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IJOES
34,2 Ethical dilemmas in the practice
of nursing
Hengameh Hosseini
School of Public Affairs, Penn State University-Harrisburg, Middletown,
250 Pennsylvania, USA
Received 18 July 2017
Revised 13 November 2017
27 November 2017 Abstract
7 December 2017
Accepted 15 December 2017 Purpose – The United States’ population is rapidly aging. As older people require more expensive medical
and nursing attention, health-care/nursing costs keep rising, to the extent that they are not sustainable. As a
result, the USA is faced with an ethical dilemma. While egalitarian ethical principles and the provisions of the
American Nurses Association (ANA) code of ethics require the provision of medical/nursing care to everyone
regardless of age, severity of disease and productivity, utilitarians view that as impossible. Assuming that
provisions ANA’s codes of ethics are the same as ethical principles, this paper aims to discuss the debate
between those two sides in detail.
Design/methodology/approach – The paper, viewing the rise of health-care/nursing costs as the cause
of the above ethical dilemma, discusses Daniel Callahan’s utilitarian argument that, given the ever-rising
health/nursing costs as a percentage of GDP, the USA will be forced to ration health care/nursing on the basis
of age. The ethical arguments opposing Callahan’s arguments will also be presented.
Findings – While the debate between those two viewpoints is bond to continue, some writers have tried to
find a compromise, a solution by assuming that, through efficiency, health/nursing costs can be lowered,
making Callahan’s age-based rationing unnecessary.
Originality/value – This paper is original as it, by including nursing costs as an inseparable component of
health-care costs, makes the aforementioned debate applicable to nursing care.
Keywords Utilitarianism, Age-based rationing, Nursing code of ethics
Paper type Conceptual paper

International Journal of Ethics and
Systems
Vol. 34 No. 2, 2018
pp. 250-263
© Emerald Publishing Limited
2514-9369
DOI 10.1108/IJOES-07-2017-0104
Introduction
The US population is aging, and the ratio of oldest members of society to the population is
on the rise. In 2010, there were 40.3 million people aged 65 or more, amounting to 13 per cent
of the total population; this is 5.3 million more people than in 2000, when they accounted for
12.4 per cent of the total population (Fuchs, 2001). Older Americans are expected to become
double in number over the next 25 years, and will likely constitute 20 per cent of the
American population by 2030 (Callahan and Cassel, 2003). This increase in life expectancy is
attributable to a reduction in mortality from cardiovascular diseases and certain infectious
diseases such as measles, malaria and tuberculosis. The reduction of birth rate in the USA is
also thought to be a contributing factor. As Andre and Velasquez argue, “the fastest-
growing age group is the population aged 80 and over – the very segment of the population
that tends to require expensive and intensive medical care” (Callahan, 1998). Obviously,
what they refer to as health-care cost also includes nursing costs. It is worth remembering
that the USA also allocates an increasingly large share of its gross domestic product (GDP)
to health care (a figure that includes nursing costs). While in 1960, the USA spent 5.1 per
cent of its GDP on health care after Medicare was introduced in 1966, health-care spending
rose to 8.8 per cent of GDP by 1980. By 1999, spending had risen to 13.1 of GDP (Douglas
and Paul, 2005), and accounts for roughly 18 per cent of GDP today. According to Gregory
Rutecki and Geib, “this figure will be 26 per cent of the GDP by the year 2030” (Lidz, 1995).
 It is obvious that older members of society use a great deal of health-related services Practice of
(including nursing services) than those who are younger. In fact, people aged 65 and older nursing
consume four times the per capita costs of health (including nursing) services than those
who are younger. Matters are even worse for the oldest of this age group – those who are
85 and older. Because American society is growing older, and older adults require more
and more medical and nursing attention, this demographic shift implies a higher cost to
society. As a result of this ever-accelerating aging process, health-care/nursing costs are
constantly on the rise, to the extent that they are spiraling out of control. Given the
251
current debate and political environment in the USA about whether health care is a right
or an option, the topic is very relevant for all aspects of health-care services, including
nursing. This implies that societies are not able to provide all necessary health-care
services, especially if the needed care is more expensive and unaffordable. Ethical
principles such as beneficence, non-maleficence and respect for the autonomy of
individual (in this case, patients), as well as American Nurses Association (ANA)
accepted codes of ethics provisions, obligate health-care providers including nurses to do
what is necessary for patients while also respecting the wishes of patients regardless of
costs. Still, some medical ethicists argue that providing health-care services to
unproductive older adults with incurable diseases will result in societies being forced to
deny those health-related cares to younger persons, and the mentally ill and other
vulnerable members of society, because of scarcity. This suggests an ethical dilemma:
The economic reality of resource scarcity does not allow us to provide all health-care
services to every member of society, regardless of the cost involved. As a result of this
dilemma, some medical ethicists who would find more egalitarian ethical principles
impractical, subscribe instead to a utilitarian notion of ethics and have proposed the
rationing of health care on the basis of age, and consequently, denying expensive care to
unproductive older adults with incurable diseases.
