Abstract
“If something is exceptionally well done, it has embedded in its very existence the aim of lifting the common denominator rather than catering to it.”
One of the most stressful aspects of medical care today, in spite of our inexorable progress in developing better medicine for all types of ailments, is the allocation of a total budget of medical resources that is vastly insufficient to satisfy demand. Those of us working in academia as grant reviewers or grant administrators are constantly faced with this sort of problem in the allocation of research funds to worthy projects. If we are tempted to feel sorry for ourselves in that context, an easy and effective remedy is to remind ourselves how much worse it is when lives, rather than merely livelihoods, are at stake.
How are such decisions made? Many factors come into play, of course. But the predominant one is simple utilitarianism: Patients are prioritized on the basis of potential benefit enjoyed per dollar spent. In particular, one must be sick enough that one will not anyway recover without treatment, but not sick enough that one will rapidly die even with the treatment.
This ostensibly simple concept has an interesting complication when we consider the role of age of the prospective patient in such decisions. The complication can be expressed in just one word: Co-morbidity. The elderly tend to have more than one thing wrong with them–and if not, they will soon. This means that if two people of differing age are afflicted roughly equally in severity with the same disease, the older person is likely to benefit less from being cured, because unrelated and unresolvable medical issues will arise sooner in that person than in the younger one. In other words, other things being equal, the utilitarian position dictates that the young should be prioritized over the old in the allocation of medical care.
There is a competing ethical principle, however—that of egalitarianism. In just the same way that (for example) we feel proud to be able to provide the physically disabled with a built environment that they can get around in, there is a clear consensus in contemporary Western society against ageism, and in favor of the position that “old people are people too.” This implies that we should discount age when allocating medical resources. But in practice, utilitarianism currently trumps egalitarianism in this regard. Whether that makes ethical sense is debatable, but it is what our society has ordained. In particular, it is reinforced by the fact that the overwhelming majority of the elderly agree with it, even though they are the “victims” of the policy.
This brings me to today's main point. What does utilitarianism mean for our priorities concerning not today's therapies, but today's efforts to develop tomorrow's therapies? I argue that the prevailing answer to that question, especially from gerontologists, is based on a profound logical error.
That answer, of course, is that we should be seeking compression of morbidity. The idea here is that the ideal life is one with a nicely long healthy component followed by as short a period as possible of ill health prior to death. But there's another aspect to the compression-of-morbidity mantra: That “nicely long” should not mean unnaturally long, but only within the normal range. In other words, there is an inherent assumption that the longer one has lived, however healthy one still is, the less entitlement one has to therapies to extend that healthy life even further.
I hope it is obvious that this does not necessarily follow from the utilitarian principle. The only way it could follow would be if one postulated that those who have lived a long time are inherently less able to derive joy from future life than those who are younger—a decidedly controversial position.
But what is more interesting is why such a simple mistake is so common. It could be because people are inherently ageist after all, feeling that there is a “fairness” aspect to entitlement at play here, whereby the young deserve more future life because they have not enjoyed so much past life. But I think the predominant reason is a different one, and a more insidious one. It comes back to co-morbidity. Most people simply dismiss, even if asked to entertain it purely for sake of argument, the idea that a healthy person's remaining time before ill health could be uncoupled, by future medical advances, from their chronological age—in other words, that aging could be brought under decisive medical control. This leads to the inference that extension of healthy longevity becomes increasingly impossible as the patient gets older, and thus that utilitarianism favors caring for the young even in the absence of any existing health deficits on the part of the elderly.
What is even worse is the belief that this is OK because staying healthy longer means being sick for less time. That may currently be true in some circumstances, but it too is completely unclear in respect of medicine of the future. Indeed, even today it seems to be increasingly untrue, because of the epidemic of Alzheimer disease that has resulted from our greater progress in postponing major killers that generally kill people more quickly (particularly cardiovascular disease) than Alzheimer does. People are certainly staying healthy to an older age than they did 50 years ago, but the average period of ill health at the end of life is not appreciably shorter by any measure and by some measures has increased.
In closing, let me put my point in another way. The disconnect that I am highlighting here is between choices and goals. In today's world, there is indisputably a trade-off between quality and quantity of life, because so many things that people enjoy are prone to hasten their ill-health. But in terms of research priorities, that is irrelevant. Rather, what should guide us is the effect that quality of life (which, for present purposes, we can define as synonymous with health status) has on the value of future life and thus on the importance of quantity of future life. And it is clear that that effect is positive, not negative! Put simply: The healthier a person is and could potentially remain, the more we should work to realize that potential. In terms of goals, quality does not oppose quantity: On the contrary, they are two sides of the same coin.