DIFFICULT MORAL QUESTIONS

Question 44: What must an elderly person do to stay alive and healthy?

I am a widow, seventy-one-years old; my husband died of Parkinson’s disease two years ago at seventy-four. I have adjusted fairly well, and keep busy working around the house, visiting with family and friends, and helping out at our parish. My income is adequate, and I have no real worries about future needs. Still, life no longer means as much to me as it did when my husband was alive. I think more about heaven than I used to, and it seems more real as I look forward to it. This hope has made me less anxious about most other things.

I had a major operation five years ago and another about a year ago. They were successful, but the tests beforehand and the aftermath were extremely difficult both times, and taking care of myself as I recuperated last year was very hard. During the past few years I also have been bothered with three smaller health problems for which there is no treatment, as I learned in each case after unpleasant and complicated tests. The operations and the tests cost a great deal. Though most of the expense was covered by Medicare or my supplemental insurance, those big bills bother me, because other people eventually have to bear the cost. That, along with everything else, has set me thinking.

It occurs to me that perhaps I may—and maybe even should—do without most health care from now on, and let nature take its course. My grandparents and other elderly people did that when I was young, though of course they had little choice. I would continue taking medicine I know I need, getting flu shots, and doing other simple things, but I would do without more difficult and costly things. Would there be anything wrong with that? If it would be all right, where should I draw the line?

Of course, if it would be all right and I do cut back, there might come a time when I no longer can make these decisions for myself. Then I would want done only what it would be wrong not to go along with. I have looked at different forms of a living will (sometimes called an “advance directive”), but did not feel sure about them, and so have not signed any. I wonder if one or another of them would suit my purpose.

I have talked with several friends about my idea. They don’t like it and don’t want it to get around. If some senior citizens voluntarily start doing without most examinations and operations, they say, the government is likely to decide that all elderly people can do without them, and then Medicare will stop covering such things. One of my friends pointed out that some writers already are claiming that the elderly are getting more than their fair share of health care, and arguing for a cutoff after a certain age.

I also have a question about eating. About ten years ago, both my husband and I had high cholesterol. Rather than take medicine, we began to walk more and changed to a strict, low-fat diet. I never have been overweight and am not about to make a pig of myself now. But the diet limits what I can offer guests and eat when I visit others, and often is inconvenient in other ways, such as requiring more frequent shopping. I would like to forget it and take a more relaxed approach. I might not live as long, but do I have to be so careful?

Analysis:

This inquiry includes three distinct questions. The basic question bears upon the extent and limits of an elderly person’s obligation to employ various means of health care. In principle, the answer is the same for the elderly as for everyone else. One may not omit health care with the intention of ending one’s life, and one should try to survive and function long enough to fulfill one’s other responsibilities. But within these limits, one should consider the benefits and burdens of available means of health care and conscientiously judge whether to accept what is available. A subordinate problem is whether the questioner could ensure, by some sort of living will, that her policy of limiting health care would be followed if she became incompetent. The answer is no. Since judgment is needed to compare the benefits and burdens of means under consideration, only a suitable proxy is likely to be able to safeguard her interests. The third question concerns the obligation to diet. For younger people, other responsibilities generally require limiting health risks; but for people without other responsibilities, temperance calls only for reasonable moderation in eating. So, the relaxation of diet proposed by this elderly questioner also could be morally acceptable.

The reply could be along the following lines:

Your reference to your grandparents and others of their generation points to one factor contributing to the problem that concerns you. Health care technology has developed with increasing rapidity during the twentieth century; many new operations, tests, and so on are available today; hospitals and diagnostic centers are filled with more sophisticated equipment; and highly trained specialists deliver far more of the care. Economic obstacles to using this vast technology have been dealt with by private insurance and government programs that have relieved many individuals and families of much of the cost.¹⁴⁴

