 An
86-year-old diabetic with serious complications shows
up with renal failure. Should you devote a precious dialysis
machine to his care? Or should you save those overstretched
resources for 'worthier,' younger patients?
These days it's impossible to get away from the gloomy
portents that say Canada's economy and healthcare system
are doomed to be crippled by our aging population. The
greying of the nation is a real issue -- in 2001 there
were 430,000 Canadians over 85; by 2041 there will be
1.6 million. A lot of the glumness feels like scaremongering,
and there's a danger that the alarmists are leading us
down an ethical garden path from which we won't easily
find our way back. There must be a just third way between
artificially (and grudgingly) extending the lives of frail
elderly and the unthinkable, refusing treatment, to preserve
health resources for future generations. Mustn't there?
Eminent medical ethicist Dr Nuala Kenny says, yes Virginia,
there is another way. Her new report, entitled What's
Fair? Ethical Decision-making in an Aging Society, released
in May by the Canadian Policy Research Networks and the
Change Foundation, tells us straight that our fear of
a grey planet is colouring the policy debate. Dr Kenny
stresses that we can't look at the issue as a generation
war.
GENERATION
GAME
The idea that successive generations are in competition
for our healthcare goodies has created the widespread
perception that the elderly are going to suck the system
dry. But Dr Kenny believes the real problem may be our
frame of reference. She proposes an "ethics of
care" which stresses the right to dignity for everyone,
not just the young. "Aging isn't something that
happens to only one generation," says Dr Kenny.
"And, in fact, our growing elderly population is
being scapegoated. As you delve deeper, you see that
the issues at stake apply to all generations of Canadians,
and that we need to formulate clear principles for thinking
about the idea of fairness."
Dr Kenny herself eschews the "generational equity"
concept that originated in American public policy in
the 1980s that sees generations as distinct and competitive.
She prefers "intergenerational equity," an
idea she says highlights the inextricable connections
between the generations, and so fosters solidarity between
them. In the report she specifically links economic
status, income, and health with personal dignity. "We
have the ludicrous circumstance of malnourished elderly
women living alone in poverty who, if admitted to hospital,
get all this expensive care," says Dr Kenny. "We
need to have a sense of how can we make judgments that
help identify the appropriate goals of medicine for
each age and stage in life."
SENSIBLE
NOT SENTIMENTAL
Both income support and healthcare are powered by the
public purse, and therefore require us to make choices
about who deserves what and how much. "There's
a reality here," Dr Kenny points out. "We
have to make choices. We can't have third heart transplants
or dialysis in 90-year-olds while we're rescuing 26-week-old
preemies, and not have cracks in the system. But these
questions have to be for all of us."
So how do we stop blaming the elderly for healthcare
costs, and focus instead on patterns of practice, prescribing,
and technology use in the system? Dr Kenny says doctors
are at the heart of the challenge. "Technology
has created some interesting tests for the doctor-patient
relationship, for medicine, and for the sustainability
of healthcare," she says. "We're the ones
who establish what the pattern of good practice is for
an 86-year-old in renal failure."
Dr Kenny also feels that there's increasing pressure
on physicians from patients' families to "do something,
do anything." "Many people now seem to believe
that if you get the right doctor in the right hospital
with the right equipment, you can fix something all
the time," she says. Dr Kenny observes that it's
difficult for doctors to say no in these circumstances,
and that accepting the limits of medicine isn't always
easy either. "A doctor's obligation is not to do
everything," she says. "It's to do no more
harm than predictable good. But we've lost sight of
that balancing act in our society. We need to acknowledge
the share of risks and benefits across the lifespan
while assuming, rightly, that the search for a fair
society is one that all generations share."
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