Part 1
As a physician, the Hippocratic Oath and the ethics of the practice of medicine do not allow me to be judgmental about patients’ states or to find a reason to treat some patients preferentially. However, this does not mean that I am not entitled to a personal opinion; only that this practice should not affect my practice. As such, I can have an opinion of which patients deserve healthcare more and inspire me to work hard to ensure they recover. In this paper, having been presented with two elderly patients who are still employed who both have life threatening conditions and superimposed congestive heart failure – a man who cares about his health and a woman who leads an unhealthy lifestyle – I give factual reasons as to why I would work harder to save the life of the man and not the lady.
First, the man is likely to have better health outcomes that the woman. The man leads a relatively healthy lifestyle and thus his concomitant morbidities are less likely to complicate and thus the man is likely to survive for a longer time and requires less hospitalization. However, for the woman, her extent of disease and her lifestyle are likely to complicate her heart failure; combining these avoidable complications with her other condition would kill her faster. As indicated in studies, exercise is important for prevention of cardiovascular diseases including heart failure; exercise is also important in slowing the progression of heart failure hence the likelihood of early mortality in her (Villacorta & Mesquita, 1999). Secondly, obesity and poor diet can compound heart failure with even more fatal complications like myocardial infarctions and stroke due to accelerated atherosclerosis (Villacorta & Mesquita, 1999). Thirdly, the fact that the woman has failed two cancer protocols already shows that her response to her primary morbidity is not good, there is a chance that the third protocol would also fail. Moreover, protocols other than the preferred first protocol for a given disease state are usually less effective or have more toxicities – a combination of these factors could lead to her worse outcomes. I would definitely work harder to save a patient I am more optimistic about their outcomes. Additionally, a long history of smoking, which is in itself a major cause of cardiovascular disease predicts makes it more likely for other cardiovascular pathologies complicating the heart failure to crop up in the lady.
In addition, based on their behaviors, it is obvious that the man is more likely to adhere to their regimen when compared to the woman. As alluded to in their histories, failure to adhere to the prescribed protocol can result in mortality due to heart failure even before the other disease gets to a much more complicated point. The lady has a history of refusing to adhere to regulated diets and does not just want to exercise, there is no guarantee that she will adhere to the prescribed protocols this time. Trying to fight for her seems like a waste of energy.
Furthermore, on the basis of Disability Adjusted Life Years (DALYs) and Quality Adjusted Life Years (QALYs), I would work harder to save the man. As earlier alluded to, the woman is likely to have complications both with the heart problem and her other chronic condition. This means that the woman is likely to have longer hospital stays or is likely to remain seated at home due to disease hence a reduction in her a QALYs (Weinstein et al., 2009). Moreover, the DALYs of the woman will be lower than that of the man. As seen in their stories, the man is still working and is likely to continue at his workplace for some time since he takes good care of his health. In other words, the man is more productive to the economy than the man. Even though the woman’s expert opinion is sought for by many organizations and governments, her personal effort and initiative to contribute to the economy are much lower than the man; the man keeps himself healthy, is liked at the workplace, and seems to love his work.
This, therefore, means that the woman has a lower value to the country’s economy than the man. As a country, part of the reason for giving preferential care to some individual and not others is based on their economic value as projected by the DALYs and QALYs of their diseases (Braithwaite et al., 2008). In fact, the value for the woman could even be in the negative ranges, considering that she has been on two different cancer protocols before. In this case, the lower QALYs and DALYs for the woman mean that in the context of the national economy, she is less valuable. In this context, a negative QALYs and DALYs will mean that the lady is a liability to the economy of the country (Weinstein et al., 2009); the man, on the other side, is still an asset wherever he works and thus contributes positively to the economy of the country. It is thus less important to keep spending on such individuals.
In addition, the woman, who has spent five times as much as the man on medical charges, has all her medical fees covered by the government. Although, both the man and the woman have Medicare, a government sponsored scheme for covering for the healthcare charges of elderly people (Hartmann et al., 2013), the man also has personal savings that can cover for his medical bills where Medicare stops unlike the woman who has not bothered to improve her private retirement account. This just shows how much the woman is a liability to the economy, she is less productive economically yet she requires larger medical cover and has little private savings that can be turned to for coverage of her medical bills.
