Daniel Callahan is my kind of guy. I first ran across him 20 years ago in his book Setting Limits: Medical Goals in an Aging Society. Everything I have read since then has been a refinement of or an extension of his argument in this book. The question at the heart of all his writings is this: “How much is enough?”
Here is what admiring fellow authors say about him on the jacket blurbs. Earl Shelp says that Callahan “poses hard questions and proposes provocative answers.” Marylee Wilson calls this book “a thought-provoking and heart-jarring assessment of medical goals…today.” Gilbert Gaul says Callahan’s book is “thoughtfully crafted and often troubling.”
Callahan is, apparently, the kind of person who will not be dissuaded from saying out loud in public truths that really can’t be avoided but that no one wants to talk about. What’s not to like? You know the person who does this is going to be misunderstood, sometimes deliberately. The arguments will be parodied and the findings contested. The proponent himself will be vilified. Callahan was 57 when he wrote the first edition of this book. He is in his mid-80s now, i.e., he is now the age of the people he characterized as “the elderly” when he wrote the book.
The problem Callahan is trying to deal with is talked about all the time as a negative proposition. People will say that we are going to have to deal with rising healthcare costs. They will say that a larger and larger percentage of those costs come from extending the lives of the elderly. Callahan wants to approach it as a positive proposition instead. He wants to see medical expenditures cut back for people who have lived long enough.
That sounds like a good approach to me although I am sure I would not want to pay the price that Callahan has paid for saying it out loud. I would not like to pay even the price Oregon Congressman Earl Blumenauer paid for his proposal that Medicare should pay for the conferences that elderly patients are supposed to have with their doctors about how they want their bodies treated when they can no longer say what their preferences are. Blumenauer’s opponents called those conferences “death panels.”
So talking about this issue in public is going to lead to stone throwing. Maybe some sticks, too.
The genius of Callahan’s proposal is that he proposes a way to curtail expenses for people who have lived “long enough” so that we will be able to offer crucial medical services to people who have not yet lived long enough—people who deserve, by our most commonly expressed values, our help in living longer. If that sounds scary, let me outline the edges by trying to express the alternatives. One is that crucial medical services to people in the midst of their lives ought to be cut back so that people who have already lived a long time can be supported even more. That doesn’t sound so good. Another is that everyone ought to have a valid claim on all the medical care they would like and that the total cost should be borne by the taxpayers. That doesn’t sound so good either. The last one is that everyone who can afford it should have all the medical care he wants and that people without resources should be denied all but the most basic medical care. I don’t like that one either.
Where does that leave us? It leaves us where Callahan begins. We need to get some kind of grip on what “enough” means, when we are talking about spending to prolong human life. Then we need to constrain expenditures for people who have reached that landmark status so we can provide more services to people who have not yet lived long enough.
See what I mean? When you say it positively rather than negatively, it just sounds like common sense. On the other hand, a lot of things sound like common sense when they are phrased in terms of public policy and then they stop sounding like common sense when they are applied to actual persons. So let’s think about these proposals in terms of an actual person. And how about letting me be the person?
Have I lived long enough? Have I already had, that is, a great deal of what people think life is about?
I think that second question is a better one. The first question sounds like it is about numbers. I’ve lived 70 years or 80 or 90 and that’s “enough.” Enough for what? But if you look at some widely used markers of a rich life, you are not just using numbers.
I have some markers in mind. Susan K. Gilmore, who is a counselor and a writer about counseling and who was, in the early 1970s, my counselor says it is often helpful to think about work, relationship and aloneness. I met Sue while I was working on a graduate degree in political science so I added “politics” to the list. I was influenced partly by the fact that adding politics gave me a set of values captured in the acronym WRAP, but I was also in mid-career as a professor of political science so I imagined that I was going to spend the rest of my career talking to undergraduates about the allocation of values in the polity.
And I have. I retired from that occupation today.
So Callahan’s question could be refined by asking, first, whether I have had as much work as anyone really ought to expect. I have, surely. I started teaching in 1960 and just now retired from it. That’s fifty-three years. And I had a brief fifteen year “sub-career” in politics in the middle of that. I’ve been hired and fired and overpaid and underpaid and overappreciated and underappreciated. I’ve had all the kinds of benefits I know about in my work life and some I just discovered when they happened to me. If that’s not “enough,” how could “enough” possibly be defined?
So I’ve had enough of the advantages people are looking for when they plan a career. How about relationship? Well, I haven’t been a hermit. I’ve been a son and a husband and a father (and a stepfather); I’ve been a lover; I have served others and have been served by others. I’ve chaired committees and written minutes and proposed agenda items. I’ve celebrated the lives of others and have been, in my turn, celebrated and treasured and—even more—been really understood. That last one has been a little unsettling sometimes, but it profoundly affirming.
So I’ve had most of the experiences people say they value when they talk about relationships. I’ve been rich in relationships. All my true relationship needs have been met, at one time or another. I have had, by even the most generous accounting, “enough.”
“Aloneness” isn’t the absence of other people; it is only the opportunity to come to grips with who I am, myself. I have had every opportunity to become comfortable with who I am, as well as with what I’ve done. I don’t know of any good metric to measure my own internal life; not even one good enough to use, myself. But I have had plenty of opportunity to learn that sweet spot between being comfortable with myself and challenging myself to do better. I have had a very rich array of models. I have had people who are willing to honor me with their affirmation and with their criticism. I’ve had the leisure to be thoughtful about myself and my life. I had, for example, a long commute to work for a number of years and it provided a good deal of leisure for this kind of speculation.
Separating achievement, which I admitted I didn’t know how to measure, from opportunity, I would say that I have had “enough” aloneness. At the very least, it makes no sense to me to claim that I have a right to more than I have already had.
Politics, my own addition to Sue Gilmore’s list, defies careful measurement as well. I have never aspired to public office, but I’ve been a policy analyst and a lobbyist. I’ve written and delivered testimony to legislative committees. I have ghost-written a lot of letters for a lot of governors. I have defined for many generations of undergraduates just what public values will have to be attended to and what they will have to know to act on their own values in the public arena. I was a teacher, after all. If those are all “politics,” and that is what I would call them, it cannot be said that I have not had abundant opportunities to hone and practice my craft.
Now comes the last little half-step. I have defined “enough life” as “enough of all the components of a life like mine.” I have touched on each of those components—work, relationship, aloneness, and politics—and have concluded that I have already had more than anyone could claim to have a right to. The last half-step is to conclude that I have had enough life.
And what does that mean? It doesn’t mean that I don’t want to keep living the life I am living. I like it very much and I want to keep doing all the things that I love and that I am still able to do. It doesn’t mean that I renounce the medical expenditures that would keep my life vivid and that would help me keep living this kind of life. It does mean that I have no claim to the simple extension of my life—just making it longer—rather than to the restoration to a health that is still possible for me. If I could live the kind of life I value if only my doctor would prescribe antidepressants for me, then I would claim the right to the antidepressants. If a feeding tube could successfully extend my dying for two months, I would say I do not have a right to that. The antidepressants would give me more “life;” the feeding tube would only postpone my death.
I want to say, on my own behalf and on behalf of all other old people who would like to associate themselves with this standard, that I affirm the first and reject the second.