As the basis of a midterm paper for an undergraduate reproductive ethics course, I examined the extent to which old people should be categorized as a fundamentally different species than young people. Of course, my decision to even consider this audacious perspective about any humans was subsequently misunderstood by my professors, and the paper was not well-received*.
Yet my attempt at geriatric speciation was not submitted as a syllogism about evolutionary biology. Instead, I was was trying to forge a philosophical shelter from the violent tempest that is the “right to life” debate regarding difficult-to-make end-of-life decisions, which I hoped would provide a defensible and moral approach for drafting humane end-of-life policies.
The “right to life” for all humans is a maxim commonly invoked by doctors and health care proponents as the essential grounds for why doctors ought to stop at no costs to save any human life. While preserving one’s right to life at any cost is certainly a noble duty in principle, I felt — and still feel — that there are some end-of-life cases for which “stopping at no costs” causes more harm than good for patients and their families. In speciating between the old and the young, I hoped to simplify things by elucidating a loophole in the right to life concept that permits doctors to allow their patients to die peacefully.
The loophole was a simple concept: the right to life applies only to personhood, rather than the more general phase of humanhood through which all persons pass. If I could demonstrate that older humans have lost their personhood, I would settle the paradox of what to do if one day medical technology is able to limitlessly prolong one’s humanood. I hoped the distinction would provide a “way out” for doctors making these difficult decisions who truly believe, as I do, in a person’s right to life. At the time, I wrote:
If—hypothetically—people near-death are not members of our species, our decision-making about their medical treatment should not be fettered to the right-to-life precept that, for non-criminal humans, is generally considered to be a categorical natural right that all people share.
At the time of composing this contentious paper, I was working as an EMT for an ambulance company that specialized in geriatric transport in the San Gabriel Valley region of eastern Los Angeles County. For those of you who think of ambulance service in terms of sirens and flashing lights — “Code 3” transport — you should take note most ambulance rides are not so gaudy. For every time you actually see or hear an ambulance with lights and sirens rushing to a hospital, there are many more instances of non-emergency transports for which the patient is sick enough that she requires professional medical assistance in getting from point a to point b, but her condition does not justify Code 3 emergency transport1.
Over the past decade, Medicare reimbursement for ambulance services has increased from ~ $600 million to over $2 billion.
No one likes putting a cost on a human life. Yet knowing these figures about ambulatory spending in the final moments of life, I felt strongly that there was precedence to argue that the money would be better allocated if it were instead used to help people who are further away from their impending passing. This assertion was supported by recent evidence suggesting that the quality of end-of-life care isn’t necessarily proportional to the cost.
In other words, no one wants to set limits on how much money can be spent near the end of one’s life, but perhaps that attitude would change if it were widely understood that there is a diminishing efficacy of that spending once it exceeds a certain amount. Unfortunately for those who advocate end-of-life spending limits, thus far it has been difficult to guarantee that cutting end-of-life spending will not have downstream consequences. One study actually set out to prove the inefficiency of inpatient spending, yet found that a 10 percent increase in inpatient spending corresponded with a decrease of somewhere between 3 and 11 percent of mortality in that month, concluding that perhaps health spending is not as inefficient as is colloquially believed.
So is an extra month or two of life worth all that extra spending? The relationship between aging and healthcare financing is a fascinating and complicated ethical dilemma that has foiled many bioethicists over the years, some of whose theories for solving the problem are even more contentious than my udergraduate paper on the subject. President Obama’s bioethics advisor Ezekiel Emanuel gained his fair share of notoriety for his controversial stance that healthcare spending ought to prioritize young people. His critics have irately charged him and the Obama administration with favoring “death panels” to decide when people ought to die.
Emanuel counters that this approach would solve many of the major issues in healthcare because more patients could be reached if our spending was focused on acute injuries and averting chronic disease rather than expensively and briefly delaying the inevitable near the end of life. Furthermore, Emanuel argued that shifting the spending equilibrium towards the young was equitable, since everyone is young at some point in their life, and therefore everyone would pass through the phase in which they are entitled to priority care.
Emanuel is basically saying that we need to perform an economic triage of healthcare resources. In many ways, I agree with him. However, there is also a very viable, alternative position that is much more consistent with an intuitive sense of right and wrong: spending should be allocated on an “as-needed” basis. Weighing between Emanuel’s model and the alternative because a central moral challenge for me as a young EMT, and I will spend the rest of this essay describing it.
One of my favorite running gags in Mad Magazine is a comic strip called Spy Vs. Spy. In it, two incredibly resourceful, albeit pragmatically inept, spies battle one-another with great fury over some unknown, assumably petty squabble. Each spy engages in increasingly sophisticated measures to defeat his opponent, and of course, they both usually end up exploding by some fantastic Rube Goldberg plot gone awry in the final panel. In a sense, the punchline of each strip is the pointlessness of their aggressive conflict. To the reader, all spies are created equally, so why can’t they just… get along?
