Читать книгу The Moral State We’re In - Julia Neuberger - Страница 10

The cost of caring for older people can only be contained if the general view is that it is morally right to do so, and that requires a public debate and a willingness to change on the part of the medical profession. Older people must not feel they are being denied care. But care in the future might be different from what they get at present. It could mean more palliative care for the relief of pain and suffering, more holistic and less scientifically driven care. Indeed, it might mean that care–rather than often futile attempts to cure–goes higher up the agenda.

This is the nub of one of the key issues facing the frail elderly and those of us concerned about their welfare. For what quality of life do patients enjoy after all the hi-tech healthcare? At present, nearly 29 per cent of all healthcare costs are concentrated on people in their last year of life (and, obviously, death rates rise with age). More dramatically, when looked at by age group, of all healthcare spending devoted to those aged 65–74, 43 per cent is devoted to those in their last year of life; for those aged 75–84 the figure is 56 per cent and for 85+ it is 65 per cent.*

It is hardly surprising that costs should be heavy in the last year of life, but if our true aim were to be the preservation of life at any cost, then we could certainly do more to keep old people alive than we do at present. For instance, are we keen to prescribe unpleasant chemotherapies for as yet incurable cancers, on the basis that our success rate is improving and one day they will work, as with the childhood leukaemias? Are we willing to say we will spend more on the life of a premature baby, a child or young person than on older people? Should we ration healthcare by age? Evidence exists for the rationing of care of people with coronary heart disease and cancer. Until recently, screening for breast cancer stopped at the age of 64. Now, women aged between 50 and 64 are routinely invited for breast screening every three years, and work has been carried out to extend the programme to women up to and including the age of 70 from the end of 2004.

One might argue that age criteria in breast screening have been in place because of lack of occurrence (in fact, incidence goes up with age) or because the life of a woman of, say, 70 who has advanced breast cancer has not been thought worth making an effort to save. Many experts argue that the cancer grows so slowly in older women that they will probably die of something else. But perhaps that is no longer the case with increased life expectancy. A woman of 70 is likely to be no longer economically active, yet it is also likely that she will be caring for an elderly husband or sibling–thus saving the state the cost of care. Is this not an economic activity? It may not increase GDP, but it certainly saves the state increased expenditure on social care.

The resource allocation arguments about rationing on the basis of age are well argued. The two positions are beautifully spelled out in the work of Professor Alan Williams of the Centre for Health Economics at the University of York, who is in favour of the use of age as a determinant for rationing decisions, and Professor Sir Grimley Evans, Professor of Clinical Gerontology at Oxford, who is strongly opposed. Williams argues* that there is a vain pursuit of immortality (true) and that people over 65 are a far larger proportion of the population than they ever were. That is a point well taken. He argues that as we get older we accumulate a ‘distressing collection of chronic incurable conditions’. Some are a nuisance, but some are serious, involving disability and pain. Though most are incurable, that does not imply that they are untreatable. We also get more problems with acute conditions such as pneumonia and flu, and find it difficult to recover from what younger people take in their stride, like a fall. Hence healthcare expenditure on older people is comparatively so large.

Yet we know that much can be done for older people that is not hugely expensive, in terms of alleviation of symptoms and improving the quality of life in an unglamorous way. But, Williams argues, these unglamorous down-to-earth activities tend to lose out to hi-tech interventions which ‘gain their emotional hold by claiming that life threatening conditions should always take priority’. (This is, of course, a separate argument.) Taken to its logical conclusion, this would suggest that no one should be allowed to die until everything possible has been tried. That in turn suggests that we will all die in an intensive care unit (as many people in the USA do).

But this is not sensible. For all of us, there should come a time when we realize that a reasonable limit has to be set upon the demands we make of the system–and on our fellow citizens. What principles should determine that limit? Williams argues that the objective of the NHS should be to improve the health of the nation as a whole–the utilitarian argument. If that is so, then the people who should get priority are those who will benefit most from the resources available. So, if the concern is for the health of the nation, the older person is likely to lose out against the younger. If those are the values of the system, then the interests of a particular interest group are less important than the interests of the whole. So age will matter in two ways. It will affect the individual’s capacity to benefit from healthcare, making the relative cost of a procedure more expensive for older people, and it will incorporate the idea of a ‘fair innings’ by which older people are somehow thought to have had their share of living.

Grimley Evans* argues the opposite. He says that each of us should be treated as an individual. He argues it would be unacceptable to disadvantage people on the grounds of race, gender or national, or social origin. How, then, can it be justified on the grounds of age?

