servicesî (Callahan, 1995, p.28). Early federal funding of research and Medicare coverage of curing therapies made this possible. The possibility of cures soon led to expectations for new cures. These ever-higher standards were met by increasingly higher health care costs. The current rise in private expenses further indicates that expectations have well superseded the resources available. Since these expectations are for cures more than care, we now feel capable of controlling life and expect the right to a long life (Callahan, 1995).
Federal expenditures bare some of the blame for overzealous expectations, but our market-based health care system is probably the main cause. We currently spend 14 percent of the GNP on health care; no other developed country spends more than ten percent. Our market-based system is lopsided, over treating many while leaving one in seven Americans uninsured. Allowing over-treatment drives up expectations. A market system "supplies wants while abandoning needsî (May, 1996, p.63). Skyrocketing expenditures and unimpeded technology are products of a market system; a shift from market values to community values is needed to limit these increases (May, 1996).
Research is largely focused on therapies for curing acute illnesses. Until recently few resources have been focused toward researching chronic illnesses, palliative care, or rehabilitation methods. For example, the National Institute on Strokes decided to research hypertension screening as a possibility for reducing or postponing stokes, rather than researching rehabilitation methods for impaired stroke victims. Essentially they chose to focus on curing rather than caring (Moody, 1994). The result of these decisions is a lack of treatment options for those suffering from chronic diseases. Chronic illnesses are not going to be cured like acute illnesses, they must be cared for.
Currently acute illnesses in elderly populations are treated just as aggressively as those in younger populations. Since acute illnesses are more likely among the elderly, they are treated more often and use more resources. The continual treatment of acute illnesses increases the likelihood of prolonged periods of chronic illness. Essentially acute illness treatments keep elderly alive longer, so they can suffer longer from their chronic illnesses. A more holistic approach is needed with the elderly, and a hierarchy of treatment that focuses on limiting morbidity must be established (Callahan, 1995).
Long-term care and hospice care are two neglected areas of medicine. Currently only 5% of elderly use long-term care homes. The goal of long-term care is "to control disease and prevent its progression, to provide palliation, and to maintain and improve self-sufficiencyî (Blasszauer, 1994, p.16). Hospice care is focused more on relieving suffering during the last moments of life. Both focus more on caring than curing. Insurance coverage and Medicare coverage currently provide little support for long-term care and hospice care. Such care is covered by families or the elderly themselves. The stress of such expenditures is the main deterrent against receiving this care (Hanson, 1994).
In the last fifty years the field of bioethics has become an increasingly important aid to medical decision-making. Several centers of bioethics and many bioethics journals have been established. Many bioethicists have written about aging, but a few deserve particular attention. One bioethicist, James Fries (1986) proposed a goal called the ìcompression of morbidity,î or more popularly know as the ìsquaring of the curve.î He hopes for two medical achievements in the future, longer lives and shorter periods of chronic illness before death. His wish is for life quality to be at a high level for as long as possible, then suddenly drop rapidly and end in a quick death. This should be held as the ideal situation. However, modern medicine has achieved longer lives, but has failed in compressing morbidity. Hence, the current focus needs to be shifted to compressing periods of chronic illness.
Daniel Callahan (1995), the founder of the Hastings Center, is perhaps the most quoted bioethicist on aging issues. Callahan believes the U.S. community needs to collectively establish a ìnatural life span.î A natural life span is complete when ì(a) oneís lifeís possibilities on the whole have been accomplished; (b) oneís moral obligations to those for whom one has responsibility have been discharged; (c) oneís death will not seem to others an offense to sense or sensibility, or tempt others to despair and rage at the finitude of human existenceî(p.115). Callahan asks society to collectively decide on an age where ìon the wholeî these three requirements will be met. He realizes the heterogeneity of the elderly cohort; some may pass on their responsibilities before this age while others may continue to have new opportunities after this age. However for the sake of public policy this age must be defined. Once a natural life span is accepted, then health care objectives should change for those above this age.
According to Callahan using age as a standard for allocation is stiff, but fair. It can serve as an ìantidoteî to increasing technology. Currently allocation is based on medical need, but needs are continually reevaluated as technology increases. Age is more of a static standard than medical needs. If the goal of medicine is to provide a ìnormal opportunity rangeî during life, there is less temptation to develop technologies that only address acute problems. Technologies will be evaluated based on how they contribute to a quality life, a life full of opportunity and devoid of chronic illness. Using age as a standard must be coupled with a guarantee of security. Elderly should feel secure from the suffering and financial ruin of chronic debilitating illnesses. Using age as a standard recognizes the need to set priorities of care. Younger groups should be protected against acute illnesses that could limit opportunities. Physical mobility, mental alertness, and emotional stability should be priorities in elderly care. Thus, younger age groups need aggressive preventative medicine, while the elderly need quality care for their current illnesses.