When it comes to formalizing ethical arguments, sometimes it feels a bit like philosopher vs. philosopher. The nuance between the arguments is easy to miss, the result begetting a sense of “what’s the difference?” to those studying ethics for the first time. We certainly have a case of philosopher vs. philosopher for the two opposing positions about end-of-life ethics that distressed me as a young EMT. In fact, it isn’t just philosopher vs philosopher, but an ever more esoteric, bitter clash between two camps within philosophy’s subdivision of normative ethics: consequentialist vs. consequentialist.
To contextualize this “consequentialist” division of ethics, it is important to understand that all consequentialists believe that the consequences of one’s actions are the ultimate basis for judgement about the rightness of those actions themselves. The broad category of consequentialism is usually mentioned in contrast with a different model for normative ethics — the study of what we ought to do* — called deontological ethics, which posit that one’s actions themselves are the basis for moral judgement, regardless of the outcome of those actions. In other words, if you’re the type who thinks that the ‘ends justify the means,’ you probably have consequentialist sympathies. But if you tend to believe that what is ‘right’ and ‘wrong’ is dictated by the Law, or even that simply ‘trying your hardest’ is good enough**, then you’ll probably favor deontological ethical arguments***.
The first consequentialist, Mr. Emanuel, is a classical consequentialist utilitarian. Utilitarianism is one of the most well-known and controversial applications of consequentialist ethics. It posits that the best course of action is the one that maximizes utility by maximizing desirable outcomes such as happiness and profit and minimizing undesirable outcomes, such as suffering. Sounds good enough, right? Utilitarianism’s critics argue that there is no nuance in the model and no emphasis on the individual. To minimize suffering is not to eliminate it: utilitarianism treats utility as the paramount value, and seeks to maximize it by any means necessary, even if it means permitting a certain degree of suffering in exchange for greater overall utility. For example, a utilitarian might argue that if you are rescuing people from a burning building, even if you have the means and ability to save the first person you find who is in cardiac arrest, you have an obligation to let that person die in order to save a greater number of people with easier wounds to treat*. There are many people who are uncomfortable with the idea of simply letting a person die, and that sentiment is a common opposition to utilitarianism.
Consequentialist number two subscribes to a lesser-known, yet more intuitive, variant of consequentialism called prioritarianism. Like utilitarianism, prioritarian ethics seek to maximize overall well-being, rather than individual well-being. However, prioritarinism differs in that it weighs worse-off individuals more heavily in its moral calculus than well-off individuals. I believe this is how many people who think of themselves as consequentialists intuitively operate. Prioritarianism is essentially the Democrats’ reasoning behind taxing rich people at a higher rate than poor people. They believe that equity in our society is achieved when everyone pays their fair share, and prioritarianism ensures that fairness is truly fungible between all parties by permitting those with less money to pay less.
In the case of end-of-life decision making, from a prioritarian perspective, medical resources are more valuable to those who are relatively impoverished of health than to those who enjoy a relative affluence it. Thus, the sick are more deserving of available surpluses of medical resources than the healthy2. If one embraces a prioritarian ethical position on health resources, the consequence is that old people, who tend to be less healthy than young people, ought to receive a good portion of the available health resources.
So which model should we pick? All that stuff I mentioned about excessive health care costs at the end of life is still true, but the prioritarian model is a whole lot less messy, because it really takes the decision out of decision-making at the end of life, since it permits a great deal of end-of-life spending. Either choice seems like a compromise that leaves us no better off! Is there any consistent moral paradigm that can help us balance our budget near the end-of-life without interfering with human dignity and natural rights?
“Personhood” is a phase of humanhood during which humans are entitled to the right to life and all other natural rights.
The problem was that at the end of the day, the distinctions were incredibly arbitrary. And while I was able to score points in class by citing the opinions of well-known bioethicists, in the real, political world of policy making, I do not think that any of the arguments were convincing enough to inspire universal acceptance of the theory. These days, I am doubtful that as a society we will ever reach a point where we can agree on an ethical model of this scale of audacity for end-of-life decision making. However, this concession about the inherent flaws in my ethical model is not to say that I am cynical about the overall potential for improvements in the process of end-of-life decisions making.
Over the years, I have heard several iterations of what I describe as the “Promethean critique” of medicine: many people express a great deal of discomfort with modern medicine’s implicit attempt to permit humans to live forever. Consider, for example, quintessential utilitarian philosopher pro tempore Peter Singer’s thought example of a radically life-extending drug that would actually fail to maximise overall human happiness compared to a placebo, i.e, a “normal” lifespan. I have to admit, the guy raises a good point. Sometimes it seems as if simply being an aging human is becoming a disease in developed societies. So given the medical developments over the past 20 years, Ray Kurzweil’s infamous fantastic voyage for immortality and disheartening news stories like the Terri Schiavo case, I cannot bring myself to blame anyone for developing a cynical attitude about the audaciously overextended practice of modern medicine.
Indeed, I have made the Promethean critique of medicine myself. One of my most stirring memories from my days as an EMT is a time when a bed-ridden 105-year-old woman pulled me close and whispered in my ear, “life or death, what’s the point?” during an emergency transport. The rhetorical implication to her question, that for her, there wasn’t a point any longer, haunted me, and evoked doubt about whether my work in modern medicine would be the service to humanity that I idealized or a futile effort to avert the inevitable that would make Heinrich Faust snicker.