Partly for this reason, partly because many physicians make decisions on narrowly technical grounds, partly due to their defensiveness about malpractice lawsuits, and partly due to their fundamentally sound commitment to promote their patients’ health and preserve their lives, practitioners often recommend or even insist on trying every means of health care that offers any prospective benefit, with little or no regard to its cost or its burdensomeness to the patient. Docilely accepting their physicians’ unilateral judgments, many patients, probably most, gladly abdicate their own primary responsibility to care for themselves. Even many people who want to make their own health care decisions have been intimidated by professionals’ expertise and the wizardry of their techniques. Moreover, the increasingly high valuation placed in affluent societies upon survival, healthful functioning, and freedom from pain has tended to detach these goods from other elements of human well-being and even to absolutize them, so that more people now than in the past are likely to make health care decisions without reference to their impact on the rest of the patient’s life and on the legitimate interests of others. Much more can be done today to keep elderly persons alive, and both physicians and patients also are more likely to suppose that whatever can be done must be done.

By contrast, you have been thinking about how health care fits into your life as a whole. Moreover, while people all too often ignore the fact that doing everything possible can become unfair to others, you rightly recognize that care paid for by government programs and private insurance ultimately imposes costs on other people and these costs should be taken into account. Thus, you perceive a moral issue: How far should you go in trying to stay alive and healthy?

Besides the limit fairness sets to seeking care, every decision about health care should meet two other definite requirements. First, since suicide is always wrong, one may never choose to do or omit anything so as to bring about one’s death—for instance, to relieve others of burdens or to forestall further suffering. Second, one should try to be healthy enough and survive long enough to fulfill all one’s other duties. The first norm can be violated by those who choose to limit treatment for the sake of “death with dignity,” for they can be seeking death as a way to avoid so-called indignity, and choosing to refuse treatment as a means of bringing about death. Nothing you say suggests you are thinking of suicide. The second norm can be violated by people who still have pressing responsibilities to fulfill—family, work, something else—or who need time to prepare for death and put their affairs in order. It seems that you no longer have exigent responsibilities to others, and I assume you are prepared spiritually and in other ways for death, and will take care to remain so.

People lacking hope are likely either to cling to life too greedily or else to regard death unreasonably as an escape to which they are entitled when they no longer find life worth living. But no matter how old and debilitated one is, life is God’s gift, which always remains a blessing. And, though death always is an evil that may never be sought, Christians not only should resign themselves to it but spiritually prepare for it and anticipate it with joy, insofar as it is the ultimate opportunity to share in Jesus’ sacrifice and the only gateway to heaven (see q. 43, above). Therefore, your more detached attitude toward this present life and more intense hope for heaven seem to me entirely sound.

Within the definite limits already explained, you and other elderly people should judge what health care to accept in the same way younger people should, namely, in terms of prospective benefits and burdens (see LCL, 524–32). The prospective benefits of any available means of health care are its likely contributions to promoting or protecting intelligible goods; its prospective burdens are its likely adverse effects in terms of intelligible goods. Each time you have a decision to make, you must exclude unreasonable motives (such as fear recognized as excessive and the sadness of depression), consider and compare the reasons for and against accepting treatment in terms of its prospective benefits and burdens, and judge which set of reasons makes a better case.

While nobody can make that judgment for you, I can indicate the limits and what to take into account.

Since life and health are good in themselves, not merely as conditions for pursuing other goods, prolonging life and maintaining or restoring healthful functioning always are benefits. In several ways, however, aging tends to reduce the cogency of reasons for accepting many sorts of health care. The older one gets, the less time one has left, no matter what steps one takes to extend life, and the fewer possibilities of healthful functioning remain. Thus, the prospects for developing one’s gifts and using them to serve others gradually lessen. Moreover, generally even the most successful operations and best remedies only slow one’s decline rather than reverse it; health care more and more staves off death rather than restores functioning. Then too, though anyone who can think and make choices always can do things of great human value, such as pray, the possibilities of attaining many goods inevitably decrease with aging, so that life and health have less instrumental value. Thus, though you have adjusted fairly well, your widowhood makes a significant difference. Marital responsibilities no longer require you to take care of your health and preserve your life; you now have more freedom to accept death because your husband no longer needs your companionship and help, and you spend your time in activities that are not exigent responsibilities—working about the house, visiting with family and friends, and helping out at your parish. Besides, since your life is less rich and your life expectancy is growing ever shorter, the benefits of lifesaving procedures are fewer for you than when you were younger and had more to look forward to in this world.

