Driving to the university the other morning during rush hour, I was delayed briefly by the motorist ahead of me, who paused to let traffic enter from a side streeta courteous, helpful gesture, certainly. Moments later, in the elevator on the way up to my office, I was delayed once againthis time by a fellow passenger holding the door open for others who were scurrying down the hall toward us. Once again friendly people, acting in a friendly way, show that courtesy and helpfulness are alive in the midlands.
Objectively, my own delays on these two occasions were of little consequence. Nevertheless, it struck me that there was a curious asymmetry about these instances of courtesy. The driver ahead of me who chose to lessen the wait of the driver on her side, imposed instead a delay on the long line of cars behind her. The passenger who held the elevator open to eliminate the wait of passengers for the next elevator, necessarily made other passengers wait on floors above, people who, perhaps, were fuming and wondering why the elevator seemed stuck at G.
As trivial and commonplace as these experiences were, they nevertheless seemed to exemplify a trait deeply rooted in our behavior as social beings, a trait both positive and negative. Because of its negative side, it is ill suited to deal with a problem that will become increasingly pressing in the near futurethe rationing of scarce resources, the problem of saying no.
Neither the courteous driver nor the helpful elevator passenger would have deliberately chosen to cause delays for others. How is it, then, that they acted as they did? I believe it is simply that they saw the person waiting to enter traffic and those rushing to catch the elevator. They did not seewere probably not even aware ofthe line of cars behind them or the passengers impatiently pushing the already illuminated up button on the floors above. Their courtesy was to the faces in front of them, not to the faces behind. The faces in front were persons; the faces behindif they came into consciousness at allwere abstractions, possibilities, altogether less immediate.
This propensity to say yes to the faces in front of us will serve us poorly as we wrestle with the allocation of health care resources, a process in which issues of distributive justice arise. In the United States today, health care expenditures represent about one-sixth of the gross domestic product. It is common knowledge that most of that expenditure occurs toward the end of people’s lives and that therefore those expenditures will continue to increase as the population ages. The number of Americans over 65 will more than double by the year 2050, and the number of those over 85 will have increased nearly fivefold by then.
If health services are to be provided then at the same rate as now, expenditures for the care of the elderly and their diseases will grow manyfold. The United States already leads the world in per-capita expenditures for health and illness services, and the increased demand will almost certainly exceed available resources. To make matters worse, the ratio of wage earners to the retired elderly will have dropped by the year 2030 from the current figure of about four-to-one to just over two-to-one. It seems highly improbable that even today’s booming economy could sustain this greatly increased load, particularly with half as many people to earn the money and to provide the care.
As if the shift in demographics were not enough, world gas and oil reserves will have been substantially depleted over the same time period. The economy of the industrialized nations, dependent as it is upon ever expanding energy consumption, will inevitably falter, constricting the discretionary resources available for health and illness services.
What might be done? It is fashionable to note that terminal illnesses account for a disproportionate share of health care expenditures for the elderly and that more restraint in obviously futile situations would save a great deal of money. While this point is certainly true as far as it goes, any comfort it may afford is largely illusory. The fact is that most interventions on behalf of the elderly are successful. Most of the futile cases are seen to have been such only in hindsight. A husband and wife of my experience have had between them five episodes of major surgery in their lives, all of them performed after age 60. Except for signs of wear and tear in other body systems, their health is today reasonably good. They most certainly would not have been healthy, possibly not even alive, without those surgical encounters. Their experience is actually quite typical. Life expectancy after major surgery in 100-year-olds is today an astonishing five years!
Technological advances in the past 40 years have greatly expanded our still growing capacity to intervene effectively in illnesses, a capacity that confers real benefits but entails real expenses. Doing nothing is cheap, at least in dollar terms, as the H.M.O. managers know very well. The explosive growth in the numbers of the elderly, coupled with a likely economic downturn produced by depletion of limited energy reserves, means that we shall not be able to say yes to everyone. If we must restrict resource utilization, it is important to recognize that it will have to be by saying no to people who could have been helped.
Because the U.S. health care system is so dysfunctional, it is difficult for most of us to get the needed perspective on this issue. It may be helpful, therefore, to look at our imminent quandary through the lens of a third world country’s experience. By the late 1970’s, bone marrow transplants had been perfected to the point that they were recognized as life-saving in certain leukemias and marrow disorders. A transplant unit was operating in Vienna, Austria, across the border from Croatia (which was then part of Yugoslavia). Yugoslavia had one of the most democratic systems on either side of the Iron Curtain for allocation of health care resources, with an extensive series of workers’ parliaments ultimately determining what services would be provided.
A worker’s child developed a condition potentially curable with a transplant, and the decision was made to send the child to Vienna. The Austrians, unable to use dinars, required payment in advance in a hard currency, preferably U.S. dollars100,000 of them. Yugoslavia, with a huge balance of payments deficit, could ill afford the drain on its scarce foreign currency reserves. Nevertheless, it sent the child.
How do you stop at one case? Another child needed a transplant, then another, then another. The highly democratized workers’ committees were not able to say noto condemn the child of a fellow worker to certain death by withholding a probable cure. The ministry of health decided, ultimately, to establish its own marrow transplant unit in Zagreb. What was perhaps most poignant about this resolution was the candid admission by responsible authorities that the same resources, spent in rural health care, would save far more liveseven far more children’s lives. The system, driven by grass-roots input, was not able to say no to the faces in front of it.
During the evolution of human social behavior, concern for others in the tribe or clan or village would have conferred a survival advantage on the collectivity. But concern for others whose existence was unknown and unseen, outside the collectivity, would have been meaningless. Additionally, the effects of our within-group actions on outsiders would have been minimal at best, and inappreciable in any case. Thus selective forces favored the development specifically of in-group courtesy. Today the village is global and our actions now do have appreciable effects on others whom we do not know personally. Moreover, knowledge of those outside of our sphere of immediate experiencethe faces behind usis an unavoidable reality. But it is only knowledge; it is not encounter.
To us in the United States, a country of unsurpassed riches, the pie has always seemed indefinitely expandable, and we have been good at denying that there might be limits on what we could do by exploiting the energy available from fossil fuels. But there must ultimately be limits. Lyndon Johnson found to his dismay that, despite his assertions to the contrary, we could not have both guns and butter. Moreover, we are already at, or very close to, a limit on our accelerating use of energy, an eventuality about which we practice the most blatant form of collective denial.
We are, of course, already saying no to manyto the uninsured and underinsured, to the homeless, the poor and the alien in our land. We are able to do that both because we do not know their faces and because, when we do see them in the media, we tend to label them as undeserving. If, as we believe, grace builds on nature and all creation groans in travail waiting for its redemption, then it is important that we get that nature right, that we understand how we function. In many cases labeling and depersonalizing seem to be necessary conditions for us to say no. That surely needs redeeming.
If the twin pressures of growing demand (because of the aging of the population) and fiscal strictures (because of depletion of energy reserves) have the anticipated effects, then we shall have to start saying no to people not so easily marginalized.
Nevertheless, leaving the office the other night, I saw someone hastening to catch the elevator I had just boarded. I knew if I let the door close and the system operate as designed, waits for everyone would be minimized. But I could not do it. I had seen his face. I held the door.