JOHN SILBER, the man columnist George Will called ``the nation's most interesting candidate in 1990,'' was at it again, this time turning his acerbic tongue to the problem of financing the future cost of health care for Massachusetts's elderly. ``When you've had a long life, and you're ripe,'' Silber said, quoting Shakespeare, ``then it's time to go. I think Jack Kennedy had it right when he said life's unfair. There's a time to be born and a time to die.'' Despite the immediate condemnation of his impolitic rhetoric by his Democratic rivals for governor, Mr. Silber was raising an old question in health-policy circles: In the face of limited resources and a critically overgrown health-care delivery system, how does government decide how those resources are to be fairly and efficiently allocated?
Answering that question means that policymakers have had to consider making dispassionate calculations about the importance of growing old, how and when medical interventions is appropriate for extending longevity, and whether expensive medical technology ought to be used merely to prolong life, while not measurably improving its quality.
The fundamental issue, suggests Daniel Callahan, a leading medical ethicist at the renowned Hastings Center, is ``what is the extent of our common obligation as a society - using the instruments of government - to provide health care for the elderly?''
For Mr. Callahan resolving that issue means looking at the impact of future health-care costs of America's elderly population, and coming to terms with the fact that approximately one-third of this country's health-care expenses are incurred by people over 65. Although this group represents only 11 percent of the population, Stanford economist Victor Fuchs has pointed out that we spend 1 percent of the country's gross national product on health care for older citizens during their final year of life.
Mr. Silber's tough talk about just saying ``no'' to an 80-year-old seeking a heart transplant speaks directly to the conflict society faces in its natural inclination to perfect technology that can extend life. But in a time of severe budgetary constraints at both the state and federal levels, it is hardly realistic to envision a time when people will be able to live beyond what Mr. Callahan has termed the ``natural life span.''
As tempting as it is to employ every medical and technological advance to the care of any patient who is deemed worthy of its use, real questions exist over whether much of that technology is worth its cost to our health-care system. Medicare costs, for instance, are now growing at 8 percent yearly. By 2040, those over 65 will make up 20 percent of the population, and 25 to 35 percent of the nation's medical expenses in any given year go to the 5 or 6 percent of that group who die during the same year. Critics say that this expensive, and seemingly irrelevant, care could be more beneficially directed elsewhere.
Not only the increasingly large number of elderly patients, but also the treatment they receive is of growing concern. A Rand Corporation study of four major surgical procedures received by a sample group of 300,000 Medicare patients found that a third of the operations were either unnecessary or contributed little to quality of life. Such studies lead Rand to suggest that careless use of high-tech medicine might account for $100 billion in yearly wasted expense.
``Government,'' says Mr. Callahan, ``cannot be expected to bear, without restraint, the growing social and economic costs of health care for the elderly. It must draw lines, because technological advances almost guarantee escalating and unlimited costs which cannot be met, and because in any case it has a responsibility to other groups and other social needs, not just to the welfare of the elderly.''
This view is particularly apt in a nation where some 35 million citizens have no health insurance, and where, according to former Colorado governor Richard Lamm, ``our octogenarians have the highest life expectancy in the world, and yet we're 20th in infant mortality.'' The shift in medical priorities has led some states to reassess how scarce resources will be allocated. In Oregon, for example, legislators in 1987 voted to exclude Medicaid reimbursements for expensive organ transplants and channeled those funds to poor women for prenatal care.
Part of the need to reassess medical care for the elderly arises from a shift in medicine itself. Historically medical care for the aged involved the simple provision of care and comfort; now, due to advances in medical technology, we can actually reverse the effects of disease and age through aggressive and often costly techniques.
While few wish to limit the development of sophisticated technological advances in medicine, policymakers have to insure that the high cost of that technology is justified by its use by groups who benefit from it most. Great Britain, for example, has already introduced rationing of medical care, and patients over a certain age who require kidney dialysis or hip replacements, as two examples, are prevented from using these procedures. Kidney dialysis, which was originally developed for patients between 15 and 50, is now used in this country by 25,000 people over 65 (30 percent of all users).
Critics of health-care rationing seek other, more humane, solutions - diverting the ``peace dividend,'' for instance - to accommodate the future demands of America's aging population. In the meantime, people like Mr. Silber will be making us face the difficult choice of ``who will live and who will die.''
Perhaps Mr. Silber might have posed his questions more delicately, but they are questions that, as a society, we must eventually ask ourselves.