This line of argument and its ethical justification was begun by American health ethicist
Daniel Callahan in 1987, in his book Setting Limits: Medical Goals in An Aging Society
(Callahan, 1987). This type of argument was also made by former Colorado Governor,
Richard Lamm, who, in a very controversial (and perhaps insensitive) statement, advised
the very sick elderly that they “have got a duty to die and get out of the way” (Time
Magazine, April 9, 1984). It is interesting to note that even in ancient Greece, when Greek life
expectancy was less than 30 years old, Greek poet and playwright Euripides also advocated
a form of age-based rationing of health care (similar to that of Governor Lamm) in the
following poem:
I hate men who prolong their lives by foods and drinks and charm of magic art preventing
nature’s course to keep off death. They ought, when they no longer serve the land, to quit this life
and clear the way for youth (Andre and Velasquez, 1990).
As a result of rising health-care costs in the USA, many writers have supported the position
that was expressed by Callahan (1998). Health-care ethicists, Andre and Velasquez,
wondered:
Has the time come when we decide that prolonging lives of the elderly who no longer serve the
land is truly a burden on the youth of society? Is the day of rationing our nation’s healthcare
services on the basis of age close at hand? (Andre and Velasquez, 1990)
In an open letter to Los Angeles Times in 2006, known Brookings Institute health economist
H. Aaron advocated age-based rationing stating that the US government should forcibly
prevent certain treatments (Aaron, 2006).
IJOES Of course, while proponents of rationing health care on the basis of age have used
34,2 utilitarian ethics to support their position, others, such as Tilburt and Cassel (Tilburt
and Cassel, 2013) and Etzioni (Etzioni, 1991), have opposed that type of rationing. The
latter group uses more egalitarian principles of ethics, which seem consistent with
those advocated by the provisions of ANA Code of Ethics, as the aforementioned ethical
dilemma is applicable to all aspects of health care, including nursing care. The above
252 disagreements illuminate a debate between those two groups of ethicists, each group
using a different set of ethical principles to defend or oppose the rationing of health care
on the basis of age. Given the ever-rising health-care costs, this debate will continue
regardless of whether the Affordable Care Act, which was designed to provide more
care by reducing the numbers of uninsured or underinsured Americans, is maintained,
is replaced by a more pro-market health system, or is someday by a single-payer
system.
The aim of this paper is to present both sides of the debate and the economic and
ethical justifications for their positions. While it is evident that there is no one-to-one
correspondence between all principles of health-care ethics and those advocated by the
proponents of nursing ethics, this author assumes that the debate that began by
medical ethicist Daniel Callahan (Callahan, 1987) should also be a concern to the
advocates of nursing ethics, as one should not separate nursing care from health and
medical care. After presenting the various aspects of the two sides of this debate and
the justifications provided, the paper also discusses the notion of fair innings, which
was proposed by British academic Alan Williams (Williams, 1997) which could serve as
a compromise.
In the Concluding Remarks section, in regard to the ethical dilemma discussed above, it is
argued that in spite of the rising costs of health care, Callahan’s notion of age-based
rationing of health care, Lamm’s proposals – which also resemble age-based rationing – or
even William’s fair innings, cannot be accepted or implemented in the USA. However, as
some writers have argued, attempt can be made to lower health-care costs so that perhaps,
use of age-based rationing of health care becomes unnecessary. Of course, given the
complexity of the health-care system, in particular in the USA, achieving these suggested
solutions many not be easy either.

Materials and methods

The problem: Why the dilemma?
In 1965, when President Lyndon Johnson signed the Medicare Bill, he and many others were
very optimistic about the impact of Medicare on the health of the elderly. As a result of this
optimism, President Johnson stated that: “No longer will young families see their own
incomes and their hopes eaten away simply because they are carrying out their own deep
moral obligation to their parents” (Lieberman, 2016). Americans over the age of 65, and their
families, have benefited from Medicare as millions of uninsured have begun to enjoy
coverage under the Affordable Care Act. However, all health-care systems that also include
nursing – whether the present US health-care system after the implementation the ACA in
2012, a totally private health-care system as suggested by conservative Republicans in the
US, or a single payer universal system – have faced or will face serious problems in the
future as a result of demographic and technological charges that significantly increase
health-care costs. After all, as suggested in a 2009 Newsweek article by J.S. Robert:
Healthcare spending, which was 5 per cent of the economy (i.e. of gross domestic product) in 1960
and is reckoned at about 18 per cent today, would lead to 34 per cent of GDP by 2040.