Finally, as a physician, having patients die while under your care is something that one looks to avoid at all costs. But, as earlier alluded to, by leading an unhealthy life, the woman is likely to complicate and mortality is very likely (Villacorta & Mesquita, 1999). Moreover, her history of failure on more than one treatment is in itself a sign of poor prognosis. This means that if the two individuals continue to live the way they do and barring any external factors which may compromise the health of any of them further like road traffic accidents, the chance that the woman will be alive in the next ten years is much lower than the chances of the man being alive. Thus, the chance of the woman dying under my care is more likely than that of the man dying under my care, I definitely wouldn’t fight to remain on a case that would only soil my mortality record. Moreover, physicians like working with cooperative patients who take the instructions given; in this case, the man is that patient. Although challenging situations can be intriguing, landing oneself a case which is likely to complicate because of a patient’s non-adherence to prescribed protocols is not interesting.
As seen in the discussion above, the man is definitely the patient I and any other physician will struggle to keep alive. The man is a patient who shows that he wants to live and is willing to do all there is to be done that can enable one to live. Moreover, considering theirs QALYs and DALYs, the man economically superior to the woman and is thus a patient one should strive to save.
Part Two
Question Three
Based on results of recent censuses conducted in the United States, rectilinear population pyramids have been derived. Rectilinear population pyramids imply that the number of individuals in each age group does not differ greatly with that of individuals in the next age group which is unlike a traditional population pyramid which was triangular in shape. In the triangular population pyramid, the dependents made the largest proportion of the population while aging individuals were the least in the community. A rectilinear population pyramid, on the other side, implies that the proportion of the population that is aging is almost equal to the proportion of the population who are in their working age and the dependents. This usually implies a slow birth rate and a much-reduced mortality rate.
In terms of policy, policies are usually designed with special focus on the majority groups in the population. This explains why many existent policies in the USA at the moment were meant to protect the young population which made the largest proportion of the population by the time the policies were made. However, with the increasing proportion of the aging population, the policymakers have shifted their focus towards them. This paper analyzes the policy implications of a rectilinear population pyramid on the USA and its benefits.
First, policymakers have moved to protect the aging population from any form of discrimination. This is mainly epitomized by the Age Discrimination in Employment Act of 1967. The act requires that employers do not marginalize aging individuals and deny them employment on the basis of their age; everyone has a right to be employed if they wish to and qualify for the employment opportunity in contention (Congressional statement of findings and purpose, 1967). The act also requires that employers do not set arbitrary age limits for individuals whom they can employ. This law is definitely beneficial, not only to the aging population but to the economy in general.
By ensuring that a large and ever-growing proportion of the population are free to seek employment opportunities that they qualify for in any organization, the daily requirement of these proportion of the population will be taken care of. Thus, the government and other individuals will not have a large proportion of people to fend for. A country which has rectilinear population pyramids and does not adapt such a policy is likely to find themselves in a situation where they have so many dependents to fend for; the policy simply allows potential dependents to fend for themselves. Secondly, as revealed in the act itself, lack of employment can lead to deterioration of skills or knowledge that would otherwise have proven to be of great value to the economy. Additionally, far from the initial thought that the law seems unfair to employers by forcing them to employ aged individuals who have little to offer, these aged individuals have a great experience that can be a great asset in the cooperate world (Congressional statement of findings and purpose, 1967). In reality, this law just enhances organizations’ ability to harness this great experience. Moreover, this law is meant to protect organizations which were set to set arbitrary age limits for employment – with time, if the trends in American population which are mainly down to a low birth rate and long life expectancies, continue in this way, it might happen that the only people available to employed are the elderly; this will put organizations with arbitrary age limits in serious conundrums of not having people to employ.
A second major policy change has been the steady increase in health spending on programs that are meant to enhance the health of the elderly individuals. This can be thought to be both a consequence and a contributing factor to the occurrence of a rectilinear population pyramid in the USA. The inception of such programs has had a role in enhancing the life expectancy which in return increases the proportion of the elderly in the society. As a consequence of rectilinear growth patterns, health policies which are meant for the elderly people are promoted since they cover the health of a majority group in the population (Hartmann et al., 2011). Among these policies is Medicare, a health financing scheme meant for the elderly that id financed by the government.
This health insurance policy is of great importance to the economy. First, this policy safeguards the health of most workers – a rectilinear population pyramid implies that most workers are aged individuals. A scheme which looks to ensure that the health of aged individuals is safeguarded is thus of great importance to an economy where the aging population is the most important contributor. Socially, the low birth rate implies that the traditional working class comprises only a little part of the population; as such, the aging population does not have many caregivers who can take care of their health. As Cola and colleagues (2012) put it, Medicare is thus a scheme where the government takes direct responsibility for the health of individuals who do not have many people to care for them.