Callahan believes defining a natural life span and setting allocation priorities can change expectations. An accepted natural life span can enable elderly and their families to prepare for and embrace death as a natural part of the life cycle. Serving the young is a source of fulfillment to elderly. Elderly are serving the young by deciding to shift medical resources to the young. The fear of suffering a prolonged lonely death can be eliminated. Shifting from aggressive preventive acute treatments to long-term chronic illness care can promise the level of health needed to attain meaning during the final years of life.
The British health care system should serve as a model for elderly care. It emphasizes quality of life through primary-care and subsidized home care. However, elderly have significantly limited access to aggressive preventative and acute treatments. An attitude of self-restraint has limited technology excesses, while facilitating quality health. Britain spends 8% of their GNP on health care, compared to14% in the U.S., and has the same infant mortality rates and life expectancies as the U.S. (Callahan, 1995).
Other countries have abused their elderly population by allocation cut-backs. The Netherlands does not financially support palliative care for serious chronic illnesses, but rather allows for active euthanasia. This combination has led to cases of involuntary euthanasia and voluntary euthanasia caused by financial difficulties (May, 1996). Hungary and other Eastern European countries put a high percentage of their elderly in nursing homes. The care in these homes is focused on aggressive drug treatments, often leaving the elderly heavily sedated. Care is highly paternalistic, degrading the elderly to ìpassive puppets.î These examples serve as a reminder that human dignity must be preserved during allocation decisions (Blasszauer, 1994).
I strongly agree with Daniel Callahan that health care resources should be allocated according to age. Age-based allocation is fair and is clear. With increasing technology, medical needs are continually being reevaluated. Allocating based on medical need is overly dependent on technology and too unsteady for affective public policy. There is also the temptation to define medical need differently among ethnic groups and social classes, exacerbating current practices of discriminatory allocation. Using age as a standard allows for medicine to take a broader perspective than the immediate problems. Goals of medicine should focus on the entire life cycle and the entire community. Early medical decisions should not interfere with later health needs; certain groups should not hoard from other populations. Using age as a standard allows medical goals to adapt to the stages of life. It promotes fair allocation to all age groups. It is not biased toward certain social classes or ethnic groups. However, we must not dehumanize the patient in allocation. Individualized care is still a top priority. The patient/caregiver relationship must be fostered, and it must factor into health care reform.
I support two basic goals of medicine. One is to facilitate a level of health in younger cohorts that allows for a normal range of opportunities. Preventative medicine and aggressive treatment of acute illnesses are justifiable if they assist future opportunities. Secondly, elderly cohorts should receive care that facilitates the attainment of meaning and fulfillment. Medicine should be more focused on long-term care for the symptoms of chronic illnesses. Technology should yield to these goals. No new technologies should be developed that intensify chronic illnesses or extend life without improving quality. Research objectives must be clarified and structured in a way that resists the temptation of seeking extraordinary cures. Instead more research should be dedicated toward developing caregiving techniques. Caring promotes a meaningful life; curing promotes a long life. Before developing cures to extend life, we must first guarantee that we have the caregiving capabilities to bring quality to these extra years.
I believe a universal single-payer system, like the Canadian system, is the best way to implement my two medical goals. Currently health care expenditures are covered by over 250 insurance payers, as well as by the patients themselves (May, 1996). It is difficult to set long-term goals in a market-based system; there are too many decision-makers with different priorities. In a market-based system patient care is often over shadowed by business objectives. The only way to develop common medical goals is to stiffly regulate market objectives. However, a government run single-payer system would allow for collective decisions to drive health care. A system built on common goals could encourage society to shift away from individual objectives to collective ones. English and Canadian citizens are less selfish about health care allocation, and thus are more satisfied with their health care than many U.S. citizens. Our medical system needs a centralized perspective before health care allocation can occur effectively. Consolidation of providers is the best way to do this. Shifting to a single-payer system will be difficult. Citizens should be active in the process, but most importantly be patient during rapid changes. Remaining confident that a single-payer system will better serve the entire community is one's best contribution to such health care reforms.
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