Furthermore, as suggested by Bill Frist and Alice Rivlin, “Americans spend over $3 trillion a Practice of
year on health care but have shorter life expectancies and higher rates of infant mortality nursing
and diabetes than our global peers” (Frist and Rivlin, 2015). Obviously, the continuous aging
of the American population bears a large share of the blame, as older adults require more
medical and nursing attention than younger ones. After all, the US life expectancy, which
was 47.3 years in 1900, was close to 80 years in 2015. It is for this reason that, according to
an AARP Bulletin Today article, the doubling of the older population expected by 2030
promises to bring with it enormous policy challenges. (Binstock, 2007). 253
The growth of the population of older adults and the availability of expensive life-
extending technology have led to various difficult and troubling questions about whether
society is equipped to meet health-care demands of the near future, as well as an
“increased tolerance of proposals for rationing” (Andre and Velasquez, 1990). Disturbed
by the high cost of health care for these elder members of society, Herb Rubenstein and
Leon and Masiewicki believe that our society cannot afford the current practice of
“spending too much public money treating chronic ailments of old age as if they were
acute diseases” (2004).
The stewards of the complex health-care system in the USA cannot ignore the
economic dimension of the problem. As Douglas and Paul reminded us many years ago,
as the population ages, the number of beneficiaries increases while the number of
productive citizens drops. Also, because the majority of the health-care expense burden
lies with the government, the decrease in number of taxpayers “will increase the burden
on the remaining wage earners. This is a formula for financial and political disaster”
(Douglas and Paul, 2005).
This economic argument also demonstrates the existence of the aforementioned
dilemma. For, it too suggests that tough decisions need to be made about how much we
should spend on health care (that also, includes nursing care) and other goods and services
to ensure a productive and healthy (and tax paying) workforce, as opposed to how much we
must allocate to the health care of the non-working Medicare population. We should
remember that every dollar spent on health care is a dollar that society could have spent on
some other public good or some private good or service. Certainly, some type of balance is
needed. Our hope should be that our policymakers are wise economically and are capable of
making ethically sound decisions.

Arguments in favor of rationing health care for the very unproductive old
Because of the skyrocketing cost of health care (and thus nursing services), and the fact that a
disproportionate share of spending goes toward the elderly, various thinkers have come to
advocate age-based rationing for societal health-care expenditures. Perhaps the most
prominent advocate of this type of rationing is Daniel Callahan, the author of Setting Limits:
Medical Goals in An Aging Society (Callahan, 1987) and other books on the subject. Callahan,
in whose view medicine and health care should have the goals of relieving pain and suffering,
curing diseases when possible, providing rehabilitation and other forms of assistance when
diseases burden people and perhaps even enabling people to have peaceful deaths, proposes
that the government should only pay for routine care of the very old, to relieve their suffering
(Callahan, 1987). To Callahan, the future goal of medical science should be to improve the
quality of people’s lives, not to lengthen them (Callahan, 1987). Attempting to maintain and
extend the lives of the very old requires exorbitantly expensive research and technology. Of
course, Callahan is not alone in making such arguments. As early as 2001, Stanford
University economist Victor Fuchs acknowledged that “the USA spends about 1 per cent of
its Gross Domestic Product on health care for the elderly persons who are in their last year of
IJOES their lives” (Fuchs, 2001). The same point was made during a 2003 Senate hearing by Donald
34,2 Hoover. “Our nation spends substantial amounts of medical care for persons in their last
years of life. This will increase as our population ages” (USA Senate Committee on
Appropriations, 2003). This trend seems also to be continuing after the implementation of the
Affordable Care Act. To Callahan, this process has led to what he calls the infinity model, as a
result of which there is no limit to the amount of medical care provided and patients want
254 more and more (Callahan, 1987). In this view, a very long life does not necessarily guarantee a
better life. To seek the greatest good (i.e. health care) for the greatest number of people,
Callahan suggests limits and boundaries (Callahan, 1987). While the health of the young can
be ensured by relatively cheap preventive measures, such as exercise programs and health
education, the medical conditions of the elderly are often complicated, requiring the use of
expensive technologies and treatments. In addition, these treatments of the elderly are often
ineffective in providing any tangible benefits for either patients or society (Callahan, 1987).
To the advocates of age-based rationing of health services, society benefits from the increase
in economic productivity that results when medical resources are diverted from an elderly
retired population to those younger members of society who are more likely to be working, or
other needy individuals including the mentally ill or developmentally challenged individuals
of any age.
