Dreams of Stagnation
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.
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.