Dreams of Stagnation

Ronald Bailey from the November 1998 issue

False Hopes: Why America's Quest for Perfect Health Is a Recipe for Failure, by Daniel Callahan, New York: Simon & Schuster, 336 pages, $23.00

Life Without Disease: The Pursuit of Medical Utopia, by William B. Schwartz, Berkeley: University of California Press, 178 pages, $22.00

In False Hopes, Daniel Callahan stands athwart medical progress yelling "Stop!" His anti-technology, anti-freedom screed would be dismissed as the ravings of a Unabomber-style lunatic if it weren't for the fact that Callahan is the co-founder of The Hastings Center, a prestigious bioethics think tank in New York.

Borrowing the concept of "sustainability" from radical environmentalism, Callahan calls for "steady-state medicine." He imagines a future "in which a socially agreed upon proportion of the GNP is devoted to health care, with a set limit (which may be tacit as well as explicit); in which technological changes are slow to come and are rigorously screened for efficacy and affordability; in which changes in the health care system from year to year are relatively slight; in which budgets remain stable (allowed to increase only in proportion to an increase in the GNP or the rate of annual inflation); in which the public for the most part expects only slightly incremental improvement in the level and quality of health care; and in which further scientific gains are not deployed until earlier ones are fully utilized." In other words, the government should forbid medical advances that threaten to make some better off than others. Underlying this harsh prescription is Callahan's quest for "equity," coupled with a profound misunderstanding of economics.

Like many other allegedly deep thinkers in the area of health care, Callahan decries the growing percentage of the U.S. economy devoted to medical spending. This is much like deploring the fact that the automobile sector represents a much bigger share of the economy today than it did in 1910, or the fact that U.S. spending on computers has grown dramatically during the last decade. In the case of medicine, Callahan seems to believe that the additional benefits are not worth the cost. But in making that judgment, he is imposing his values on the patients who seek more and better medical care. He has decided that they are wrong.

Callahan blames rising medical costs on technological improvements. As an example, he notes that ultrasound imaging for prenatal screening, rarely used at first, is now routine. But that's because the cost of an ultrasound has fallen dramatically relative to wages.

Research conducted in recent years has also reduced the cost of ulcer treatments. Physicians now recognize that 90 percent of ulcers are caused by a bacterium. These ulcers can be cured with a combination of antibiotics and acid blockers such as cimetidine (Tagamet) and ranitidin (Zantac), avoiding the need for surgery. This development has saved billions of dollars and spared millions of people intense pain.

Yet it is precisely this sort of continual improvement in medical care that seems to upset Callahan. "The criteria for normality are constantly raised, keeping in step with medical possibilities," he complains. "No longer is sixty-five thought to be a reasonable age after which death is not `premature.' No infant mortality rate, however low, is good enough. No ache or pain should go unrelieved if relief is desired. Most important, what would have been accepted as a decent level of health in one generation is unacceptable in the next." If it was good enough for granddaddy, Callahan implies, it should be good enough for you.

Callahan ignores the main factor underlying increases in medical costs since World War II: third-party payments. For decades, American patients have had little reason to worry about how much they spend on medical care, because someone else usually pays for it. Consequently, doctors and hospitals have little reason to control their expenses. Spiraling costs are the predictable result. The federal government helped create this situation by exempting employer-provided health insurance from wartime wage controls and from the income tax. It also added its own third-party payments through programs such as Medicaid and Medicare. Nowadays patients are accustomed to low out-of- pocket medical expenses, and big companies are expected to give their employees gold-plated health insurance policies.

When it comes to medical care, the whole idea of insurance--of protecting against unexpected losses--has been obscured. Think how expensive your car insurance would be if the cost of routine maintenance such as oil changes and tire purchases were included in your premiums. This is the problem with most health insurance policies today. Instead of insuring against large, unpredictable costs such as chemotherapy or a heart bypass, many policies cover what is essentially routine maintenance: flu shots, annual physicals, and so on.

Rather than unravel this dysfunctional system of third-party payments, American companies have turned to health maintenance organizations, which constrain both doctors and patients to keep costs low. Callahan says HMOs have been ultimately unable to control costs, so the government needs to step in. "A steady-state, equitable medicine will have to limit, not expand, patient choice," he writes. "It will require frank rationing. It will work to resist patient demands, particularly demands stimulated by market pressure and incentives."

Callahan does not even consider the possibility of using "market pressures and incentives" to control costs. Tax-free medical savings accounts (MSAs), for example, allow people to manage their own health care budgets to a far greater extent than third-party payment systems permit. MSA holders buy catastrophic health insurance policies with up to $2 million in coverage at remarkably cheap prices. My quarterly premium is just $215, less than my car insurance payments. Because I pay for routine medical care, I carefully inquire about prices and compare services before I buy.

Callahan is right when he argues that health is not the supreme value. But he does not seem to grasp that markets allow people to set their own hierarchies of values. One person might prefer to preserve the family fortune and pass it along to her heirs rather than spend it on medical treatments that extend her life by a few months. Another might prefer to buy an expensive new car rather than purchase comprehensive health coverage. Instead of embracing its potential to accommodate diversity, Callahan decries the market as "a notably goal-less institution."

Callahan clearly has a problem with such open-endedness. He treats people as interchangeable parts of a collective, suggesting that we "look at health in terms of the need to have healthy citizens in order that the institutions and groups of the society might function well." He argues that "coercive efforts to change unhealthy behavior" are justified because "bad individual health behavior...does harm to others, even if the health risk-takers pay their own health care costs. Money is diverted from other uses, personnel are diverted from other patients, and lives are wasted that could serve us all." By Callahan's reckoning, then, we cause "harm to others" when we spend money on expensive meals, fancy clothing, or any other purchase of which he does not approve. Perhaps we should all be compelled to eat at Burger King and shop at K-Mart for the greater good of society.

Callahan says decisions about health care "must be subject to public debate and politically ratified....The principle here is that what medicine can do for individuals will almost certainly have social consequences, and thus requires community approval." But everything has "social consequences" in the capacious sense meant by Callahan, including my preferences in soft drinks, magazines, and department stores. His "principle" leaves no room for private choice.