According to the advocates of age-based rationing, the government spends a great deal
on the health of the very old than that of the very young. This skewed distribution of health-
care resources is not only detrimental to the overall health of the society but also unjust. For,
they argue, the elderly people receive a disproportionately large piece of the health-care pie,
whereas a far greater number of younger people are deprived of an equal share of the
nation’s economic resources. To the advocates of age-based rationing, need should not be a
fundamental criterion for determining how much health care to the elderly (or others) is
allocated.
Advocates of rationing also support Callahan’s contention that the draining of health-
care resources to prolong the lives of elderly violates the rights of the young to live out a
normal life span. To them, elderly persons, who have lived a natural life span, should be
entitled to receive only the types of treatments that relieve pain and suffering. Thus, given
the scarcity of resources available to society, they should not receive the types of (expensive)
treatment that extend and prolong their lives at the expense of those who have not yet lived
out a normal life span.
Advocates of age-based rationing believe that withholding treatment from the elderly
should not be regarded as inhumane. For, to them, everyone grows older. In the words of
Andre and Velasquez, “If we treat the young one way and the old another way, over time
each person is treated the same” (Andre and Velasquez, 1990). In a 2003 debate with an
opponent of rationing, Callahan argued that the young should not impose the limits on the
old (Callahan and Cassel, 2003). Rather, it should be decided collectively on the basis of two
conditions:
[A]s my particular proposal, let me stipulate two important conditions. One is the elderly have to
accept this. It is not something to be imposed by the young on the old. [The second is] this is to be
democratically achieved. The elderly themselves decide [. . .] (Callahan and Cassel, 2003).
Of course, one may argue that the growing individualistic and perhaps hedonistic tendency
in society may be motivating older or unproductive individuals to seek longer life by any
means necessary. If this argument is correct, an effort to ration health care may have an
ethical justification. The idea that patients should not be forced to do things against their
will is not new; it goes back at least to Plato who felt each patient knew what was “good” for
him or her. In Statesman, Plato even accused physicians who force a patient to accept what Practice of
the physician thought was best instead of using persuasive argument of making an nursing
“unscientific and baneful error” (Lidz, 1995). Plato also discussed the concept of persuasion
in his Gorgias, where he emphasized that a trained rhetor would have better results in
persuading a patient. He believed that consent should be obtained prior to any treatment
(Lidz, 1995).
255
The arguments against age-based rationing
The arguments presented by the proponents of age-based health-care rationing have
provoked strong disagreements among opponents. In a 2003 debate about age-based
rationing with Daniel Callahan, Christine Cassel presented various difficulties that exist in
deciding this type of rationing (Callahan and Cassel, 2003). She argued that because life
expectancy is on the rise, and the aging of society is a byproduct of human progress, it is
difficult to decide a normal age and an age limit for imposing age-based rationing of health
care. In other words, this type of rationing requires the selection of a “normal age”, which is
difficult to decide.
By this view, another difficulty with setting such a limit is that, in terms of health, older
people are not a homogeneous group. Indeed:
[. . .] people at the age of 80 or 90, or [. . .] even 100, are very different from one another. The degree
to which they can benefit from any degree of medical care is also very different (Callahan and
Cassel, 2003).
Writers such as Sandra Lipsitz Bem, the author of The Lenses of Gender: Transforming the
Debate on Sexual Inequality, have reminded us of gender inequality in general (Bem, 1993).
According to Bem, an age-based rationing method would also lead to a lack of fairness for
women, because “women still have a survival advantage of six to seven years over men”
(Bem, 1993). In her eyes, if we were to choose a particular age after which life-prolonging
medical care would no longer be provided, women would face an unfair disadvantage.
Would policymakers accordingly choose different ages for men and women? (Bem, 1993)
Cassel agrees with Callahan that “we have to figure out some way to ration health care”,
and that there are infinite potential demands for health care (Callahan and Cassel, 2003).
However, to her, this is “not so much related to age as it is related to new technologies and to
enhancement technologies – techniques that don’t necessarily improve health but that are
desirable for a range of other reasons” (Callahan and Cassel, 2003). Cassel also blames the
problem on the fact that, in the USA, the cost of health care is enormously expensive in
comparison to peer developed countries. The statistics surrounding the health-care system
are very troubling. The USA spends more on health care than any other nation in the world,
$1.8tn in 2004, and this figure is increasing at a rate more than twice as fast as incomes. Yet,
the nation ranked a lowly 16th in a study of 22 industrialized countries, in terms of medical
outcomes (Saporito, 2005). Furthermore, according to Nobel Prizewinning economist Paul
Krugman, the US government spends more on health care than the governments other
developed countries, even though in the USA, the private sector pays a far higher share of
the bills than in any other country (Krugman, 2005).
