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Am I My Parents' Keeper? An Essay on Justice Between the Young and the Old.

Some one-idea books put forth a simple novelty, any curious notion that is briefly engaging but quickly forgotten in addressing the everyday issues of the world. Other books though they are a much rarer species-also develop a single, central idea, but one of such power that it succeeds in illuminating an enormous range of issues that have previously seemed intractible. Norman Daniels's Am I My Parents' Keeper? is one of this rare latter species. Appropriately, this book has already become a classic, widely recognized both for the importance of its central idea and its sophistication in exploring iL

Am I My Parents' Keeper? is concerned with issues of justice among age groups. What is a fair distribution of resources between the young and the old, it asks, with respect to such goods as health care, long-term care, and income supports? Should allocations be equal to all age groups, and are unequal distributions to different age groups unjust? More specifically, are we justified in providing extensive Medicare expenditures to elderly persons, particularly in the last six months of life, while societal aid to

Am I My Parents' Keeper? An Essay on justice Between the Young and Old. By Norman Daniels (New York. Oxford University Press, 1988), 194 pp. $19.95. poor children, for example in programs like Aid to Families with Dependent Children, has been declining? Does our social security program meet the requirements of justice? Ought families provide care for elderly parents and grandparents, and ought social policies oblige them to do so?

To pursue these issues, Daniels draws on the theory of distributive justice developed by John Rawls. Those distributive policies will be just, Daniels contends, which would be chosen by parties in the "original position" who do not know their own age groups, and so will not favor the old over the young, the young over the old, or for that matter the powerful middle-aged over any other age group.

It is within this Rawlsian framework that Daniels introduces the central contribution of his book. He observes that we tend to think of issues of intergenerational justice as issues between competing age groups, much as we think of other issues of justice as matters of competition for societal resources between, say, racial groups or gender groups. But the young and the old are not groups competing in this way. Rather-and this is the heart of Daniels's central idea-all persons pass through different age groups or lifestages in the course of a normal lifespan. While we do not change our race or sex, we do age: we are all first young, then middle-aged, and then, provided the normal lifespan has not been interrupted by a premature death, old. Hence we must revise our conception of competition" among age groups: The choice each of us would make as a rational self-interest maximizer in the original position should not be conceptualized as involving distributions between age groups, but as a rationally prudent allocation plan over a lifespan. While different individuals currently fall at different points along the normal lifespan-some are currently young, some are currently old-as rational self-interest maximizers they will all agree about what would be the most prudent allocation of resources, under conditions of moderate scarcity, over the course of a lifespan.

Specifically, they will agree that since adequate health care in youth is prerequisite to maintaining in middle and old age that "species-typical functioning" which is of moral importance because it protects equality of opportunity-indeed, adequate health care may be prerequisite to the young's surviving into middle and old age at all-prudential planners thinking about the allocation of resources over their entire lifespans will favor heavier allocations to younger age stages, lighter ones to the elderly stages at the end of life. Furthermore, they will understand that the resources saved by reducing lifeprolonging care in very old age (in practice, this means age-rationing that precludes extensive care to stave off death in the very elderly)-can be used more efficiently when transferred to the care of the young; after all, fewer resources are in general required to preserve normal function in the young than in the elderly, where multiple organ systems begin to fail. But since allocation plans to use resources more efficiently at ages where they are most needed benefit everyone over their lifetimes, they will be attractive, under stable institutions, to rational self-interest maximizers, since these parties know they could not be the losers under such distributive schemes. Older persons are not rationed against," even though allocations to them would be reduced; on the contrary, they will already have realized substantial benefits from this system, including the current benefit of having an increased chance of reaching old age. To be sure, many objections can be made both to Daniels's strategy and to his conclusions. Some might object to his use of a Rawlsian framework, though his application of A Theory of Justice is among the most innovative and compelling since the publication of th at book. But the more telling critique involves pointing out that Daniels's prudential savings scheme presupposes a background of just institutions that are stable over time and involve closed systems, and can thus guarantee that savings realized at the end of the lifespan are actually transferred to earlier stages of the lifespan where they more efficiently promote species-typical function. The real world is not like this. Our background institutions are neither just nor stable. Scarcities in health resources are to a considerable degree artifactual rather than genuine. The situations of different birth cohorts are quite different: for instance, older cohorts were born before the development of antibiotics, and so as cohorts have already incurred a much greater risk of premature death than younger cohorts. Individuals are also members of different racial, gender, and socioeconomic groups, all of which influence their health prospects tremendously. In addition, a transfer scheme has difficulty accommodating fluctuations in population growth-like the baby boom-especially where costs precede the realization of savings. Funhermore, the U.S. does not currently have a closed health care system, such as the British National Health, where savings in one pan of the system are available as additional resources in another. And finally, a savings scheme of this son faces formidable start-up problems, since those who now reach old age would be asked to make sacrifices the benefits of which they can no longer realize in their own youth. Indeed, all of these objections are appropriate. Daniels recognizes and discusses them all. But they are appropriate only as objections to a real-world application of Daniels's lifespan approach, and Daniels explicitly asserts that he does not intend it in this way. "It is important to see," he says (p. 96), "that my argument is part of an ideal theory of justice, in which we can assume general compliance with principles of justice which govern other aspects of our basic social institutions. The argument does not readily or easily extend to nonideal contexts... " This may lead some readers to dismiss Daniels's exploration as uninteresting, if it does not permit inferences to be drawn about such practical realities as Medicare, social security, or national health. But this is precisely the wrong conclusion to draw: Daniels's exploration is very interesting, in pan because it provides new and compelling reason to make our institutions more stable, more just, and more capable of the efficient use of internal savings. The reason?doing so is of maximal benefit to all. This will be an extremely important book to read during the increasingly heated discussions of national health in the U.S.

One warning, however, is crucial to the use of this book. It appears to recommend a variety of policies that would exacerbate, rather than correct, current injustices-especially age-rationing by denying treatment to the elderly. This is compounded by incomplete attention to the distinction between normal and optimal age-specific functioning in the elderly, where normal" functioning is often already impaired by inadequate resources and poor care. But Daniels correctly insists that his account "is easy to misconstrue and misapply," (p. 96) and that it does not in general sanction rationing by age. Close, careful reading is essential if one is to understand this important volume. It does deal with real-world structures such as Medicare, social security, and national health, but only obliquely, by showing what conditions must obtain for versions of these structures to be just. Fortunately, Am I My Parents' Keeper? is already a classic; unfortunately, like many classics, it is easily put to dangerous and unintended use. It is not an argument for age-rationing health care here and now. Daniels acknowledges in his conclusion that his "simple intuition" about the distinctive nature of the age group problem-that we all age, and so are, over the course of a lifespan, both young and old-has grown into a "baroque construction" (p. 154). He is right about this: It is a "one-idea" book gone big, but big in the best of ways. It is the baroque at its best Caravaggio and Rubens, Handel and Bach-a permanently important work of philosophical art.
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Author:Battin, Margaret Pabst
Publication:The Hastings Center Report
Article Type:Book Review
Date:Mar 1, 1990
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