Health care also always involves burdens, several of which you mention. Many means involve risks of death or disability, suppress or interfere with normal functioning for some time, and/or are painful. Many also have bad side effects for other goods by preventing one from moving about freely, isolating one from family and friends, and/or interfering with one’s inner life. As one ages, burdens usually grow more serious as the ability to deal with them decreases due to diminishing personal powers and decreasing help from loved ones, who also decline and die. And all health care imposes economic costs, for the most part, usually, on other people. Even if accepting these costs is fair, Christians often may and sometimes should forgo health care to which they are entitled so that the resources will be available for others in need.

In view of the many ways aging tends to decrease the prospective benefits and increase the prospective burdens of many means of health care, it seems to me that people like you, whose other, stringent responsibilities no longer require efforts to stay alive and healthy, might well judge that a difficult and costly major operation or examination is not appropriate for them. So, you might well conclude that it is appropriate to forgo some currently available, technological means of health care. If you do, there will be nothing wrong in doing without them. However, no clear line can be drawn, since no general policy could take into account the impact on you of the shifting combinations of more and less foreseeable burdens and benefits of diverse means that might be used to diagnose or treat more and less serious health problems. Therefore, a fresh judgment will be needed each time you must make a choice.

Obviously, to judge properly, you must have relevant information. To gather facts, you must continue to have regular checkups and at least obtain an initial assessment of any new symptoms. Moreover, since many conditions that are easily treated if caught in time become far more serious if neglected, it would be a great mistake to neglect or put off seeing your primary care physician. However, when that physician proposes that you see a specialist, undergo a further test or examination, or go into a hospital, you can ask about the pros and cons, and then decide whether to accept the proposal. Similarly, you can insist on explanations so that you can judge for yourself whether to take the advice of specialists to submit to difficult tests and examinations, undergo surgery, or be hospitalized. Even if you become gravely ill and some professional care is indispensable, you can consider alternatives to hospitalization, such as nursing care in your own residence or terminal care in a hospice.

Someone might object that what I have said would allow you to decide to forgo examinations such as sigmoidoscopies and mammograms, which are ordinary means of detecting early cancer, and simple, lifesaving major surgery such as a hysterectomy to deal with uterine cancer. Three things can be said in reply.

First, at present you very likely would decide that all or some of the procedures mentioned as examples are appropriate, and you probably will refuse them only if changing circumstances lead you to consider their prospective benefits less and their prospective burdens greater than at present. Who would argue that a permanently bedridden, ninety-year-old woman has a moral obligation to continue undergoing regular sigmoidoscopies and mammograms, or to submit to a hysterectomy and other aggressive treatment of incipient cervical cancer? Between that woman’s condition and yours at present, however, lie a continuum of conditions each differing only infinitesimally from the next. Somewhere a line must be drawn, and I simply have said that only you can rightly draw it for yourself.

Second, if you thought you could spend your retirement more peacefully and comfortably on a remote tropical isle that happens to lack modern health care services, I doubt that anyone would consider your choice to move there morally wrong. But if you could rightly forgo such services in avoiding the distractions of life in an affluent society, why should it be wrong to forgo them to avoid the various burdens they entail?

Third, to say such examinations and surgery are “ordinary” means is ambiguous. If that signifies common in affluent societies, I concede, but no ethical conclusion follows. If it means always morally obligatory, I deny, and the objection simply begs the question at issue.

How should you answer your friends’ objections? If they still have exigent family or other responsibilities—for example, toward grandchildren who are not being brought up well, toward friends who need spiritual help—make it clear that they still have a reason to take care of themselves that you no longer share. Make it clear, as well, that you still consider your life a precious gift of God and have no intention of killing yourself by neglect, but only of forgoing health care you judge excessively burdensome for you.