Cassel disagrees with Callahan and his supporters that there is a tension or inequity
between the young and the old. Instead, she maintains that those who most strongly
advocated for Medicare in 1965 were not the elderly. Rather, they were the grown children of
those older people who were responsible for paying their parents’ medical bills (Callahan
and Cassel, 2003).
IJOES While, for Cassel, establishing an age-based health system as proposed by Callahan
34,2 would be difficult, to other opponents the situation would be much bleaker if the system
were actually developed and put into practice (Callahan and Cassel, 2003). Many critics
dispute the claim that rationing could strike the best balance of benefits among all members
of society by arguing that any policy of rationing that deprives the elderly of potentially life-
saving medical care would actually result in few benefits and give rise to tremendous costs.
256 Specifically, a rationing policy could lead to increased anxiety among young people thinking
ahead to and dreading their futures, and despair among elderly people who do not wish to
die and feel cast aside by society (Andre and Velasquez, 1990).
Besides, even if financial savings were achieved by rationing health care by age, there is
no guarantee, given our present political system, that any savings on the old would actually
be passed on to the young, or that they would result in real improvements in the overall
health of citizens. The actual benefits, in the view of those opponents, would depend on what
kinds of resources were applied to what sorts of treatments.
To the opponents of age-based rationing, people should be treated similarly unless there
are morally relevant reasons for treating them differently. In the words of Ralph Ellison
(Ellison, 1952), the elderly should not be viewed as invisible. Instead, in determining who
should or should not receive health care, it is relevant to consider a person’s need for health
care, the likelihood of recovery, and/or the likelihood of improving a person’s quality of life.
Age, however, reveals little about a person’s medical need or prognosis, and thus should
have no more influence on the distribution of health care than race or gender. It is the
medical liabilities we often associate with old age, and not age itself, that should count as
relevant and legitimate reasons for treating people differently. If society’s objective is to use
costly resources more effectively, then we ought to deny treatment to all patients whose
prognosis indicates a short life span, chronic illness or little likely improvement in the
quality of life rather than denying treatment simply on the basis of age.

Discussion
Ethical dimensions of the dilemma
According to Gregory Rutecki, no medically advanced society can provide all people with
every medical intervention and actually survive (Rutecki, 1993). To him, this principle “is
the basis of any discussion which considers the rationing of medical care” (Rutecki, 1993).
Our concern here, of course, is age-based rationing of medical/nursing care. We want to
know the ethical implications of this type of rationing. This inquiry requires the application
of the principles of medical/nursing ethics. According to physician/ethicist Kenneth Prager
there are four relevant principles of medical ethics (Prager, 2002). The first of these is the
principle of beneficence and non-maleficence which, to him, “basically means do good and
don’t do bad” (Prager, 2002). The second of these principles is that of autonomy, according to
which patients who have the capacity, and are in a suitable state, to make health-care
decisions should have the final say on their own treatment, regardless of whether those
decisions are approved by either family members or the physician. The third principle is
respect for the sanctity of life. The fourth is the notion of justice. To Prager, there are two
even, opposing sides to the notion of justice that lead to different consequences. The first of
these two is the strictly utilitarian ethical notion of justice, and the second is the idealistic
ethical viewpoint that Prager describes as that of giving “help to people who need it the
most” (Prager, 2002). Beauchamp and Childress introduce us to various theories of justice
(Beauchamp and Childress, 2001). John Rawls, in 1971, discussed two principles of justice.
These are the liberty principles, which emphasize equality of rights for each person, and the
difference principle, which justifies social and economic inequalities only if they exist with Practice of
the greatest benefit to the least advantaged in society (Rawls, 1971). nursing
Among the aforementioned ethical principles, the principles of justice and sanctity of life
seem to have been invoked the most interest within the literature dealing with age-based
rationing of medical resources. For example, to Callahan and his followers who invoke the
utilitarian notion of justice, scarce health-care resources should be allocated in a manner that
would bring the most good to the greatest number of people. This scheme would limit public
medical expenditures for the very old whose medical needs and expenditures far exceed 257
those of the young.
While for Callahan and likeminded, the utilitarian notion of justice can be applied to age-
based rationing of health care, to Prager it is problematic. Holding a position similar to that
of Cassel, Prager contends that this utilitarianism will lead to problems because men and
women have different life expectancies. To him, the application of utilitarian ethics to age-
based rationing “will be disproportionately felt by women” (Prager, 2002). Prager, however,
is more in agreement with the application of the idealistic notion of justice and with
allocation on the basis of need (Prager, 2002).