It’s true that the quest to live forever is at best icky and at worst depraved. And so the Promethean critique of medicine, or some varient of it, has become a pervasive argument not just among utilitarian consequentialists looking to cut costs at the end of life, but among many people who are increasingly critical of the general practice of modern medicine. Although my experiences as an EMT fomented a deep sympathy for the heart of this argument, I bring it up here because on its own legs, the Promethean critique is not a reasonable justification for why modern medicine ought to draw in the reins on end-of-life treatments and enact an arbitrary limit on the human lifespan.
Most people confront the intimate reality that everyone dies eventually on a daily basis; it is not uniquely the place of a physician to resolve this strange paradox and reveal the meaning of life to the rest of us. The Promethean critique falsly suggests that it is the medical establishment’s responsibility to come to a consensus about how much fire we ought to steal, when in truth we are simply the humble chariot drivers; at best, we can only tell you when it’s getting too hot. The point here is that it is not — and should never be — the core role of doctors to determine how hard we should try to avoid death. I submit that it is uniquely the core role of a doctor of moderm medicine to internalize a deep appreciation for the human value of opportunity, in this case, the opportunity to live longer.
Doesn’t our knowledge of death make life more precious? - Don Delillo
In Don DeLillo’s meditation on the fear of death, White Noise, he poses the question, “Doesn’t our knowledge of death make life more precious?” I believe that the key assumption of modern medicine is that for many people, regardless of age, it does. Just as warm water becomes hot after you place your hand in something much colder, for many people, the imminent plausibility of death makes life, even a dull or painful life, seem that much more precious. In other words, modern medicine operates under the assumption that for many people, there is a point to the struggle. And the key feature of modern medicine that makes it such a unique discipline is that is can offer patients the opportunity to participate in that struggle with degrees of success unimaginable to even our most recent ancestors.
The point is that one does not need to understand the meaning of life to appreciate the desire to avoid death and suffering. The old lady who whispered to me her indifference for continuing to fight for life might be ready to end her struggle now, but is it fair to assume that everyone in her situation would feel the same way? Human lifespans have nearly doubled over the past 500 years, during which time the very definition of what it means to even be a human has fundamentally changed. To posit that there is a ‘natural’ span of a human‘s life that ought to inform our end-of-life decisions seems rather ludicrous. To frame my position a bit differently: it seems ludicrous that we would consider crippling the efficacy of all of our chariots simply because some people will choose to use them in such a way that they burn themselves*.
In effect, I wrote this essay to say that I was wrong about my previous assumptions about allocating scare medical resources. Those of us who love debating philosophy are tempted to find or develop some moral “law” to help guide our decisions about these topics. Unfortunately, we have not observed enough data about the way that human life ends in the 21st century to make a strong, useful claim about this subject.
Perhaps the conclusion of consequentialist vs. consequentialist bout that I described earlier shouldn’t be all that different from the way Spy vs. Spy always ended in Mad Magazine: neither consequentialist wins. The problem is that it was a moot fight from the get go. Both brands of consequentialism imply that we have access to knowledge about how categories of end-of-life treatment decisions will affect terminal and non-terminal patients and their families. They shift the treatment focus to the type of decisions we ought to be making to improve the overall human condition in some way, rather than focusing on the unique needs and concerns of the patient and her family. This shift in focus presents several problems. The most severe is that it takes the empericism out of medicine. We do not presently have the luxury to know, categorically, what the outcome of any particular disease will be. The job of a doctor is to use her judgement as best possible to determine a good treatment decision. If we choose to adopt a consequentialistic ethical paradigm for end-of-life decision making, we would be incorrectly positing that the medical community has a useful understanding of what the best outcomes would be.
Yet I am not back at square one entirely with my hope for dramatic improvements in end-of-life decision making. The measure of our success in improving end-of-life outcomes does not need to be measured by the soundness of an argument for one policy or another. I believe that through narrative awareness of the challenges of end-of-life policy, as humans, we will begin to find a way to balance our desire to live longer with the resources avalible to us and their costs. Narrative is the key word here, because it respects both the individuality and the community considerations that must be balanced in all medical decisions. A narrative is personal, with an undefined resolution, yet it also invites others to participate in discovering that resolution. My best friend from high school, Ben Tuller, made a beautiful documentary recently about the families struggling with end-of-life decisions for their children at a children’s hospice. This work is a perfect example of how narrative is the right way for us to move foward with understanding end-of-life policy.
Any good doctor will concede that nature is not exact, and it’s important to remember that modern medicine rarely offers and guarantees for its outcomes. Yet through research and discovery, physicians have and will continue to develop strategies to reduce harm ever lower. How is anyone’s guess, and I beleive doctors need to reserve the right to be the first to discover how they can flourish the opportunity to live a healthy life. Perhaps grandma really is a different species than her grandchildren, but for the time being I’ll leave it up to her family and her doctors to decide what that means for her end-of-life care.
Footnotes
Published on September 26, 2010 in Medicine
David Lempert.