One of the earliest advocates was the bioethics pioneer Daniel Callahan, who has long advocated in books and journal articles for rationing based on age. He has another deeply pessimistic article out in the Journal of Law, Medicine, and Ethics, Spring 2012. After proclaiming he has been right all these years, Callahan gets to the point. First, he defines the term. From “Must We Ration Health Care for the Elderly?” (Yes, we must) Abstract only:
Rationing is a word that is open to many interpretations, too numerous to inventory here. I will simply stipulate what I mean by the term — consonant, I think, with common usage. Rationing is an organized effort by a public or private institutions (e.g., Medicare or a private insurer) to equitably limit the availability of some desired or needed medical treatments in the name of preserving the economic sustainability of the institution as a whole or equitably distributing a scarce resource.
Ah, the term “equitable.” We are to deny efficacious treatment based on an invidious personal characteristic–in this case, age. Hardly “equitable.” Back to Callahan:
First, rationing should be done by policy, not by individual doctors and patients at the bedside. There would otherwise be too much variation in decision making, discrepancies between doctor and patient values, and the possibility of physician bias. Rationing must, that is, be removed from the ordinary doctor-patient relationship and shifted to the policy level. Second, policy must be set by democratic process (which could be accomplished by Congress delegating responsibility to a federal agency). Third, the policy must be carried out in a transparent way. Fourth, there should always be a provision for appeal.
So, a member of the technocratic class wants fellow technocrats to impose these decisions via faceless and unaccountable federal bureacrats, which is hardly a “democratic” process. And as for appeals: Who is Callahan kidding? Appeals of federal bureaucratic decisions are interminable and are very rarely “equitable.” If you doubt me, just try appealing an adverse decision by the Veteran’s Administration as my family did without success. It. Took. Years.
Worse, Callahan supports the odious approach of the UK rationing board NICE and the QALY system it imposes on the people of the United Kingdom, a policy in which the young and able-bodied have greater value than others based on “quality of life” judgmentalism:
As for the substantive content of rationing decisions, I am most drawn to the British National Institute for Clinical Excellence (NICE)…One of the main (though not exclusive) economic tools it employs is that of Quality-Adjusted Life Years (QALYs), a way of relating the estimated extended life years a technology will bring in relationship to the quality of life it will bring. It is a leading means of assessing the cost effectiveness of a treatment. Its use requires careful evidence-based research, which in the U.S. could be provided by a federal agency. Instead of contending as I did in my book that an age would have to be specified for setting limits, I would now use QALYs to determine (but not solely) what they would be, thus using a methodological tool applicable to all age groups.
In other words, with Obamacare, we would spread quality of life rationing beyond Medicare to the general population. And that would target the ill and people with disabilities for having less value than the healthy and able-bodied.
Callahan says that his is a “common good” approach. But in practice, it would really be one in which the politically powerful benefited at the expense of the weak. Bottom line: Discrimination is wrong. And that is what rationing based on invidious criteria is all about.