Many health-care ethicists have applied the notion of justice to age-based rationing. For
example, several years ago the state of Oregon confronted its medical shortages with a
rationing plan that engages a “just standard” through a program based on the “what” and
not the “who” that gets covered (Rutecki, 1993). To accomplish the “what,” Oregon began
with a list of 709 disease entities, later pared down to a list of 587. The diseases were ordered
in a hierarchy, according to a valuation of certain care methods (such as prenatal) over less
favored and more expensive technologies (Rutecki, 1993).
Some scholars find the utilitarian concept of justice as applied to age-based rationing of
health services to be consistent with the Bible (Rutecki and Geib, 1992). According to
Rutecki and Gieb (Rutecki and Geib, 1992), the application of the Scriptures leads to the
following conclusion about such rationing: Paradigms for rationing medical care to the
elderly seem essential because the use of money for the medical care of the elderly
potentially compromises the care of those of younger and functional age (Rutecki and Geib,
1992). In other words, applying a biblical interpretation supports the Callahan utilitarian
view.
Another physician, F.E Payne, has used biblical passages to develop what he calls
efficacy-futility criteria, which is also consistent with the utilitarian notions of justice
emphasized (Payne, 1992). Edelstein et al. (1967) find this concept consistent with
Hippocratic tradition in ancient Greece. To them, prudent Greek physicians had an
obligation not to treat incurable diseases.
Using Kant, Martin Buber’s philosophy about establishing a meaningful I-thou
relationship and the third principle of ethics discussed by Prager (2002), one could argue
that all individuals should be respected and regarded as ends in themselves. As such, then,
every person, young and old, must have unlimited access to the best that the health-care
system can offer. To Rutecki and Geib (1992), biblical passages, too, can be used to prove the
sanctity of life.
As the aforementioned discussions demonstrate, ethical principles have been used to
support both sides of the debate/dilemma. Although because of scarcity, aging and other
problems discussed above, some type of age-based rationing seems logical or even ethical,
an age-based rationing may also lead to “slippery-slope” problems. Let us illustrate three
such scenarios:
(1) Proponents of age-based rationing want to limit the health-care expenditures of the
very old. Even if such limits are acceptable to the very old, society must still
IJOES determine a clear definition of what the “very old” is. Is it 65, 70, 80, 90, or 100?
34,2 What is to be done when life expectancy rises as it usually does? Would an age
decided to be the limit be the same in all countries when life expectancies are
different? If so, how can one ethically justify this inconsistency, particularly from a
Rawlsian justice point of view?
(2) If one limits health-care services to the very old on the grounds that they are
258 unproductive, then what should be done in the case of other unproductive
members of society who are much younger? Where should society stop in this
respect?
(3) If society decides age is the criterion for limiting health-care services, what is to be
done in the case of the very old who are sick but are also very productive members
of society?

Concluding remarks: Can there be a solution?

Given the aging of American society, the greater increases in the cost of medical services
in comparison to other components of the GDP, and the rise in the use of more expensive
technologically advanced medical devices, various experts find the current rate of
increases in health-care costs as unsustainable. Particularly because of government’s
involvement in the financing of Medicaid and Medicare, the nation and policymakers (i.e.
agents of change) must work to find a solution. We must remember that, because of the
scarcity of resources, we are faced with societal tradeoffs. For, every dollar spent on
health care is a dollar that society –whether private individuals, corporations, or
governments – could have spent on another private public good or service. If one does not
attempt to find a solution to the problem of health care discussed above, we may face
other societal problems. For example, we may become a society of medical “haves” and
“have-nots”. Or, society in the future might affords less and less housing, transportation,
education and other important necessities.
To resolve this dilemma, various solutions have been proposed. No matter what
solution is proposed, one must bear in mind the uniqueness of the US health-care system
and its critical differences from the health-care systems of other industrialized countries.
