The Elderly

Legal and Ethical Issues in Healthcare Policy

Martin Lyon Levine, Martin Lyon Levine

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351890861
• Edition: 1
• Topic: Medicina
• Subtopic: Ética en medicina

Aging is a public health priority that is becoming increasingly important in both developed and less developed nations, with individual health care providers and law-makers each facing difficult ethical and policy dilemmas. The complex issues physicians deal with include informed consent and patient decision-making capacity, use of advance care planning and decision-making by family and medical staff, and withdrawing and withholding life-sustaining interventions. Broader questions include: has aging been over medicalized? Is it ethical for older patients to receive less medical care than younger ones, through unspoken practice or formal rationing? Is there inevitable conflict between the generations over scarce medical resources? How should physician, patient and family confront end-of-life decisions? How have different nations responded to increasing numbers of the elderly? Have social values changed as to family responsibility and individual autonomy? This volume brings together the most significant published essays in the field.

Part I

Healthcare in an Aging Society

The Demographic Context

[1]

Making Aging a Public Health Priority

Robert Kane

It is high time that public health took a serious interest in the problems of aging. That this issue of the Journal focuses on aging is an acknowledgment of this subject’s timeliness. The topics in this issue reflect a range of public health concerns about older persons. Many of the articles address how aging and the treatment of diseases affect the functioning of older persons. As with other public health activities, efforts are being directed toward prevention and improved treatment, and toward assessing the effects of that care in terms of both health status and expenditures.

Whereas public health has used age-based criteria actively in the past to identify special populations of concern, the emphasis has traditionally been on children, who were viewed as especially vulnerable and exploited. Some might argue today that older persons present a similar picture of vulnerability, although others might suggest that older people are favored, at least with respect to health insurance coverage.¹

There are similarities between the plight of children and that of older persons, but there are also important differences. Both populations are more likely to be influenced by their environment than to influence it, but it would be a serious mistake to expect that all older persons are dependent. Indeed, many continue to lead productive lives, contributing much to the generations that follow them, up to the time of their death. The general social debate that has pitted one generation against another is often framed in terms of investment versus payback. Older persons deserve some reward for their years of social contribution, whereas children represent the future. Both can make compelling cases. The choice between them may prove an artificial dichotomy.

Do older persons warrant special attention? At least two disciplines have evolved to address the special problems of aging: geriatrics and gerontology. The latter is inclined to study the aging process in biological, social, and psychological terms, whereas the former is concerned with rendering older persons specialized medical assistance. However, the distinctions are not so clear in practice, and both disciplines are relatively new.

Gerontology has no specific date of birth, but its serious origins are usually traced back to research on the biology of aging early in this century.^2,3 The first White House Conference on Aging in 1961 laid the groundwork for the establishment of the National Institute on Aging within the National Institutes of Health in 1974. In the following year, Butler and Van Nostrand’s book on the plight of older persons attracted national attention.⁴

Although the term geriatrics was used in the early part of this century,⁵ practical programs that offer specialized services for older persons are a new phenomenon in the United States. Effectively, geriatric programs began in earnest in the late 1970s and early 1980s with active federal and foundation support for training programs.⁶ In 1988, nearly 4300 physicians took the first national examination to certify physicians as having special competence in geriatrics. Similar certification programs are available in other health professions. The recent past has seen considerable progress and change in both the biological understanding and care of older people.⁷

Both geriatrics and gerontology owe their rationale to a belief that there is a body of knowledge unique to older persons. From the perspective of clinical care, older persons present a higher risk of frailty, a greater likelihood of having chronic diseases, and a consequent probability that their status will reflect the interaction of multiple problems rather than a single condition. Clinical conditions may present with symptoms different from those seen in younger patients, and the relative benefits and risks of therapy may differ from those that are appropriate to younger patients. However, it is as difficult to express precisely when aging begins as it is to know for sure when youth ends. Likewise, one of the most difficult differential diagnoses is distinguishing processes attributable to aging from those attributable to disease. It is recommended that aging research em-phasize both the search for the etiology of aging-related problems and an improvement in the overall quality of life for older persons.⁸

The view of the elderly as a separate group is also apparent in public policy. Certain benefits have historically been reserved for persons at a given age. Social programs, like Social Security and Medicare, are triggered by a birthday. Special rates are often offered to seniors, sometimes out of deference to their age and other times as a marketing ploy. At the same time, discrimination on the basis of age has been made illegal. Even mandatory retirement is now prohibited.