He then suggests it is easy to do so because older people in Britain, unlike in the United States, have not traditionally been organized politically. They rarely complain, refuse to pay their taxes, or cause riots. Militancy is virtually unknown amongst older people in Britain. Yet things may be changing, despite a slow start. Ageism remains legal thus far in the UK, and there is a growing body of evidence on age discrimination in a whole variety of services, particularly in health and social services as they affect the very old. Older people are beginning to complain. But Grimley Evans reserves his real scorn for prejudice. The old are seen to have less worth than younger people. Public attitudes in some surveys suggest this to be true. Survey interviews are rarely confidential. It is unlikely that people would say that one should discriminate on the basis of colour–even though there is racism in British society. But racism is publicly unacceptable. Ageism, on the other hand, is acceptable, and palpably so, and it is this that has led to a society in which there are so many frightened old people.

Grimley Evans then attacks the health economists. He suggests economists should restrict themselves to finding the most cost-effective way of distributing resources and that the ideology of efficiency, markets, and cost containment is no more valid than the ideology it replaced–of common purpose, collaboration, and social purpose. In the current NHS system one’s viewpoint depends on whether one is a user or a provider. The professional providers, one way and another, look for the best return on their investment of time and money. Users of the service, on the other hand, see the NHS as a sort of AA or RAC, there for use when they want/ need it. Citizens as taxpayers might agree with Williams, but British citizens as patients would ally themselves with service users, whose desire is to have their needs/wants met. Grimley Evans suggests that the users’ perspective provides a rationale more consistent with national values and with the explicit intentions of the NHS at its foundation. That is, in my view, having examined the earliest documents about the foundation of the NHS, debatable to say the least.

Do we then believe that all service users should be treated equally, however old? The measurement of outputs in units based on life years indirectly (or directly) puts different values on people according to their life expectancy. Older people are disadvantaged and, more generally, people are no longer reckoned equal. Secondly, the economists’ view assumes that the value of a life can be measured by its length. But if we assert the unique individuality of the person, then the only person who can put a value on a life is the person living it. Grimley Evans’ conclusion is that lives of people are not formally comparable; it is ‘mathematically as well as ethically improper to pile weighted valuations of them together as an aggregable commodity like tonnes of coal’. He continues by taking a swipe at nations who value their citizens only for their use to the state. Yet the NHS was at least in part set up to create that healthy workforce for the state, and people were not expected to live on into frail old age and lengthy retirement. He also suggests that the UK has a different set of values about individual human life from the economists’ outlook. He may be right, but it is as yet untested. He argues that we should not create, on the basis of age or any other characteristic over which the individual has no control, classes of untermenschen whose lives and well-being are deemed not worth spending money on.

But however the argument is played out, it has influenced older people. My father, who had his first heart attack at the age of 51 in 1965, survived to be 82. He was plagued with coronary heart disease for the rest of his life, but managed, despite a second coronary, to continue working until he was seventy years of age and to survive, with considerable determination, two coronary heart bypasses, one endarterectomy to prevent him having a stroke when the carotid artery became narrowed, and several other minor bits of surgery. Towards the end of his life, when he was over eighty, he would often say to me, as some other intervention or new drug was proposed, that perhaps he should not be having all this attention lavished on him. Yet he had a considerable quality of life. He carried on writing and thinking until just before he died. Determination made life, for him, very much worth living. And it did so for us, who did not want to lose him.

It is against that background that I think every day about the question of rationing on the basis of age. Can it be right? Is age the only determinant? Is it, indeed, a determinant of the kind of care one should receive? Pensioners make up a quarter of the bottom fifth of the income distribution. Householders aged 75+ are more likely to have housing that is unfit or substandard. Over 250,000 are on council waiting lists for sheltered accommodation. Isn’t the test of a civilized society not only how it treats minorities, but also how it cares for its older people who are dependent on it? Do we send them to the knackers’ yard, drown them in the well, cook them up for a stew like the cock? At least we’d get some last bit of use out of them. Or do we value them for who they are? Is there an inter-generational obligation?

Can we calculate what people should be entitled to? Should families have to look after their older relatives? What does that mean as families change? Should an ex-daughter-in-law look after her ex-parents-in-law? If so, this tells us a lot about older people and families generally. Can we judge other people’s families and what they do? Or is it a state duty to provide? Our four animals ended up living happily ever after in a house that had been taken by robbers, which they then took by force from them. We have no equivalent, unless we argue that being denied care when the NHS promised to look after them ‘from cradle to grave’ is a kind of robbery. But, whatever we feel about that analogy, the point has to be made that caring for older people properly is expensive. Someone has to pay, and it may be older people themselves. Even so, is it acceptable to treat them so poorly? Or is there truly a lesson to be learned from the Bremen town musicians: that older people will only succeed in getting decent care if they extract it by force? And what would that suggest then for the nature of our society, if groups had to become violent to get noticed?