Setting Limits/Born to Pay:

...Longman and Callahan agree that the reforms they propose will not be possible without a fundamental change in values...

...According to the Social Security Administration's "best-guess estimate" (1986), the Medicare trust fund will be depleted by 1996...

...Long-term thinking about the public good is needed...

...Morally speaking, protection against catastrophic need represents an acceptable baseline for health care...

...others are vigorous in their mid-eighties...

...At the same time, some people are very old at sixty...

...Even more, it will mean clarifying the meaning of the good life and the good society in a vision of human existence far deeper and richer than secular intellectualism can ever provide out of its own resources...

...It is at this point that Longman's need-based criterion supported by a tax on consumption begins to make sense, as a morally defensible alternative within the limits of American politics...

...Callahan is sensitive to objections that an age criterion will be arbitrary and undermine the principles of medical need, patient preference in medicine, and "the moral virtues of charity and compassion" in American society...

...He believes health care resources as well as research spending are heavily skewed to the advantage of the elderly over against the general population, especially the young and the poor...

...Second, only palliative treatment to relieve suffering ought to be provided for elders who have attained a natural life span...

...Callahan has two motives in prescribing age as a norm for health care...

...The case for the age criterion runs into even more serious problems on the political plane...

...A good example of the limits of contemporary philosophical ethics is Callahan's reasoning on filial obligation to elderly parents...

...The high cost of health care, unrelenting technological developments, and the good of the elderly themselves," he pleads, "require that [the presumption of patient interest] be examined afresh...

...Which brings us back to the question in the first paragraph and the hope that seriousness and show business are not mutually exclusive...

...The result is a pattern of taxation and distribution which places an excessive burden on younger generations and promises to mortgage the nation's future in a blind frenzy of deficit spending...

...To be sure, there are still aged poor, but overall the grave needs which frequently degraded the elderly and overtaxed their families are now met by government entitlements like Social Security and Medicare...

...Both Longman and Callahan have defined a set of complex social questions for which the costs of old age are but a symptom...

...GERALD WEALES The twilight of the aging The United States has gone a long way toward eliminating poverty as a condition of old age in the years since Dr...

...As a practical matter, he sets the late seventies or early eighties as a cut-off point for all but routine medical treatment...

...The problem, as Phillip Longman states it in Born to Pay, is that these universal entitlements for which old age is the only criterion assist rich and poor alike...

...He paints his face, puts on Liling's discarded robe, and commits the necessary suicide, while Liling, now the repentant male, stands above and calls out in a broken voice, "Butterfly...

...Ours is a culture, Longman laments, "that no longer believes in or cares about the future...

...But regrettably, Callahan retreats from this position because of that old bugbear, the authoritarianism implicit in rationalized (nonmarket) health care delivery...

...It is a wonderfully theatrical moment and it is possible that this scene-along with the Chinese opera battle, Liling's transformation, Wong's strip scene-will stay with the audience longer than the awful irony of the end and the implicit rejection of sexual and racial myths that it embodies...

...While criticizing individualism, medical utilitarianism, and contractarianism as sources of the crisis in health care, Callahan's rational models for moral obligation come almost exclusively from those very sources...

...There is an intuitive plausibility to Callahan's proposal...

...The answer, Longman offers in Born to Pay, is a need-based social insurance program funded by taxes on consumption...

...Secondly, in technical medical terms he finds "need" an alluring, but exceedingly slippery norm...

...The difficulty with this proposal is that the economic and technological trends are such that guaranteeing basic needs in an elusive compromise between the affluent and the disadvantaged may well prove insufficient to provide the required fiscal restraint...

...the disability insurance fund will be exhausted by 2026...

...As a practical matter, this proposal comes very close to recommending something like the British national health system...

...Callahan replies that he quite deliberately questions the individualist bias of medical practice and the ethic of unlimited compassion for those in need...

...Again and again, Callahan falls back on emotive appeals to make the case for filial responsibility...

...but it cuts costs by denying payments to the affluent as long as they can afford to pay for their own care...

...Callahan himself, after playing down variations among the elderly, seems to acknowledge the relevance of such differences when he elaborates a casuistry for treatment of diverse classes of the elderly (demented, severely ill but alert, physically vigorous...

...Men and women who have lived four-score years have lived out a "natural life span," he writes, in which "life's possibilities have on the whole been achieved and after which death may be understood as a sad but nonetheless relatively acceptable event...

...As a way of controlling the escalation of medical costs and correcting the skewed distribution of resources to the elderly, Daniel Callahan in Setting Limits rejects the criterion of "medical need" for a strict standard of age in the allocation of health care services...

...Public policy can alter motives at the margin by be-haviorist methods like tax policy, but it cannot alter deep-seated attitudes...

...Each makes policy proposals which need debating...

...Neither public policy analysis nor moral philosophy is likely to produce such a cultural revolution...

...Most adults have known some old men and women who feel they have outlived their natural span of life...

...The prescription of such treatment for the elderly is not only extremely costly, but leads to still additional costs in the treatment of the chronic diseases which accompany extended life expectancy...

...Arriving at consensus on the solution to those issues will take long public debate...

...In interest-group democracy, as both Callahan and Longman acknowledge, there is no guarantee that savings from allocations for the elderly will go to other needy groups...

...politically, it is the kind of weak egalitarianism compatible with traditional American politics...

...Callahan, in his characteristic and very successful role as worried ethicist, raises especially probing questions about geriatric ethics and social policy...

...The general public is also uneasy about the often painful effects and excessive costs of aggressive medical interventions with the very frail and terminally ill...

...Callahan's proposal means that first, government will be obliged to support only those life-extending technologies which would assist people in living out a natural life span...

...He wants to believe that a woman can so worship an unworthy man that, by Puccini out of Belasco, she can kill herself for love...

...Levies on consumption, he adds, will increase savings, thereby reducing the overconsumption which leads to deficit spending...

...Medical need tends to be defined by changing technology...

...the Social Security pension fund will be in the red by 2020 and completely bankrupt by 2054...

...Health care is the field in which disproportionate expenditure on the needs of the aged is plain to see...

...So Gallimard becomes Butterfly...

...People do possess a sense of natural life span...

...As a condition of cost-cutting at the upper age limit, Callahan would require redistribution to currently disadvantaged groups whose chance for a healthful life in a normal age range would be increased by making greater health services available to them...

...out of its own resources...

...Francis Town-send first agitated during the depths of the Great Depression for a national pension system...

...Moral philosophy is still locked into an individualistic belief system which lies at the source of the problem, and the analytic style in moral philosophy prefers to raise objections and sustain doubts rather than to illuminate our moral convictions and practices...

...First, like Phillip Longman, he is concerned about intergenerational justice...

...Once organ transplants and bypass surgery become technically feasible, they become medically indicated...

...Callahan confesses that "only a full-scale change of habits, thinking, and attitudes would work to make [denial of Medicare coverage on grounds of age] morally and socially plausible...

...The need standard, argues Longman, answers everyone's basic fear that old age will leave them ruined...