While other industrialized countries have a variation of the single-payer system, thus
much government involvement, in the USA, we have a hybrid health-care system in
which the private sector plays a much more important role. This explains why so many
times attempt has been made to repeal the Affordable Care Act (ACA or Obamacare)
which intended to bring more government involvement to the US health-care system. As
suggested by a recent OECD report, of the 34 OECD member countries (that include
industrialized and some emerging countries), the USA and Mexican governments play
the smallest role in overall financing of health care. As a result of this uniqueness of the
more difficult. As a result of this uniqueness of the USA health-care systems, even in
2014, after the implementation of the ACA, only 89.6 per cent of Americans had some
type of health insurance, with 66 per cent of employees being covered by some type of
private health insurance plan. I contrast to other industrialized countries, for the same
year, among all Americans having health insurance, only 36.5 per cent received coverage
through the USA government: through Medicare (health insurance for older adults),
Medicaid (for the poor) and Veterans or other military health care. Those who attempt to
propose new solutions for the US health-care system must also remember that health
insurance coverage is uneven, since often minorities and the poor are under insured. An
example being that two out of five among those do not have access to paid sick leave. Or,
especially prior to the implementation of the ACA during Obama presidency, millions of Practice of
Americans have no access to health insurance. The ACA made a great deal of difference. nursing
While 41 million Americans were uninsured in 2013, according to the 2015 Kaiser Family
Foundation Report, as a result of the implementation of the ACA that number was
reduced to 32 million in 2014.
In 2014, just 49 per cent of American adults reported getting health insurance from an
employer. But coverage by employer–provided insurance varies if we consider wage
level. While firms with higher proportions of low-wage workers are less likely to provide 259
access to health insurance, those with low proportion of low- wage workers are more
likely to provide health insurance to their employees. (Kaiser Family Foundation Report,
2015). Provision of health insurance to employees also differs if we consider full-time
versus part-time employees. According to the above report, while, in 2014, among full-
time workers 11.2 per cent were without employer-provided health insurance, for part-
time workers it was 24 per cent in 2013, but, as a result of the ACA, it declined to 17.7 per
cent in 2014. Additionally, providing health insurance to employees also differs among
small and larger firms in the USA. Smaller firms are significantly less likely to provide
health insurance to both full-time and part-time workers. In 2015, while 98 per cent of
large USA firms provided health coverage to their employees, for small firms – i.e. those
with three to 199 employees – it was only 56 per cent.
Another point worth mentioning is that, in the USA, the percentage of uninsured
individuals also varies for different ethnic groups; percentage of uninsured being larger
among minorities (and children). For 2014, after the implementation of the ACA, for non-
Hispanic whites in the USA the percentage of uninured was 7.6 per cent, while for African-
Americans it was 11.8 per cent, for Asian-Americans it was 9.3 per cent and for Hispanics it
was 19.9 per cent. Again, the implementation of the ACA caused a decline in the number of
uninsured, including for younger adulates (19-25) who are now able to remain on their
parents’ health plan.
The solution proposed by Callahan was discussed above. American society and
policymakers in the USA are by no means ready to accept, or even discuss the type of
age-based rationing of health care proposed by Callahan. The Brave New World of Health
Care (2004) written by Richard Lamm several years after his aforementioned rather
insensitive statement, also provides a solution (Lamm, 2004). To fix the system, Lamm
envisions a comprehensive solution that has various dimensions. In terms of its ethical
dimensions, perhaps influenced by Callahan, he proposes reexamining the ethics of
medical care and rejects the view that it is right to give to each individual in the system
all the health care that could benefit them or extend their lives. Because of his
pragmatism and belief in utilitarianism, Lamm asserts moral standards must coincide
with economic reality. As a result, he argued, every medical decision paid for by pooled
funds, such as Medicare, Medicaid, the programs put into place by the Affordable Care
Act, or even insurance, should withstand a careful cost-benefit analysis test that
economists use to evaluate the feasibility of any policy or project. He also proposes a
reduction in what he believes is an excessive reliance on the use of technology; he points
to the fact that more MRIs are performed in Colorado than Canada, a rich country with
several times the state’s population. Lamm wants government to consider carefully
which funding strategy results in the most health. Based on that, the government should
raise retirement/eligibility age for full Social Security benefits to 70; provide limited
health and retirement benefits to people ages 62 to 65; reduce health and social security
benefits to the non-poor elderly; limit cost of living adjustments for the non-poor elderly;
restore the 50/50 individual/government balance to pay for Medicare Part B; index
IJOES premiums for Medicare Part B to costs; add 20 per cent co-payment for all clinical tests
34,2 and at home tests ordered through Medicare; add extra premiums for non-poor elderly for
Medicare Part A; and create an incentive system for employers to retain their employees
after 65 years of age while encouraging workers to continue to work after that age. In
addition, Lamm also proposes that members of the health-care professions should limit
the number of specialists; limit the access to specialists through the use of gatekeepers;
260 increase the number of family doctors; limit medical malpractice suits; and reduce
bureaucracy and administrative costs, including billing challenges (Lamm, 2004).
American society is not in the position to follow Lamm’s suggestions.
