Author Harry Moody's book, Ethics in an Aging Society, contends that two major trends have brought the nation to a crossroads: 1) advances in medical technology are forcing bio-ethical issues; 2) unprecedented numbers of elderly people are affected by and dependent upon governmental social and economic policies.1
Intimately woven into this discussion are two basic principles that Americans hold near and dear to their hearts; autonomy (the basic freedom to make one's own choice), and justice (fairness to individuals and between generations). Americans define themselves by their freedoms. No where has this core value of freedom been more strongly asserted than today in the U.S. Americans perceive themselves as fair (individually), and just (as a nation), though this "justness" relies heavily on "freedom" to decide what is fair.
The Supreme Court hearing arguments about "right to die" issues is kind of a silly exercise, given that we are all going to die. The issue is not really about right to die so much as whether those who are terminally ill and mentally competent should have the right to choose the timing and method of death with the aid of a physician.
"Once in a generation, the Supreme Court issues a ruling that rearranges the nation's social and legal landscape."2 The cases heard in favor of or against this freedom of choice tear at the very heart of the autonomy of the individual. Those in favor of the right to die feel they should have the freedom to choose this last act; those against it are fearful of others overruling their choice to live, perhaps because they are too poor, or it is too expensive to care for them.
So, the disagreement stems not so much from the choice aspect as the consequences of that choice. Is this discussion about choice or about rationing of health care? This is a valid concern. In 1983, Alan Greenspan of the U.S. Federal Reserve Board made a statement that 30% of all Medicare funds were annually expended on 5-6% of the Medicare insurees who died within a year. Further, since our 65 and older population comprises about 12.5% of our population, we are talking about 5-6% of the 12.5%, indeed a very small portion of the population for such a large expenditure of health care dollars.3 To be clear, besides covering people 65 and over, Medicare also covers persons who are spouses of Medicare recipients, certain disabled individuals, disabled working individuals and individuals with permanent kidney failure. While not everyone covered by Medicare is over 65,4 a rational individual has to question the use of so many health care dollars being spent so disproportionately.
Statistics have repeatedly shown that young children are among the poorest groups in America today. While most of us would argue we are compassionate about the individual plight of frail, older Americans, most must admit honestly what really gets our attention is Alan Greenspan talking about the effects on our pocketbooks.
Should we revisit our basic presumptions about autonomy and justice? What are the ramifications of advances in medical technology; massive population aging; conditions that render humans mentally incompetent; and inequities in health care quality and availability, based in the context of social status and economics? Does the concept of autonomy apply equally to each of our nation's members? Does the ideal of "justice" nullify compassion? Whatever we do, let's not stop talking to each other. For in our willingness to communicate our feelings we are open to possibilities for solutions.
Author's note: The next two articles will deal with the specific subjects of advance directives and the chiropractor's role in end- of-life decision-making. Personally, and as health care providers, chiropractors will be faced with choices on these and other concerns of an aging population. I invite your questions and comments in letters to the editor, or to my e-mail address:
References
- Moody HR. Ethics in an Aging Society: Old Answers, New Questions, (p. 1). Baltimore: The Johns Hopkins University Press, 1993.
- Mauro T. Is there a right to die? USA Today, Jan. 7, 97;pp. A1-2.
- Binstock RH. Old age and the rationing of health care. In: RH Binstock and SG Post (Eds.), Too Old for Health Care. (pp. 4,5). Baltimore: The Johns Hopkins University Press, 1991.
- Events that can end your Medicare protection. Your Medicare Handbook 1995. (DHHS Publication No. HCFA 10050). Baltimore: U.S. Government Printing Office.
Barbara Zapotocky, DC, MA
Honolulu, Hawaii
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