This sense of separateness can be a two-edged sword. Some social philosophers suggest that older persons should not be entitled to certain services specifically because of their age.⁹ Others argue that older persons have been disproportionately favored, especially over children. Some have even suggested that age should no longer be a primary criterion for determining eligibility for social benefits; rather, such benefits should be assigned in response to need across all age groups.¹⁰

Public health in the United States has only lately focused attention on older persons. The Gerontological Health section of Aging and Public Health Association was founded in 1978. Yet the skills needed to address this population are fundamental to public health. In addition to basic demographic trends and forecasts, there are important questions to be answered through epidemiological studies.^11–14 Aging represents both a biological process and the accumulation of various insults over time. An understanding of what constitutes aging at the individual level may be achieved through a careful comparison of aging among different subgroups to isolate environmental factors from intrinsic ones. The incidence as well as the prevalence of certain diseases increases with age. Health planning and policy must recognize the special needs of older persons in terms of both their disproportionate use of various forms of health care and the special care needs their disabilities warrant. Because older people are more sensitive to their environment, especially when it is broadly defined to encompass more than their physical surroundings, special attention should be directed at ways to limit the inherent threats and enhance the potential for positive effects.

Despite the enormous impact the elderly have had on health and health care, the special problems of this population have not been a conspicuous part of public health curricula. It is therefore encouraging to see this Journal devoting special attention to this group. Efforts should be made to prepare the next generation of public health practitioners to understand and address the societal challenges of an aging society. □

Robert Kane

The author is with the University of Minnesota’s Institute for Health Services Research, School of Public Health, in Minneapolis.

Requests for reprints should be sent to Robert Kane, MD, Institute for Health Services Research, School of Public Health, Box 197, D-351 Mayo Memorial Bldg, 420 Delaware St SE, Minneapolis, MN 55455.

References

1. Hayward RA, Shapiro MF, Freeman HE, Corey CR. Inequities in health services among insured Americans: do working-age adults have less access to medical care than the elderly? N Engl J Med. 1988;318:1507–1511.

2. Metchnikoff E. The Nature of Man: Studies in Optimistic Philosophy. New York, NY: GP Putnam’s Sons; 1903.

3. Cowdry EV. Problems of Ageing; Biological and Medical Aspects. Baltimore, Md: Williams & Wilkins Company; 1939.

4. Butler R, Van Nostrand J. Why Survive? Being Old in America. New York, NY: Harper & Row; 1975.

5. Nascher IL. Geriatrics; the Diseases of Old Age and Their Treatment, Including Physiological Old Age, Home and Institutional Care, and Medico-Legal Relations. Philadelphia, Pa: P Blakiston; 1914.

6. Kane RL, Solomon DH, Beck JC, et al. Geriatrics in the United States: Manpower Projections and Training Considerations. Lexington, Mass: DC Heath; 1981.

7. Morley JE, Solomon DH. Major issues in geriatrics over the last five years. J Am Geriatr Soc. 1994;42:218–225.

8. Institute of Medicine. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: National Academy Press; 1991.

9. Callahan D. Setting Limits: Medical Goals in an Aging Society. New York, NY: Simon and Schuster; 1987.

10. Neugarten BL. Age or Need: Public Policies for Older People. Beverly Hills, Calif: Sage Publications, Inc; 1982.

11. Ostfeld AM, Gibson DC. Epidemiology of Aging. Bethesda, Md: US Dept of Health, Education, and Welfare; 1975.

12. Haynes SG, Feinleib M. Second Conference on the Epidemiology of Aging. Bethesda, Md: National Institutes of Health; 1980.

13. Wallace RB, Woolson RF. The Epidemiological Study of the Elderly. New York, NY: Oxford University Press; 1992.

14. Brody JA, Maddox GL. Epidemiology and Aging: An International Perspective. New York, NY: Springer Publishing Company; 1988.

[2]

Health Care Implications of An Aging Population

MICHAEL MICKLIN, Ph.D

Professor Nanjing University – Johns Hopkins University, Centre for Chinese and American Studies

Summary

The principal objective of this paper is to develop and illustrate an analytic strategy for assessing the health care implications of the aging of human populations. The paper first reviews recent trends in population aging as well as changes projected to occur over the next several decades. I conclude that the most severe impacts of population aging will be experienced by the less developed nations, largely owing to the rapidity of their population aging and the absolute numbers of elderly added to the population over the period examined.

The argument then considers the principal mechanisms through which population aging affects the health care system. These processes involve changes in the patterning of disease and illness and the demand for health services. The result is a series of strains on existing and planned health care services.

The final section of the paper offers an analytic framework for the evaluation of a health care system’s capacity to meet the challenges of population aging. The framework consists of a typology based on two dimensions: system operating requirements (information, human resources, institutional structures, and policies) and evaluation criteria (including service quality, costs, and means of finance). Use of the framework is illustrated with case materials pertaining to health care conditions and actions in selected developing nations.

World Population Aging

Over the past several decades the age structure of the human population has changed, though not dramatically (United Nations, 1985; Torrey et al., 1987). In 1950 just over one-third of humankind was under 15 years of age, while only about fi...