A critique of Callahan's utilitarian approach to resource allocation in health care.

• Author: Cohen-Almagor, Raphael
• Position: Intensive-care patients - Daniel Callahan

ABSTRACT: The rationale of this article is grounded in the liberal tradition. It places the individual at the center of concern, and attempts to fortify the individual's basic right to health care. Attention is focused on the writings of Daniel Callahan, arguing that his approach is too cold and detached, and that age should not serve as the decisive criterion. The criticism of his views on older patients and on patients in post-coma unawareness (PCU) stems from two different lines of reasoning: the medical and the moral-contractual. From the medical perspective, while age is an important variable in determining a patient's medical condition, there are other--no less important--factors that influence one's health. From the moral-contractual line of reasoning, liberal society should not desert its citizens at the time they need its help most. The age criterion is too simple, too general, too sweeping. It provides too convenient an answer to a tough and troubling question. Similarly, the argument with regard to PCU patients should be qualified, taking into account the age of the patient, the cause of the condition, and the length of time in state of unawareness.

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In most liberal societies, basic health is seen as one of the necessary conditions for the exercise of personal autonomy. It is generally acknowledged that individuals have a right to health care. The prevalent assumption is that this right generates an obligation or duty on the part of the state to ensure that adequate health care is made available and which further requires that equal access to available health care is provided through public funds. The state has no obligation to provide a health-care system itself, but the state does have the obligation to ensure that such an adequate system is provided. Basic health care is now recognized as a "public good" rather than a "private good" that one is expected to buy for oneself. (1) The Constitution of the World Health Organization states: "The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition. (2)

The constraints on the financial resources allocated for care of the ill force us to consider, in an honest and serious manner, the tension between the ideal and the real. Currently, challenges to our health have medical solutions, albeit sometimes partial, that were unimaginable in the previous century. The new technology is very costly, and some have claimed that saving lives is not a goal that should be achieved at any cost. (3) Costs and benefits must be examined and priorities determined so as to invest resources only in "worthy cases." The term "worthy cases" is often juxtaposed with the term "quality of life." (4) The claim is that expensive technology should be used to help patients who are likely to maintain a certain quality of life. When there is a low quality of life, it is preferable to exercise discretion as a society and to reserve our finite resources to treat patients who are more likely to lead autonomous lives.

The financial resources are obviously limited, and the national budget must be prioritized according to various needs: technology, security, education, culture, health, housing, food, transportation, science, the legal system, environmental protection, etc. The debate about how to allocate health care resources revolves around three basic concepts: duty, ability, and rights. The central questions are: Does a democratic society have a duty to provide optimal health care for each and every citizen? Can the state provide optional health care for each and every citizen? Do citizens have a right to demand such a commitment from their government?

In the liberal framework, the concept of "rights" is understood in terms of a need that is perceived by those who demand it as legitimate and, therefore, the state has a real responsibility to provide health care for each and every citizen. "Rights" are primary moral entitlements for every human being. (5) In this context one can differentiate between an individual's rights with regard to the state or government, and an individual's rights with regard to his or her fellow citizens. Rights, which are conceived to be legitimate, must be met by the state (e.g., the right to life, to shelter, and to associate). They justify taking political actions to fulfill them. Rights regarding other individuals who act illegitimately justify the use of coercive measures against those individuals either by concerned citizens (right to self-defense or to protect one's property) or by the state.

More specifically, with regard to health, citizens have a "negative right" to not have their health impaired by the actions of the state. A democracy is expected to refrain as much as possible from taking actions that might endanger the health of its citizens. This does not mean that citizens in a democracy may demand that an army will not conscript them in a time of crisis but a democracy may be expected to take action to remove elements that are detrimental to our health. Hence, citizens have a right to demand that chemical, biological, and nuclear plants not be situated in populated areas. Citizens also have a right to demand that products that are harmful to our health be labeled properly as a precaution. (6) The "positive fight" to health care is concerned with providing proper treatment to overcome illnesses and other traumatic conditions that are endemic to our health. In this context, constraints that are forced upon citizens must be handled, such as scarcity and costs of resources.

Many researchers express concern regarding this "positive right," especially when medical expenses are increasing due to technological development. Those researchers claim that no society can afford to spend such large sums of money on health care. Some of the researchers raise concerns about our social responsibility not to cater to the needs of certain patients. These arguments are made most often with regard to patients whose quality of life is seen by these researchers as particularly low. Emphasis is placed on the high costs of care for these patients, the psychological and economic burdens on the patients' families, and the financial constraints operating on hospitals. (7) The focus of these researchers' analysis shifts from the individual to society, as exemplified by John F. Kennedy's famous remark: "Ask not what your country can do for you. Ask what you can do for your country."

Every discussion on the allocation of resources is bound to reveal the tension between the macro and the micro, between the needs of society and the needs of the individual. The tension is inescapable, and the work of drawing the appropriate balance is delicate. Emphasizing the needs of society might inevitably result in ignoring the needs of some individuals. The questions obviously involve balancing and weighing various considerations. In the liberal tradition, the starting point is the individual rather than the society Liberals conceive shifting the emphasis from the individual to society as a very dangerous move.

Indeed, the sacrifice of the individual citizen for the good of the state is contrary to the spirit of liberalism. Liberal ideology places the individual at the center: all liberal reasoning derives from seeing the individual in the focus of analysis, and all its reasoning is aimed at the advancement and development of the individual which, in turn, results in the progress of society This tradition evolves from the philosophical thought of John Locke (1632-1704), Thomas Paine (1737-1809), Alexis de Tocqueville (1805-1859), John Stuart Mill (1806-1873) and more contemporary, in our time, John Rawls and Ronald Dworkin. This longstanding liberal tradition places the individual, not the collective, in the center of analysis, viewing the state as a mere instrument to serve the interests of the individual. The liberal state is seen as a means of protecting society from external attacks, a framework regulating the implementation of the law for the prosperity of the citizens and a sophisticated tool to ensure individual fights.

The function of liberal democracy is to promote the prosperity of the individuals even when they are ill. Democracy has an obligation to preserve individuals' rights; namely, it recognizes that certain demands of its citizens are legitimate and should be satisfied within the framework of society The right to life is recognized as a first priority. Some (most notably John Locke) call it a natural right, in the sense that it is the consequence of nature, a right that precedes the state. Assuring health care to citizens is perceived as one of the basic duties of every democracy. (8)

One of the approaches dealing with the problem of allocation of scarce resources is the utilitarian, or the cost-benefit approach. Generally speaking, it seeks a policy that will bring the greatest number of advantages to the largest number of citizens. Recognizing that it is not possible to provide for the health needs of everyone, a decision is made in advance to exclude certain categories of people from receiving treatment. Treatment is equal for those who do not fall into the excluded category and for those who cannot afford more expensive medical insurance. The affluent people will find means to care for themselves and hence, this approach deals with most of society, not all of it.

The following discussion will criticize this version of the utilitarian approach. The writings of Daniel Callahan, one of the main representatives of the age-rationing approach, will be examined. He suggests that it is preferable to invest in the youth who have a better chance of recovery as well as a better chance to live longer and more quality-filled lives than older persons. Callahan sees old age as a valid criterion for limiting medical care...