BY: PHILIP W. BRICKNER, MD
We all believe that human existence is sacred, that it is worth much effort to preserve, that a desire for a long life is a good goal, and that as we age we are to be held in esteem and affection. But do these premises remain valid? Today there are, in fact, genuine threats to the welfare and the very survival of portions of the U.S. population, particularly the frail elderly.
Threats to the Elderly
Threats to those of advanced age flow from three sources: demographic change, the loss of integrity of the family, and the distortion of values by money.
Demographic Change
Fifty years ago, men and women 85 years old or older were a rarity in the United States. But the 1990 census revealed 3 million such persons. One million of these were 90 or older and 36,000 were centenarians. Very old persons are now common, and will become more so. Demographers project that, by 2030, 2 percent of our population, or about 8.1 million persons, will be 85 years of age or older.
Loss of Family Integrity
The impact of a dependent aged relative on family relationships has become a widely recognized concern. Daughters in their seventies now find themselves responsible for aged parents, as well as for their own children and grandchildren. Pressures are high and responses vary. We all know of instances in which individuals have had to make substantial personal sacrifices to sustain their families. The opposite happens as well. Some years ago, when I was serving a medical rotation in a New York City emergency room, aged men in wheelchairs were twice abandoned at the hospital by relatives who were never seen again.
Distortion of Values
Most of us remember a time, not far distant, when the sight of a deer was an awe-inspiring moment, one of wonder and great charm. Today, there are too many deer — they have become pests. A close parallel exists in our society's view of older people. Those responsible for the country's economy tend to be concerned with budgets rather than with the implications of major policy decisions for human beings. This is morality in reverse and the distortion of values.
The Elderly Are Vulnerable
As a result of these threats, the health, safety, and lives of the frail elderly are at risk. To speak and act in their defense, we must understand why these risks are present. The prime reason is that it is costly to keep them alive; the frail elderly cannot contribute to the economy, and they cannot defend themselves. There is a growing temptation to consider this growing segment of our population to be a useless burden to the public welfare, ballast to be tossed overboard to keep the ship of state afloat.
What is the evidence for this concern? Consider the following items:
- When Richard Lamm, then governor of Colorado and more recently a presidential hopeful in Ross Perot's party, said in 1984 that older people "have a duty to die and get out of the way," he revealed a mind-set that those in government rarely allow themselves to show in public.
- In 1987 I attended a meeting with several midlevel bureaucrats from the Health Care Financing Administration (HCFA), the federal agency responsible for Medicare. I was too eloquently arguing the case that Medicare should pay for long-term home healthcare of the frail aged, an interest of mine. I proclaimed that this field of service should be covered because care at home was cheaper than nursing home care. A HCFA staff member interrupted me, saying, "But, Doctor, wouldn't it be even cheaper yet to leave them at home unattended with no help at all?"
- A recent culmination of this way of thinking is the physician-assisted suicide movement. This is a concept so reprehensible that most of us thought it could never happen. But today it is a reality in one state, Oregon, with perhaps others to follow. The potential for euthanasia is well known, already an established consequence of physician-assisted suicide legalization in the Netherlands.
Each Life is Sacred
If human beings are to become victims of economically driven decisions about who shall live and who shall die, which are those most likely to be sacrificed to profits? Surely it will be those who cannot resist; who have no voice; who are expensive and apparently useless; who cost insurance companies, HMOs, and Medicare so much money in those famous "last six months of life." This description fits well the isolated frail aged.
"Every person is entitled to develop his or her potential to the fullest at every stage of life," according to CHA's Committee on Continuum of Care/Aging Services. This honorable statement of principle applies equally to the fetus, the newborn, and the demented 90-year-old. It would be disingenuous of us to distinguish one from the other. Each is a human life. If we sacrifice one, we cannot defend our support for all.
Dr. Brickner is chairman, Department of Community Medicine, St. Vincents Hospital and Medical Center, New York City.