Shades of Gray

In just two years, the first of the 78 million baby boomers will turn sixty-five, and the long-anticipated graying of America will begin in earnest. By 2030, the number of Americans over sixty-five will double from the current 35 million to a stunning 71.5 million, or 20 percent of the population. While the proportion of people older than sixty-five is expected to peak in 2030, the so-called oldest old will continue to grow in number: those aged eighty-five and older will climb from the current 5.3 million to 21 million in 2050. It is this group that presents the greatest challenges because over half are significantly limited in their basic functioning (bathing, dressing, or walking, for example), and about one-third have cognitive impairment. Figuring out how best to respond to our oldest citizens is a political, financial, medical, and ethical problem.

The ethical issues were first comprehensively laid out by Daniel Callahan in his much-maligned but critically important 1987 book, Setting Limits: Medical Goals in An Aging Society. Callahan begins by asking how we should regard aging and death. Should we accept human finitude and accordingly seek ways of enhancing quality in life's last phase, or should we continually seek to prolong life? Callahan comes down on the side of accepting aging as part of the human condition. His endorsement of age-based restrictions on life-prolonging technology rests on his belief that we have to come to terms with aging.

Mortality is of course nothing new, nor is the quest for immortality. What has changed is the proportion of people surviving to old age and the technical possibility of extending average life expectancy (and possibly maximum life expectancy). But whether we should strive to further expand the limits of human existence or not, we have an obligation to figure out how best to care for those who are physically or cognitively frail. Just what that responsibility entails, and whether it falls on families or government or a combination of both, is the next major ethical issue confronting an aging society. The answer to this question is intimately linked to people's views of aging and death. Patients and families may be more likely to seek extreme life-prolonging measures if they are not reconciled to the inevitability of death.

Defining the appropriate care of patients near the end of life is also closely linked to the third major ethical dilemma discussed by Callahan—the just allocation of scarce resources. Regardless of whether it is ever appropriate to utilize invasive and marginally effective treatment in older people near the end of life, inflicting pain and suffering on a person close to death becomes harder to justify when the treatment is also expensive. Arguably, the central ethical issue arising in an aging society is how to balance the demands of older people for medical care against competing demands by other segments of society. Devoting increasing amounts of money and effort to the medical care of older people comes at a price. Combined federal spending on Medicare and Medic-aid is already 4.6 percent of the gross domestic product and, according to Congressional Budget Office projections, is expected to soar to 20 percent in 2050. At the current rate, just about half of every tax dollar will go to funding these two programs by midcentury. Outlays for Medicare (the major payer for medical care for older people and the main source of the increased costs) and Medicaid (the major payer for nursing home care) will drive out support for education, roads, and national security. We are already choosing to spend our health care dollars on the elderly at the expense of the young: a ninety-year-old with advanced dementia who cannot walk, speak, or recognize her family will have her stay in the intensive care unit paid for by Medicare when she develops pneumonia and respiratory failure, but according to the Institute of Medicine, eighteen thousand people will die each year from preventable diseases because they had no health insurance.

Over the last twenty years, discussion of the ethical issues engendered by...