Thursday, July 2, 2009

ObamaCare and the Elderly: Beware

Healthcare Reform: Will Obama Let You Into His Lifeboat?

By Victor Morawski

The term “lifeboat ethics” is used to describe ethical issues that arise in situations involving the allocation of limited resources. It originally came out of a landmark 1974 article by philosopher Garrett Harden in connection with ethical questions surrounding the issue of providing food aid to underdeveloped nations.

He pictured wealthier nations as being like so many lifeboats---all with limited capacity, of course---afloat in a sea surrounded by many swimmers who need saving: the residents of poorer nations. His discussion there concerned the ethical guidelines that ought to govern who, if anyone, should be picked up and saved by those in the lifeboats.

The picture of the lifeboat is, quite obviously, an analogy. And from a logician’s perspective, an analogy is a tool used in a particular type of argument. If I am using an analogy to convince you of something, then I am arguing that two things, A and B, are alike in certain important respects, hence they should be seen as being alike in at least one more relevant respect: that which represents the conclusion of my argument. As a logical tool, an analogy works where it works. Its applicability is not necessarily tied down to only one situation or ethical position.

The lifeboat analogy has surfaced in several ways in the Health Care community and is relevant to the current debate over Health Care Reform. Here we are also dealing with the allocation of limited resources.

Perhaps the most legitimate use of this analogy in health care situations concerns triage decisions in disasters, both natural and man-made [what used to be called “Terrorist Incidents”]: “During overwhelming disasters, health systems must be considered lifeboats with insufficient capacity to minister to all, and thus decisions regarding who is best served by the lifeboat must be made.”

These “high-consequence event” situations have something in common with the original analogy that is so obvious it may easily be overlooked. The lifeboats and the individual swimmers are in the water because a disaster has just occurred; a ship has slipped beneath the waves. Sometimes I think that using lifeboat ethics type cases as if they should furnish us with generally applicable moral guidelines is a little like bringing up the experience of the Donner Party to introduce a discussion about whether cannibalism should be seen to be more acceptable morally than is generally recognized.

Lifeboat ethics cases do not provide us with examples for general moral guidance but instead present situations that are so extreme that they force us to raise questions about whether, in them, some generally accepted moral guidelines and ordinary standards of professional ethics may justifiably be suspended. Indeed, the Homeland Security study mentioned above recognizes this:

“The threshold for what constitutes life-sustaining care could also be lowered if staff degradation and or physical plant damage prevent the delivery of advanced acute and critical care therapies. Depending on the scope, magnitude, and duration of the disaster, sufficiency of care could mean little more than providing intravenous fluids or ventilator-assisted breathing.”

The translation of the above is that under the extreme circumstances it finds itself in, the staff will just have to do the best it can with what resources it has and cannot morally or reasonable be expected to do much more.

But not everyone agrees with my view that Lifeboat Ethics cases are best used to discuss exceptions to general moral guidelines rather than to set the guidelines themselves. And since Obama has insisted on many occasions in the past, especially when running in the primaries against Hillary Clinton, that it is his health care plan we are considering when we discuss the plan soon to be presented to Congress, it is I think reasonable to now ask relative to some important situations, whether Obama would let you into his lifeboat.

Situation One: Are you over 70 years old? If so, then you have real reason to worry about whether he will let you in. Developers of his plan understand that the bulk of the nation’s health care resources are used by senior citizens and they are looking for ways to ration care to the elderly.

In our last article we looked at an argument they favor which would ration care to the elderly and terminally ill based on a Cost-Benefit Analysis. Another plan now being seriously considered here and in Great Britain is to set an arbitrary age cap on receiving health benefits. This hearkens back to an idea originally espoused as far back as 1987 by Daniel Callahan, that humans have an average expected life span (figures of 70 yrs. to 85 yrs. have been mentioned in discussions of this point) and persons who have lived up to this age have no right to expect that we extend them medical care beyond it.

In other words, we are not here talking about a situation where, for example, if two patients, a 75 year old and a 25 year old were competing for the same donated liver, then the relative age of the patients would be one factor health care workers could take into account when making the decision as to who gets the organ. This proposed policy would instead use age alone as the sole criterion for denial of care. And it would not be health care workers but government who would exclude the 75 year old by setting a standard which would deny him/her from receiving health benefits on the basis of age alone!

A point made in these discussions is that such a person has put in enough innings in the game of life and its time to pull them out of the game and put another younger person in, whether they want to come out or not. They will thus not be brought on board the lifeboat of health care.

Situation Two: Are you ill as the result of a lifestyle choice? For example, have you been a heavy smoker or drinker and now things have caught up with you? You should have serious worries about whether Obama will let you into his lifeboat, even if you are not now at an advanced age. Hershel Elliot, an ardent supporter of Harden’s work, succinctly summarized its relevance to healthcare rationing by lifestyle in a 2003 article when he said, “You are unlikely to learn to take care of your health, if you are free to abuse your body by overeating, lack of exercise, and dangerous behavior while society must pay the costs of restoring your health. When individuals are free to damage their own health and society has to pay the costs of curing them, medical costs can spiral out of control.”

Of course, his conclusion is that since these individuals’ health situations came about as a result of their own behavior arising from their lifestyle choices, then society has no moral responsibility to bring them aboard the lifeboat of healthcare and is justified in leaving them alone in the water to suffer the consequences of their choices. Not only will care be rationed on the basis of lifestyle choices in the proposed Obama plan, but government bureaucrats will use the threat of denial of care as the basis for meddlesome intervention into people’s private lifestyle choices. If the government is picking up the bill, either in whole or in part, then these choices are not private anymore!

Curiously, the one application of Garrett Harden’s Lifeboat analogy that his followers judiciously choose to leave out when they apply his views to healthcare, but which might be the most relevant, is the one he himself made in his original article in connection with our moral obligation to supply food aid to poor nations. And that point, which is just as applicable to healthcare, is that Marxist-inspired, redistributionist ethics won’t work. If we apply the Marxist principle of “to each according to his needs” and bring 100 additional needy swimmers out of the water into a nearly full lifeboat that only holds 60, then the lifeboat sinks and everyone loses out.

And sadly, this could be the impact of the Obama, socialist-inspired, universal healthcare plan: it will either sink the US healthcare system lifeboat or drain the economy that keeps it afloat.

Victor Morawski teaches philosophy at Coppin State University. His column, "The Philosopher's Stone," is distributed nationally free of charge by the Liberty Features Syndicate. Should you wish to subscribe, contact Alex Rosenwald at


undertaker said...

The lifeboat analogy is appropriate for Mr. Soetoro. He just happens to be the smiling iceberg that has struck the hull of the Republic.

Anonymous said...

The American military jumps around the world backing american corporation dominance in the so called free world, and yet those corporations don't pay any extra taxes for those benifits. Health care is not this big socialist twist in american polotics.Health care education, and retirement in this so call wealthy great nation of ours should be a priority I feel like a 16th centuary peasent trying to explain common sense to a right wing ditto head. The money is there its all in the tax stucture

Bitmap said...

Using lifestyle as a justification for rationing is scary. Especially when the government will decide what lifestyles will not be covered.

If the government wants to push people towards driving little tin can cars then they will publish a study that shows driving pickups and SUVs is dangerous because they flip over too easily, so if you drive a pickup or SUV you won't be covered. There was a fanciful study that showed owning firearms was dangerous to the owner so if you own firearms you won't be covered. Of course there would be exceptions to these rules for qualified government professionals and elected officials.

One thing about socialized medicine: when you have to pay for my health insurance then my lifestyle becomes your business.

Do we really want to go there?

Anonymous said...