The public authorities could not soundly use the explanation I have given as an argument for denying difficult and expensive tests and surgery to elderly people. Elderly people do receive a larger than average share of health care, but that does not show that any elderly person is receiving more than his or her fair share, since fairness depends on factors such as need and potential benefit. Using age as a criterion for denying or rationing health care would be unjust, since age does not of itself specify anyone’s responsibility to tend to health problems or affect the burdens and benefits of the various means available.¹⁴⁵ Indeed, as has been explained, no general criteria can adequately guide reasonable health care decisions. Thus, if self-denial by some were used as an excuse for official denial to all, government would preempt individuals’ responsibility to judge what is suitable for themselves. Furthermore, insofar as mercy toward others is part of one’s motive for forgoing health care to which one is entitled, to limit everyone similarly would unjustly impose what should be an act of free self-giving.

In the absence of a sound argument for using age as a criterion for rationing health care, doing so would be manifestly discriminatory. Recognizing themselves as victims of discrimination, the elderly would pose a formidable threat to any officeholder or candidate tempted to treat them unfairly. Thus, your friends’ worries almost certainly are excessive.¹⁴⁶ At the same time, if elderly people are just and merciful in using available resources, younger people are less likely to resent the cost of sustaining them and more likely to respect their rights.

The factors requiring judgment about what health care to accept and making it impossible to draw a clear line also make it impossible to draw up a satisfactory living will (advance directive) limiting what will be done for you and to you if you become incapable of making decisions for yourself. Any such directive will be so vague in some respects as to leave the judgment to care givers, and so specific in other respects as to allow many things a reasonable person might well refuse while perhaps excluding some things such a person would accept in certain circumstances. Moreover, a living will is likely to be interpreted too broadly by some health care providers, especially as euthanasia becomes more common, and to be ignored by others, who will provide unwanted care unless a court orders them to desist.

There is an alternative to signing a living will, namely, designating someone you trust to make health care judgments and choices on your behalf when you no longer can do so, and then discussing your views about the burdens and benefits of various sorts of means with the person you designate, so that he or she will gain insight into your thinking and desires (see LCL, 528–29). You would do well to consider this approach.

As for your low-fat diet, you no longer have the reason to follow it that you had while your husband was alive. When taking meals with others, you plainly have a good reason to set it aside and accept somewhat greater health risks from higher cholesterol. Temperance in eating requires only reasonable moderation, not the healthiest possible diet, and you intend not to eat so much as to become overweight. Therefore, it seems to me that you need not be as careful as you have been. At the same time, you might regard the reasonable restraint still necessary as a sort of fast in preparation for the heavenly wedding banquet!

Finally, though you can rightly limit your efforts to sustain your life, never regard the time that remains to you as useless. Even if your capacities gradually fail, you will be able to do much good for yourself and others—for example, by praying for the living and the dead, and offering your sufferings for the needs of the Church and the world.

Among those you pray for, please include me and my work. I pray that your hope will be fulfilled and you will rejoin your husband in heaven.

144. See William L. Kissick, Medicine’s Dilemmas: Infinite Needs versus Finite Resources (New Haven, Conn.: Yale University Press, 1994), 1–10, 23–32.

145. This proposition is entirely consistent with what I have said above about the significance of aging. People age at different rates, so that some eighty-year-old persons can get greater real benefit from various health care measures than most people who are only sixty. So, making seventy the cut off for any particular form of health care would be unreasonable. Thus, I disagree with Daniel Callahan, Setting Limits: Medical Goals in an Aging Society (New York: Simon and Schuster, 1988), 115–58, who argues that age can be a valid principle for cutting off governmental support for various forms of health care. However, if fairly applied, a criterion based on life expectancy could be reasonable—e.g., that for those whose life expectancy is less than six months, public programs will pay only for palliative care. But such a criterion would apply to everyone regardless of age.

146. This statement probably is not true for people in some countries other than the United States. In some affluent nations, age already is being used as a basis for discrimination with respect to health care, employment, and other matters. Under such conditions, elderly individuals renouncing health care that they could rightly seek or accept should do what they can to prevent their action from indirectly contributing to injustice against other elderly people.