Some thoughts on “Principles for allocation of scarce medical interventions”

This is in reference to the article referred to in my January 15th post, Health Care for the Disabled? It was authored by Govind Persad, Alan Werthheimer,and Ezekiel Emanuel, one of President Obama’s top health care advisors. [Lancet 2009; 373: 423-31 Department of Biothics, The Clinical Center, National Institutes of Health, Bethesda, MD USA (G Persad BS, A Wertheimer PhD, E J Emanuel MD)]

The article reviews the major approaches to the situation (including the DALY- Disability-adjusted life-year allocation) and recommends what the authors call the complete lives system.

Now it is not good to take  others’ words out of context. The authors, in their conclusion, consider objections to their complete life system. (P. 7) This is an important section of the article for understanding their conclusions. I cannot stress enough how important it is to read the whole article. But when one has done so, pay careful attention to this section. Since this article is marked Public Domain, here is a sentence for consideration:

Some people believe that a complete life is a universal limit founded in natural human capacities, which everyone should accept even without scarcity. By contrast the complete life system requires only that citizens see a complete life, however defined, as an important good, and that fairness gives those short of a complete life stronger claims to scarce life-saving resources.

I offer these observations for your consideration as an ordinary U.S. citizen who will feel the effects of this approach at some point in my life or the lives of my loved ones. I acknowledge that medical people are indeed much more aware of the full scope of the dilemma than I am; nevertheless I feel the responsibility to respond to what the experts are planning for us.

The Young and the Old

Except perhaps for the very young, young people in general are healthier than older people and require, in general, less medical interventions. I find it curious that this is not addressed. Our society is a society that values youth and youthful energies, and sees the adventures of youth as the fun time of life. Could it not be said that we even worship youth and value those “fun times” as the best times of life?

“Flee also youthful lusts; but pursue righteousness, faith, love, peace with those who call on the Lord with a pure heart.” (2 Timothy 2:22)

Older people have in times past been seen as those to whom the young turn to for wisdom concerning the meaning of life and the solution of life’s difficult questions. But now older people, (many of whom, in our society, admittedly, have applied themselves more to acquiring goods than wisdom, unfortunately) are often viewed as people behind the times (lost in the dizzying pace of technological advance), and in their last years, as burdens on society. But perhaps the experiences of older people, even if they have made mistakes, (I, on the verge of 55, sure have!) while different, have something to say to younger people- an under-utilized resource.

“You shall rise before the gray-headed and honor the presence of an old man and fear you God” I AM the Lord your God.” (Leviticus 19:32)

Here’s a scripture portion from the Orthodox Christian Old Testament that speaks to the issues involved here:

There was once a man pleasing to God and loved by Him, and while living among sinners he was taken up. He was caught up lest evil change his understanding or deceit deceive his soul. For envy arising from lack of judgment obscures what is good, and a whirling of desire undermines and innocent heart. He was made perfect, for in a short time he fulfilled long years, for his soul was pleasing to the Lord; therefore He took him early from the midst of evil. Yet peoples saw this but did not understand, nor take such a thing to heart.

(Wisdom of Solomon 4:10-14, The Orthodox Study Bible, Thomas Nelson, 2008, p. 897.)

The notes in my Orthodox Study Bible say this refers to Enoch (Genesis 5). But the words also find application toward a definition of a complete life: a. It is not measured in years. b. The peoples did not understand. That is, those that are not of the people of God. Here’s the previous passage:

But though a righteous man may die before his time, he shall be at rest. For old age is not honored for its length of existence, nor measured by its number of years; but discernment is gray hair for mankind, and a spotless life is the maturity of old age. (vv. 8-9)

This is not to say that we are to devalue older folks that we do not deem wise. (The passage could be understood that way.) The point that I see in this is that simply measuring people by years lived is not God’s way of measuring people.  One dying young, somehow, painfully for loved ones left behind, can fulfill God’s purpose for themselves in a shorter life.

The authors of the article, in effect, are saying God (assuming they believe He exists) is not fair in taking certain people before what is considered the full span of life, and are seeking to compensate for this. But as we believe that our God is all-wise, we cannot support a systematic shifting of resources from the old to the young as a way of compensating for God’s unfairness. Is it too strong a statement to say that to do so would be playing God?