A third policy which has been made for the elderly population in the USA is the increase in nursing homes and other long-term care facilities (Health and Aging Policy, 2017). As earlier alluded to, the reduced number of caregivers for the elderly population demands that the government itself takes the responsibility to care for the senior citizens. Creation of centers where these old individuals can be cared for is one of the things that the government has done to help them. At the same time, the advancement of the idea of medical homes has also progressed. These medical homes are meant to ensure that the elderly in society receive medical care from a set up that is comfortable enough to be comparable to home for them.
Question 6
The distribution of the population by age and social affluence in the USA as at now is skewed. The biggest urban areas in the country have most of the young, energetic, working-class, and affluent Americans. This leaves the rural areas with older people who are less affluent. However, by looking at the current trends in American population which are dominated by low birth rates and longer life expectancies, it can be postulated that this young and affluent population in American urban areas will at one point become old, sick, and senescent. At that time, the urbanized areas of America will be in a serious economic predicament. The economic predicament which can result from having an old and sick population is discussed below.
The first and the most obvious of the economic problems that a city of the country with an aging and sick population are likely to get into is the lack of human resource or labor. Lack of human resource definitely slows the economy even in the presence of large amounts of financial and other material resources. A thinning labor force definitely translates into decreased productivity. Decreased productivity will translate into what can be seen macro-economically as a decrease in GDP. However, reduced productivity also affects the locals adversely.
A decrease in available laborers in a country or city with an almost constant population – low birth rate and prolonged life expectancy – means that there will be a decreased proportion of the local population who will actually be working. This, coupled with the reduced productivity has been known to reduce the per capita income in the given city. Reduced per capita income translates into poorer conditions of living that what was there before.
Moreover, having an aging population will definitely increase the elderly dependency to almost unbearable levels for an economy which has stagnated (Little & Triest, 2001). Considering the fact that the law of the USA allows for coverage of the medical bills of persons and many other fees of persons just because they are elderly, an elderly population in any city in the USA will thus encroach on the resources of the city. Again, because of the low birth rates, most likely, the old and sick individuals will not have left behind any young and responsible individuals that can take care of them in their old age. Everyone will be sick and retired and entitled to free healthcare that is sponsored by the government. Considering the fact that, the economy of the city will have itself stagnated, such will cause a big problem. The local government expenditures on health alone in such a situation can cause economic collapse. McMorrow and Roeger predict that in countries whose population pyramids are linear and the population of the elderly is increasing out of proportion with that of the young, their GDPs are likely to fall. The two postulate that the US will be one of those countries and that the GDP of the US is likely to fall with up to 10% (Chen, 2009). This means that because of the flipping economic tide, the fall in the GDP of the specifically affected cities like Los Angeles will even be higher.
McMorrow and Roeger cite a paper by the IMF which sheds further light on the issue of the drop in GDP and increase in the dependency ratio; the paper reported that increase in the dependency ratio definitely reduces the rates of saving in any country. This is because the finances that would have been saved will now be required to cater for the daily needs of the dependents. If the dependents in question are the elderly, then the coast increases further considering their increased susceptibility to certain disease conditions. In other words, the reduced saving is not only on the side of the individuals but also on the side of the governments who have to cater for the health requirements of the dependent elderly population as it is in the American setup. A reduced rate of saving definitely translates to a reduced rate of investment; without investment, little progress in terms of GDP is made.
In addition to the increase in the government’s expenditure on health, the government’s expenditure of pensions and other retirement benefits is likely to increase (Little & Triest, 2001). The chaotic situation in the city will be one in which the majority are retiring and demanding retirement benefits yet there is no one to replace them at their workplace. This, coupled with the drop in productivity and GDP precipitates a situation where the government’s expenditure exceeds the governments the income. This is what sets in a vicious cycle that can eventually lead to economic collapse.
Part of the key components of the vicious cycle that is mentioned above is the reduction in the expenditure on education in order to cover for the other government expenditures which will be predominated by hospital fees and retirement benefits. Cutting on expenditure on education will definitely interfere with the progress of the youth and thus the future population. As a result, the aging population will be replaced by fewer and inadequately prepared younger individuals. As such, individuals with less expertise than their predecessors and no experience at all cannot save an already collapsing economy, thus the economy will only grow worse until total collapse is achieved.
