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Age rationing, the virtues, and wanting more life

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Abstract

The goal of this paper is to show that Callahan's reasons for withholding life extending care cannot be made out exclusively in terms of contemporary notions of distributive justice and fair allocation. I argue that by relying on a notion of justice which links the merit of the individual with the fairness of a social pattern of shares, Callahan imputes vice to the elderly as he denies them eligibility for life-prolonging care. Aristotle's doctrine of the mean is a useful tool for character evaluation. One can speak meaningfully of a proper disposition of a person of a certain type (an elderly person) with respect to the good of continued life. I claim that the mean of one's disposition with respect to the good of continued life would be relative to one's age group, and would be determined by that principle by which an elderly person of practical wisdom would determine it. This leads to very different conclusions than those drawn by Callahan.

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References

  1. Daniel Callahan,Setting Limits, Simon and Shuster, 1987 p. 116, hereafter abbreviated as SL. See also p. 137.

  2. Nancy S. Jecker (“Disenfranchising the Elderly from Life-extending Medical Care”,Public Affairs Quarterly, 2:3, July 1988) argues that Callahan's argument turns upon dual key concepts: natural life span and tolerable death. She counters his claim that the death of one who has completed a natural life span receives a tolerable death by pointing out that thequality of the future life one might enjoy can determine whether we should withhold life-extending resources. If the quality of life would be good, we would notnecessarily consider it tolerable to let death claim the patient. Jecker relies upon the contemporary principle of patient autonomy and a liberal political theory of the rights of modern citizenship. My method differs from Jecker's in that I avoid appealing to intuitions about tolerable death altogether, and address Callahan's reasoning within the context of its own justice—theoretic and virtue—theoretic assumptions.

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  3. At issue between liberal theorists (in the tradition of John Rawls, Ronald Dworkin, and others) and communitarian theorists (in the tradition of Charles Taylor, Alasdair MacIntyre, and Michael Sandel) is the proper relation between the individual and community. In medical ethics this debate is well represented by H. Tristram Engelhardt, Jr. (The Foundations of Bioethics, Oxford, 1986), who takes an extreme autonomy stance which emphasizes political and economic liberty, and Erich H. Loewy (Suffering and the Beneficent Community, SUNY Press, 1991), who presents a developmental and biosocial model of concern for the welfare of others which sets limits on the validity of claims to rights of noninterference. However, the extreme libertarian position of Engelhardt should not be taken to define the total contribution of liberal theory to the understanding of social obligations. Since a conception of the nature of social obligations supplies the context within which the issue of health care rationing is to be understood, liberal theorists must take seriously the communitarian challenge to the traditional concept of selves as separate units, which when aggregated constitute a community. At the forefront of this discussion is Will Kymlicka (Liberalism, Community, and Culture, Oxford, 1989), who argues that traditional liberalism can accommodate a notion of community in which community is seen as the precondition for the meaningfulness of individual choice.

  4. Setting Limits, p. 28. See also p. 220, and Jecker.

  5. Setting Limits, p. 30. The individualistic vision of modern aging misleads the elderly; since they will be dependent on younger people, they would be better advised to endorse a reciprocal exchange of social goods with younger groups, devoting part of their efforts in exchange for custodial and medical care and emotional support.

  6. See for example theNicomachean Ethics V.3,Politics III.13.

  7. Norman Daniels inAm I My Parents' Keeper? An Essay on Justice Between the Young and the Old (Oxford, 1988, pp. 12–20) distinguishes between age groups (persons who fall within a certain age range) and birth cohorts (persons whose date of birth falls within a certain range). As Daniels notes, age group classifications locate one position in the life span, whereas birth cohorts track persons over time. Callahan's arguments range over both concepts, and the lack of distinct terms for describing the problems of intergenerational equity often obscures his point.

  8. Setting Limits, p. 40. Callahan supposes that all humans experience the life course in this way, but even if they do, it is not obvious that this experience constitutes evidence for ages of life as natural kinds.

  9. Setting Limits, p. 43. See also p. 77.

  10. Nicomachean Ethics I.7/1097b. All quotations are taken from Sir David Ross's translation.

  11. Alasdair MacIntyre stands alone in objecting to the translation of ‘pleonexia’ as ‘greed’. He says that greed is the name of a type of desire, whereaspleonexia is the name of the disposition to engage in a type of activity. I find the extension of the English term ‘greed’ to the Aristotelianhexis (that in virtue of which we are in a good or bad condition with respect to the passions, N. E. II.5/1105b25-26) of justice in the special sense entirely appropriate. MacIntyre's peculiar reasons for objecting to it do not apply here. For his discussion see pp. 111–112 ofWhose Justice? Which Rationality?, University of Notre Dame Press, 1988.

  12. Nicomachean Ethics V.2/1130a. For the best discussion of the particular vice of injustice, see H. H. Joachim's commentary,Aristotle, The Nicomachean Ethics, Oxford University Press, 1951, pp. 132–141.

  13. Nicomachean Ethics II.6/1106b, 1108b.

  14. Nicomachean Ethics III.12/1119b.

  15. In the Matter of Clare C. Conroy, Supreme Court of New Jersey, 98 N.J. 321, 486 A.2d 1209.

  16. Nicomachean Ethics I.10/1101a.

  17. Setting Limits, p. 74.

  18. Nicomachean Ethics V.1,2. ‘Again, if one man commits adultery for the sake of gain and makes money by it, while another does so at the bidding of appetite though he loses money and is penalized for it, the latter would be held to be self-indulgent rather than grasping, but the former is unjust, but not self-indulgent; evidently, therefore, he is unjust by reason of his making gain by his act.’ (N.E. V.2).

  19. Nicomachean Ethics II.6.

  20. See Judith Jarvis Thomson, “A Defense of Abortion”,Philosophy and Public Affairs 1:1 (Fall 1971).

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Purviance, S.M. Age rationing, the virtues, and wanting more life. J Med Hum 14, 149–165 (1993). https://doi.org/10.1007/BF01141687

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