Of course, if, say, a 20 year old person needed a new heart and I, at 55, also needed one, and there was one available, I would defer to the younger person. Surely Christ, who gave Himself for us, would have us who follow Him to walk in his footsteps in lives of self-sacrifice.

Would I do it for a 75 year old? According to my Faith, I believe I’m called to be willing to defer here as well. Of course, the 75 year old would probably have something to say, too. That person’s prognosis and his spiritual state enter into the decision. Is he at peace with God? If so, he may be ready to move on. I would also be consulting my spiritual father and others whose counsel I trust in such a situation.

Here’s an excellent reflection on this matter, entitled Moral Pluralism and the Crisis of Secular Bioethics: Why Orthodox Christian Bioethics has the Solution”, by Dr. H. Tristam Engelhardt, a physician and Orthodox Christian bioethicist:

Now if a 40 year old and a 60 year old, and their families, would all be demanding that heart, someone else would indeed have to make a decision. The authors, in all fairness, are limiting their recommendations to situations of scarce medical resources, in which a third party may have to make the decision. If the authors’ “complete lives system” would be restricted to such situations of scarce resources, where a third party has to decide, it has a certain logic, from a human standpoint. But I personally have no idea how often such situations actually happen.

Medical decision-making

The authors write of

a complete life, however defined

Now Christ shows us what authentic humanity is. Man, created in the image of God,” is called to restoration to the likeness of Christ, the “visible” of the Father, to sharing in the energies of the Holy Trinity. As St. Peter writes, we are to become “partakers of the Divine nature.” (2 Peter 1;4) We can know God, but not exhaustively; we will never understand Him in His essence, which will remain beyond the comprehension of all created beings.

If our God (and by extention, man,  made in His image) remains in certain ways a mystery to those who have received Light from above concerning their nature and purpose, how much more is the human being a mystery for those who recognize no settled definition as to what we human beings are,  or for the purpose of our existence? Should not the very fact of their lack of clarity on these large questions cause them to pause before developing such plans?

And why should we be a willing and obedient flock of sheep for shepherds without clear vision?

And while it must be said, in all fairness, that the authors are limiting their recommendations to situations of scarce medical resources, where a third party may have to make a decision, such policies could easily become more generalized. Could not the step from situations of scarcity to questions of cost easily be taken by those whose focus is the economic “bottom line?”  (“How much is this person’s extended medical treatment going to cost?”)

It seems to me that the struggle in our society in this matter is increasingly between persons and their families making hard end-of-life choices and certain health care professionals who want to make the choices for them, according to their  bioethical conclusions- and not necessarily in situations of scarce medical resources. See the following for examples of this:

Medical decisions are often most agonizing. Obviously people are not meant to be perpetuated biologically with no brain waves by machines. Conversely, alleviation of pain (in some cases by substances that can hasten death) must be weighed alongside the need of a dying person for a time of spiritual reflection as he approaches the end of his life. And there is so much more involved. Who decides?

This struggle is also between those who believe that life is a sacred gift (which means for Christians, not only biological life, but divine life in Christ) and those who look at people according to how useful they are. This view, while critiqued in the Lancet article, is also somewhat present in it, in my opinion.

Beyond Roe versus Wade,  judicial decisions allowing physicial-assisted suicide are spreading in the U.S.- first in the state of Oregon, then in Washington, and now Montana seems to be opening this door.

Where the fallen world sees a chronically ill person as a burden, the Lord Jesus sees a person counted as “the least of these” whom we are called on, in the strongest terms, to serve. This is, as I said before, the Orthodox Christian bottom line- St. Matthew 25.

Lord have mercy, on me, a sinner, who has not always lived up to these words.

I would also ask all readers for forgiveness if I have treated these matters inadequately and simplistically, neglecting important aspects.

But the matter pertains to persons with disabilities, which most of us will be at the end of our lives in this world.


3 Responses to “Some thoughts on “Principles for allocation of scarce medical interventions””

  1. 1 medical alarm June 17, 2013 at 9:30 PM

    Hi! I know this is somewhat off topic but I was wondering if you knew where I could locate a captcha plugin for my comment form?
    I’m using the same blog platform as yours and I’m having trouble finding one?

    Thanks a lot!


  1. 1 Some thoughts on “Principles for allocation of scarce medical … | Drakz Free Online Service Trackback on January 23, 2010 at 5:05 PM

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