Another suggestion that should be mentioned is the notion of fair innings, which was
proposed by UK York University professor Alan Williams in 1997. According to Williams’
fair inning thesis, every person in society has a right to certain quality-adjusted life
expectancy, and people should favor intervention to achieve it. To Williams, anyone failing
to achieve this is cheated, and anyone getting more than this is living on borrowed time.
Williams’ fair innings has four important characteristics. First, it is outcome-based, not
process- or resource-based. Second, it is based on a person’s whole life experience, not about
their state at any particular time. Third, it reflects an aversion to inequality. Fourth, it is
quantifiable (Williams, 1997). The notion of fair innings too seems to be too difficult to
accept in the USA.
As stated above, it is not likely that the solutions proposed by Lamm (2004), as well as
William’s fair innings (Williams, 1997), would be accepted or even debated by policy
makers in the USA. But, given the high cost of health care, one should ask whether there
is something that can be done to reduce the costs of health care in the USA? Different
writers have made varying suggestions; a few of these will be summarized below.
In a Harvard Business Review article entitled: “How the US Can Reduce Waste in
Healthcare Spending by $1 Trillion”, Sahni et al. (2015) argue that by reducing waste in
the US health-care system, the medical establishment and society can reduce health-
care costs substantially. These authors identify four areas for which waste can be
reduced substantially. The first is clinical waste – which, to them, can be reduced
through the following strategies: by using better prevention or higher quality initial
care; by replacing services with less resource – intensive alternatives; or by improving
processes by standardizing best practices. The second concerns administrative
complexity. In other words, spending that could be eliminated with simpler, more
standardized processes for billing and collection, credentialing, compliance and
oversight (Sahni et al., 2015). The third concerns excessive prices by suppliers and
providers. To reduce this type of cost, they suggest tying price to efficiency, outcomes,
and a fair profit. The fourth is about fraud and abuse. The authors suggest reducing
spending associated with illicit schemes to extract payments for the illegitimate
delivery of health-care services (Sahni et al., 2015).
Another essay relevant to this discussion was a May 2015 USA News and World Report
entitled “The Power of Prevention: USA Healthcare Reform Should Focus on Prevention
Efforts to Cut Skyrocketing Costs”, by physician Bill Frist and noted policy economist Alice
Rivlin. These authors argue in that piece that “Americans spend over $3 trillion a year on
health care but have shorter life expectancies and higher rates of infant mortality and
diabetes than our global peers” (Frist and Rivlin, 2015). According to these experts, the US
policymakers should focus on prevention efforts to cut skyrocketing costs. To emphasize
their point of view, they state that: “an ounce of prevention is worth a pound of care” (Frist
and Rivlin, 2015). These two authors truly emphasize prevention.
 A June 2013 Fiscal Times essay makes a global comparison, suggesting alternative ways Practice of
for reducing health-care costs. Haseltine (2013) argues that Singapore has been able to create nursing
a most efficient, high-quality health-care system (thus with lower costs), suggesting that
perhaps the USA should follow Singapore’s footsteps to be able to create an efficient and a
highly efficient health-care system. This author, being aware that the health-care system in
Singapore is tremendously different from that of the USA, believes there is no harm
summarizing Haseltine’s discussion and his suggestions that reflect his understanding of
Singapore universal health-care system where the government ensures affordability of
261
health care within the public health system, largely through a system of compulsory
savings, subsidies and price controls. To him, Singapore has followed the following six
steps to achieve efficiency:
(1) Price and outcome transparency: Singapore requires that all prices for health
providers and hospitals be publicly available. This is to allow patients and third
party to shop for the best price.
(2) Central to Singapore’s health-care system is a higher co-payment system, which, to
him, provides an incentive for the lowering of health-care costs.
(3) Payment by capitation and outcome, not fee-for-service.
(4) Differentiated service: Public hospitals in Singapore offer five different categories
of services, all with access to the same doctors and procedure. The difficulties lie in
the amenities. Those who select the highest level have access to fully private
rooms. However, those who select the lowest level are housed in multi-patient
wards. The price differences among five categories are significant.
(5) Catastrophic health insurance: The most common health insurance in Singapore
covers catastrophic events that require expensive or prolonged treatment. Nearly
every citizen of Singapore has such coverage. However, while the deductibles are high,
as insurance pays only 20 per cent of the cost, a government safety net helps those
most in need and, for others, if the additional costs exceed the ability to pay.
Furthermore, catastrophic health insurance costs are far less than comprehensive, low
deductible health insurance plans.
(6) Transition from hospital to home and common care.

Singapore has recognized that the demands for an aging population on the health-care
system, which is on the rise, require a shift from hospital to home and community hospitals
(Haseltine, 2013).

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263
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Corresponding author
Hengameh Hosseini can be contacted at: huh19@psu.edu

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