The demands of our aging society, medically and economically, pose unprecedented problems. They require reform of the health care system and of policies and practices that impact our economic security. They no less require a rethinking of the progress-driven, technology-hungry model of medicine that feeds that system and consumes a large share of resources. That model has put an unbridled pursuit of cure, not care, in the saddle, a balance that must now shift to a better balance in the direction of care. It has made end-of-life decisions more difficult, blurring the line between living and dying and offering seductive hope that death can be indefinitely overcome. The latter is both damagingly expensive and often an affront to human dignity and a peaceful death.
The present over 65 generation, as well as the aging baby boomers, will be caught in the throes of the necessary revolution. They need a strong voice. Their own welfare is at stake, and their wisdom and insight are necessary for the good of all.
1. A stronger role for seniors: A much livelier, wider, more articulated, and stronger role for the elderly must be initiated to address the future of Medicare and related health and economic problems of old age. That aim will require a dialogue among themselves, with their physicians, and with legislators. All three will be important.
2. Self determination: The importance of self-determination in seniors’ lives needs to be strengthened and clarified, not only for end-of-life care but also for the managing of their health and illness in general. Yet that self-determination will only become meaningful if they have had many occasions early in their elder years to talk with other elders about how to discover and shape their personal values about illness and their inevitable mortality. Many seniors come into old age without a well-defined set of values about how they might best think of their aging and making medical decisions, particularly in the face of complicated, life-threatening, chronic illness. Even when they do have some well-formed values, they can encounter complexities that were unforeseen or resistance from doctors or family members in following their wishes. Understanding oneself, and one’s aging, takes work, experience, and some help.
3. More care, less technology: The balance between cure and care is now too heavily weighted to an unbridled pursuit of cure, even when the potential for cure is vanishingly small. The health care system needs more care and less technology. The present system is beset with excessive and costly diagnostic tests, the use of treatments with poor evidence to support them, and doctors too inclined to respond to illness with technological fixes and desperate “last ditch” interventions at the expense of compassion and a good doctor-patient relationship. Seniors need to support comparative- and cost-effective research, which is a powerful way to determine the value of various technologies. Armed with that information, they can learn when to say no to tests and treatments that are not beneficial and to embrace those that fit with their needs and values.
4. Confronting the cost problem: At the heart of the present Medicare debate is the high and increasing cost of that program. Those costs must be attacked by adherence to evidence-based, efficient care, some reduction in prices, as well as some combination of reducing benefits and raising taxes. There will be no painless way to avoid making these changes. Seniors should be part of that debate, not simply resisting the painful reforms. A central, but neglected, issue for discussion should be that of intergenerational responsibility. What do the young owe the old and what do the old owe the young? Medicare is a pay-as-you go system. That means that the cost of the present Medicare beneficiaries is borne by the younger generation of workers today and future generations tomorrow. How heavy a burden can be asked of them by those who are old? What is a reasonable obligation of the young to the old? What are the reasonable obligations of the old to the young?
5. The economic and family needs of the over 65 generation: A large proportion of the baby boom generation will go into their late 60s and 70s with inadequate financial resources, estimated on average to be only 40% of their retirement income. Those pressures will in too many cases be exacerbated by the need to be family caretakers for their spouses or partners. Even now, most people over 65 are responsible for at least one spouse, parent, or other relative of an advanced age. That burden can all too often be financially and emotional overwhelming (notably in the case of Alzheimer’s). The burden they in turn will place on their baby boom children will be no easier—and many more will have to bear it in the future. That certainty not only touches directly on intergenerational obligation but no less on what family members owe to each other—and to what extent they can ask for government help to lighten the pressure on them.
This project will begin with a blog and move on from there to a full research project.
James Sabin, M.D.
Clinical Professor of Psychiatry
Harvard Medical School
The Hastings Center
Public Affairs and Communications Manager
The Hastings Center