Furthermore, as a late effect of the increase in government expenditure, there is likely to be an increase in the levels of taxation (Little & Triest, 2001). A government that spends more will definitely look to earn more. This can only be made possible if such a government demands higher taxes. The increase in taxation, especially of basic commodities, is what cause inflation. Inflation is in itself a sign of a poor or worse, collapsing economy. On the citizens, increased taxation and the resultant inflation make life harder for them as it becomes harder for them to afford basic commodities. In other words, the opposite of the high level of affluence that preceded this situation is achieved. As such, stagnation in population growth can convert a given population from high affluence to very low affluence.
The other main problem faced by economies that are made of aging populations is their dependency on external markets for their products (Chen, 2009). Naturally, as people age, their likes for certain products reduces, this means the locally produced goods which targeted the young and energetic population that was there in the past now lack market totally. Considering the fact that these products which lose market might have had major significance in the economy, the decline in their market locally will negatively influence the economy. This, therefore, means that the local firms have to seek for markets elsewhere – something which might not be easy or even not feasible at all. Although this decline in the market for certain commodities seems to be opening an economic niche for some certain products that are favored by the older population, this is not always true. Moreover, the consumer behaviors of the elderly are markedly different from those of younger age groups – the elderly have diseases and many other things to think of and thus they do not provide a market as reliable as one that can be provided by younger age groups. As such, the decrease in local market compounds the already decreased productivity hence a greater negative impact on the economy.
In addition, the process of transitioning from an economy whose demand is driven by requirements of a young and energetic population to one where demand is driven by the opposite age group, though not necessarily negative, can be tough and can lead to massive problems in the process of transitioning (Freeman et al., 2012). Before producers of the new increasingly demanded products settle and manufacture just the right goods for the population, the manufacturers who had been there before will already have collapsed.as such, the economy in a country with an aging population is likely to go through a shock stage from which they may or may not recover.
As seen from the discussion above, all members of a given population are important. And although a rectilinear population pyramid has been described as being the best economically, its precipitating factors like a low birth rate and longer life expectancies can lead to worse problems in future. These problems are exemplified by an aging population. An aging population will mean a decreased labor force, increased government spending, higher rates of taxation, and an inevitable drop in GDP.
References
Braithwaite, R. S., Meltzer, D. O., King Jr, J. T., Leslie, D., & Roberts, M. S. (2008). What does the value of modern medicine say about the $50,000 per quality-adjusted life-year decision rule?. Medical care, 46(4), 349-356.
Chen, S. (2009). Aging with Chinese characteristics: a public policy perspective. Ageing International, 34(3), 172.
Colla, C. H., Wennberg, D. E., Meara, E., Skinner, J. S., Gottlieb, D., Lewis, V. A., … & Fisher, E. S. (2012). Spending differences associated with the Medicare physician group practice demonstration. Jama, 308(10), 1015-1023.
Congressional statement of findings and purpose. (1967, December 12). Retrieved May 08, 2017, from https://www.law.cornell.edu/uscode/text/29/621
Hartman, M., Martin, A. B., Benson, J., Catlin, A., & National Health Expenditure Accounts Team. (2013). National health spending in 2011: overall growth remains low, but some payers and services show signs of acceleration. Health Affairs, 32(1), 87-99.
Health and Aging Policy | Health and Aging Policy Fellows Program | Shaping a healthy and productive future for older Americans. (2017). Retrieved May 08, 2017, from http://www.healthandagingpolicy.org/health-and-aging-policy/
Little, J. S., & Triest, R. K. (2001). Seismic shifts: the economic impact of demographic change. An overview. In Conference Series-Federal Reserve Bank of Boston (Vol. 46, pp. 1-30). Federal Reserve Bank of Boston; 1998.
Twenge, J. M., Campbell, W. K., & Freeman, E. C. (2012). Generational differences in young adults’ life goals, concern for others, and civic orientation, 1966–2009. Journal of personality and social psychology, 102(5), 1045.
Villacorta, H., & Mesquita, E. T. (1999). Prognostic Factors in Patients with Congestive Heart Failur. Arq Bras Cardiol, 73(3), 353-363. Retrieved from http://www.scielo.br/pdf/abc/v72n3/a08v72n3.pdf
Weinstein, M. C., Torrance, G., & McGuire, A. (2009). QALYs: the basics. Value in health, 12(s1), S5-S9.
