Dreams of Stagnation

Ronald Bailey from the November 1998 issue

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In the same vein, Callahan regularly lumps together choices made by consumers with choices made by governments. For example, he assumes that "developed countries will not be able to devote a steadily growing proportion of their gross national product (GNP) to health care...a limit will be set, politically and economically." This limit, he says, has almost been reached by many countries; there is "a growing public unwillingness to pay steadily higher prices or taxes for health care, or to devote an ever larger portion of national resources to the improvement of health care." Thus, Callahan conflates the willingness to pay higher taxes for other people's health care with the willingness to pay more for one's own. He assumes that "national resources" are to be allocated through a centralized political process; the idea that some resources do not belong to the government seems utterly foreign to him.

Not surprisingly, Callahan finds much to admire in European systems of socialized medicine. "Those countries began... with low expectations and a relatively
ineffective medicine," he explains. "For Europeans, almost any level of health care was initially acceptable, whereas for Americans practically nothing that can be mentioned is ever quite adequate." He notes that "in Europe most allocation and rationing decisions have historically been made by politicians and experts working together in private, without much public knowledge, much less participation. This makes life considerably simpler for everybody." He approvingly observes that European medicine "has remained for the most part heavily paternalistic and authoritarian."

But even the Europeans, Callahan sadly notes, have been contaminated by "the quest for perfect health." His nostalgia is palpable. "If we had exactly and only the same range of technologies as were available twenty or thirty years ago, there would be no problem in equitably allocating resources," he writes. "We could readily afford that level of medicine and health care." (It would be even cheaper, of course, if we returned to using rattles and beads as remedies.) Callahan says political philosopher Daniel Sarewitz is "not far off the mark when he writes: `Political and cultural institutions might find their goals better served by responding to [their] problems as if scientific and technological progress had come to an end and the only recourse left to humanity was to depend upon itself.' "

Thus, Callahan would happily sacrifice human progress to achieve his egalitarian dream. For him, a growing economic pie gets in the way of redistribution because people can see that they are going to get more in the future if they don't stop progress. Beguiled by growing wealth and ever superior technologies, humanity foolishly rejects Callahan's vision of a stagnant but equal utopia. "If people have been tutored to look for progress without end and progress without final goals," he writes, "they have no less been tutored to think that whatever technology we have now, whether medical or automotive or communicative, is as nothing compared to what we will have, and deserve to have, in the future."

William B. Schwartz would wholeheartedly endorse that expectation. His book, Life Without Disease: The Pursuit of Medical Utopia, is almost diametrically opposed to Callahan's pessimistic rant. Schwartz, a professor of medicine at the University of Southern California and a fellow at the Pacific Center for Health Policy and Ethics, does not fear progress without end or goal. The aim of medicine is plain enough to him: "Our exploding knowledge of the genetic mechanisms of disease begins to make plausible the once impossible dream of a largely disease-free existence," he writes. "The possibility of
a broad-based victory over disease and a dramatic increase in the human lifespan in the not too remote future must now be taken seriously. The reimagining of our medical future seems all the more important in light of growing scientific evidence that the aging process itself may be subject to medical intervention....Conceivably by 2050, aging may in fact prove to be simply another disease to be treated."

That's Schwartz's rejoinder to Callahan's insistence that humanity reconcile itself to disease and death. Instead of searching for the "meaning of death," as Callahan urges, Schwartz wants to conquer it. It is just this type of triumphalist medicine from which the crabbed spirits of Callahan and his ilk recoil. Citing recent and anticipated advances in treatment, Schwartz paints a plausible picture of a future where damaged heart muscle can be replaced by genetically modified cells to restore normal pumping action; where neuroprotective drugs preserve brain cells after a stroke; where genetically modified animal organs replace damaged kidneys and livers; and where new vaccines are developed as soon as microorganisms are identified as possible sources of infectious diseases.

Schwartz agrees with Callahan that health care was more affordable 50 years ago, but he points out the reason: "In 1950 costs of health care were remarkably low, because, for a large percentage of patients, doctors really couldn't do much. People spent relatively little on health care (only 4.4 percent of gross domestic product) and got what they paid for--very few useful diagnostic tests or effective treatments." This is the way that Callahan prefers to see it: "Before modern medicine, some peace was made with the finitude of the body--never a perfect peace, but one that allowed people to find some meaning in a life marked by disease and death." But as Schwartz says, what choice did they have?

Things are about to change drastically. "By the year 2050, the conquest of many diseases could be a reality and health-care costs brought under control," declares Schwartz. "The resulting increase in longevity, perhaps forty years or more, could bring into play an entirely new set of problems caused by generations of healthy humans who refuse to die." Though Callahan says citizens of developed countries live plenty long already, most people will be happy to deal with the problems caused by long, healthy lives.

Like Callahan, Schwartz is worried by the rising cost of health care, but he is not in thrall to Callahan's egalitarian lunacy. "I have espoused the unpopular idea that the rapid rise in health care costs resulting from our medical successes cannot be controlled without acceptance of painful but necessary limits on the availability of certain expensive treatments to some or all patients," he writes. He believes that "the view of medical care as an unlimited entitlement" is untenable.

In other words, Schwartz understands that just as some people can afford to eat at expensive French restaurants while others eat at McDonald's, so too some patients will be able to afford the latest biotechnological treatments while others will rely on more conventional and less expensive therapies. Patients who can afford cutting-edge treatments pave the way for future patients who will be able to take advantage of these new developments as they become more refined and cheaper. The first doses of penicillin, for example, were extremely expensive, but now the drug costs pennies per pill. Schwartz also understands that future generations will be much wealthier and thus will be able to afford even more expensive treatments than those contemplated now.

As Schwartz's book reminds us, individual choice has never been wider, and technological progress continues to accelerate. Meanwhile, voices of the old order like Callahan's are denouncing freedom and calling us back to lives of solidarity and simplicity. Fortunately, they are opposed by researchers like Schwartz, who are working hard to help fulfill the desires of people everywhere to live healthier and happier lives.

Though he sees it as cause for despair, Callahan is right about one thing: "The dream of medical progress does not have any logical or obvious endpoint or any intrinsic constraints." Thank goodness.