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HOW OLD IS TOO OLD?. How old is too old? How sick is too sick? (How young is too young ?). Daniel Callahan. “The very quest to overcome our biological limits is destructive of health care systems.”. Why We Talk About This. • Nearly 30% of Medicare spending is in the last year of life

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how old is too old
HOW OLD IS TOO OLD?

How old is too old?

How sick is too sick?

(How young is too young?)

daniel callahan
Daniel Callahan

“The very quest to overcome our biological limits is destructive of health care systems.”

why we talk about this
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

rationing medical care
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

core ethical principles a primer
Core Ethical Principles: a primer

• Beneficence

• Non-maleficence

• Justice

• Autonomy

beneficence
Beneficence

• Roots in the Hippocratic Oath

• Foster patient well-being

• Moral obligation to promote goodness

• Reduce pain and suffering

non maleficence
Non-maleficence

• Ethical obligation not to harm

• Embedded in the Hippocratic doctrine:

“primumnon nocere”

• More strict requirement than beneficence

justice
Justice

• Personal: respect and fairness

• Social justice (common good):

- access

- resource allocation

- dovetails with medical futility

autonomy
Autonomy

• Capacity • Substituted judgment

• Informed consent • Best interest argument

• Self-determination • Paternalism

• Surrogate decisions • Resuscitation status

positive and negative rights
Positive and Negative Rights

• “Negative” right: legitimate

-Chooseamong, 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

palliative care
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

dnr in the operating room
DNR in the Operating Room

Can a patient with an

active

DNR have surgery?

dnr in the or asa guidelines
DNR in the OR: ASA Guidelines

• Full resuscitation

• Limited resuscitation: procedure-directed

• Limited: goal-directed #1

(temporary & reversible events)

• Limited: goal-directed #2

(statement of patient desires)

Goal-directed approach:

Prioritize outcomes, not procedures

sociology and ethics
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

conclusion rationing
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