Examining The Limits of Life

By BONNIE ANGELO/NEW YORK

Americans have an "insatiable appetite for a longer life," complains Daniel Callahan, 57. They should be "creatively and honorably accepting aging and death, not struggling to overcome them." Medicine, Callahan chides, ought to "give up its relentless drive to extend the life of the aged," who in any event are often "being saved from death for chronic illness, with Alzheimer's as a tragic example." It is time to honor a "natural life-span" that normally winds down in the late 70s to mid-80s, he says. "How many years do we need to have a reasonably decent life, to raise a family, to work, to love?"

A provocative argument: longer is not better. But Americans have shied off from similar points made in recent years. When former Colorado Governor Richard Lamm spoke out in 1984 about the terminally ill's "duty to die," his forthrightness seemed eccentric. In his writing, the late Dr. Rene Dubos urged more emphasis on the quality rather than the length of life, but his eloquence failed to generate sustained debate. Callahan, arguably the nation's leading medical ethicist, means to make discussion of the subject inescapable. For 18 years, as director of the Hastings Center in Briarcliff Manor, N.Y., he has grappled with the tide of problems arising from biomedical advances. In a new book called Setting Limits (Simon & Schuster; $18.95), he makes his hard case with a care that is feeling but unflinching.

The fastest growing age group in the U.S. proportionately is the over-85s, he reports, and children born this year can expect to live 16 years longer than their grandparents born in 1930. Such statistics prompt visions of a life-span beyond 100 years, a prospect Callahan finds alarming. In the past two decades, the amount of the federal budget spent on those over 65 leaped from 15% to 28%; and the $80 billion spent in health care for the old in 1981 is expected to pass $200 billion by the year 2000. The result is a serious threat to the economics of health care.

Callahan's long-term limits -- medical, economic and social -- will seem harsh to many. He would have Congress restrict Medicare payments for such ! procedures as organ transplants, heart bypasses and kidney dialysis for the aged. States should give legal status to "living wills," allowing individuals to demand that they not be kept alive artificially. Respirators would not be used for the terminally ill. On the emotional issue of extending life by use of feeding tubes, he reasons that as external life extenders in some cases, they also should be treated as artificial intrusions. His logic moves inexorably on to the withholding of costly antibiotics.

The author firmly opposes euthanasia, however, which involves active steps toward direct killing. And he would have doctors provide the elderly with greater relief of their suffering and more home care and support. He would also increase medical resources devoted to defective newborns, the now hopeless victims of AIDS or any nonaged patient with slim chances of recovery. "A 35-year-old has not had a chance to live out a full life-span," he says. "Some research may come along in time to save them -- we don't know that they are all going to die." Callahan carefully avoids setting a flat cutoff age, preferring to let the condition of the patient, the judgment of the doctor and the wishes of the individual interact.

Part of his argument rests on a deep concern about "intergenerational equity." There are "better ways to spend money than indefinitely extending life," he charges. Long treatment of the elderly drains funds from the health needs of other groups and from urgent social problems. He also has withering views about many of the non-ill elderly: the "young-old" who deny age and indulge an "it's-my-turn" attitude. Their lives, says Callahan crustily, would gain meaning "if instead of taking a cruise, they work for a cause."

He knows that rationing health resources on the basis of age is an "austere thesis," but he takes to the intellectual battlements willingly. Thinking through the fundamental moral and practical problems of life is the unique concern of the Hastings Center, which he co-founded with Psychiatrist Willard Gaylin in 1969. Reared in a comfortable Roman Catholic family in Washington, Callahan earned a Ph.D. in philosophy from Harvard in 1965. By then he was a leader in the effort to liberalize Catholic thought as an editor of the Catholic weekly Commonweal. But about 1968 "I started fading from Catholicism," he says without elaboration. "I ceased being a believer." His wife Sidney, a psychology professor and writer on religion and feminism, converted to the church and remains active in it; they have six children.

Writing a book in 1968 on the morality of abortion -- he describes his stance as "conservative pro-choice" -- Callahan hit on the idea for a think tank on biomedical ethics. At the start, Callahan and Gaylin wondered if there would be enough moral issues to keep them busy. But since an initial project on the definition of death, Hastings researchers have dealt with organ transplants, artificial reproduction, surrogate motherhood (Callahan opposes it; some of his colleagues approve), AIDS testing and privacy, genetic engineering -- a never-ending list.

The center, which now has twelve professionals and a support staff of 15, is housed in a stucco mansion on the Pace University campus and runs on an annual budget of $1.6 million, met largely through foundation grants and contributions from its 11,000 members. In addition to publishing regularly, the Hastings ethicists develop model legislation, draw up guidelines for public policy, consult in such tortured cases as Karen Anne Quinlan's fate and assist universities in setting up ethics departments. "People used to think of medical ethics as between doctor and patient at the bedside," says Callahan. "We consider wider public policy, how Government spends its money, issues that affect millions of lives, as well as the exotic issues where the number is small."

He puts artificial reproduction and genetics at the top of his list of emerging concerns. The possibility of selecting a child's sex, he contends, has "profound social implications." Advances in genetic screening that identifies whether the unborn individual will be subject to heart disease or cancer or schizophrenia raise a new round of issues. Would altering the defective genes in utero be ethically permissible, given the risk of unforeseen results for future generations? The moral dilemmas spawned by the high-tech world of biomedicine -- closer to salvation or Pandora's box? -- are sufficient to keep Callahan and his Hastings associates busy for a lifetime. A natural life-span, of course.