The Corner

Health Care

Pushing ‘Healthspan’ Duty to Die for the Elderly?

The bioethicist and Obamacare architect, Ezekiel Emanuel, made headlines — and raised hackles — when he argued a few years ago that 75 is the right age to die, or at least, to stop fighting medically to extend life.

Now in “From Lifespan to Healthspan,” published by The Journal of the American Medical Association (JAMA), University of Illinois professor S. Jay Olshansky argues that it is time to shift medicine’s focus — starting at age 65 — away from “life extension” to maintaining quality of life or years of healthy living, which he calls “healthspan”:

With death inevitable, the modern attempt to counteract aging-related diseases reveals a phenomenon known as competing risks. When the risk of death from a disease decreases, the risk of death from other diseases increases or becomes more apparent. . . . For example, finding a cure for cancer may cause an unintended increase in the prevalence of Alzheimer disease.

The inescapable conclusion from these observations is that life extension should no longer be the primary goal of medicine when applied to people older than 65 years of age. The principal outcome and most important metric of success should be the extension of healthspan.

It is one thing if a patient decides to make healthspan the primary focus of his or her medical care. But it would be quite another for the system to require that approach through rationing laws, insurance-coverage guidelines, or ethical directives to doctors.

Indeed, lurking ominously between the lines of these discussions is a bioethical concept known as the “duty to die.” Proposed most (in)famously by bioethicist John Hardwig in 1997 in the Hastings Center Report — the world’s most prestigious bioethics journal — the duty to die seeks to prevent people who have lived complete lives from becoming burdens on themselves, their families, and society. From, “Is There a Duty to Die?

1) A duty to die is more likely when continuing to live will impose significant burdens — emotional burdens, extensive caregiving, destruction of life plans, and, yes, financial hardship — on your family and loved ones. This is the fundamental insight underlying a duty to die.

2) A duty to die becomes greater as you grow older. As we age, we will be giving up less by giving up our lives, if only because we will sacrifice fewer remaining years of life and a smaller portion of our life plans . . . To have reached the age of, say, seventy-five or eighty years without being ready to die is itself a moral failing, the sign of a life out of touch with life’s basic realities.

3) A duty to die is more likely when you have already lived a full and rich life. You have already had a full share of the good things life offers.

Most bioethicists who denigrate the equal importance of the lives of the elderly and/or who promote age-based health-care-rationing schemes are not as explicit or impolitic in their advocacy as Hardwig. But changing the “primary goal of medicine” to “healthspan” — if involuntary or based on policy — would come perilously close to justifying that same utilitarian end.

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