A leading expert on medical ethics argues that the cause of America's health-care crisis is not inefficient organization and waste, but rather society's and the medical community's relentless quest to extend life and find a cure for every disease. 20,000 first printing.
How do we approach the seemingly intractable problems of our health care system? We clearly cannot afford to continue the old fee-for-service medicine, but now patients and physicians are becoming increasingly unhappy with the competitive, price-driven managed-care market that is replacing it. What is more, growing evidence suggests that an unregulated market probably will not keep costs down much longer. Our medical care system grows ever more expensive, dysfunctional, and inequitable. And yet, in the four years since Congress rejected the Clinton reform plan, no one has proposed anything resembling a realistic, comprehensive solution. In a political climate hostile to federal planning, few experts dare to suggest more than modest, piecemeal adjustments, and even fewer have looked ahead to see where the present system will take us in the next century.
Now we have two important new books that address the long-term future of medical care in the United States. One is by Daniel Callahan, a philosopher and one of our most respected bioethicists. The other is by William B. Schwartz, a distinguished academic physician who has been studying health policy from an economic perspective for more than two decades. I warmly recommend both these books. They are well written and offer many important insights.
But let me warn readers who may be looking for concrete answers to our present predicament. There are very few to be found in either book. Both authors provide us with thoughtful analyses of the problems, but neither does more than suggest the broad outlines of a possible long-term solution. Considering the complexity of the issues, such may be all that could have been expected. I confess, however, to finishing both these excellent books with a certain sense of disappointment. I had hoped to find practical help to start us on the road toward a better and more viable health care system, but Callahan and Schwartz have different ends in mind. However, they deliver their respective messages with impressive authority and style that make the reader forgive their failure to deliver a practical take-home message.
Callahan's work is the more general and reflective of the two. It provides few or no hard data about medical practice or medical economics and focuses instead on personal and social values as they determine the kind of medical care Americans want and expect. Schwartz's book, although shorter than Callahan's, cites more objective data and gives more details about the organization and function of the medical care system. He acknowledges the importance of human values in medicine, but for the most part his basic approach to policy is that of an economist, who measures values in dollars. Given their different backgrounds and perspectives, it is not surprising that these authors see the health care problem in different terms and come to different conclusions.
Callahan's analysis begins with a proposition that has been frequently argued by Schwartz -- namely, that the relentless advance of medical science and technology is a major cause of cost increases and that no cost-containment policy can be successful unless the introduction and use of expensive new technology are controlled. However, he places Schwartz's argument in a broader social and philosophical context and draws conclusions that Schwartz probably would not accept. To achieve a sustainable medical care system, Callahan says, we will have to rethink our notions of limitless and continuous progress in medicine. We must be willing to accept illness and death after our normal life span of 75 or 85 years has run its course. We should be satisfied with that fate and try to make it available to everyone by targeting the causes of premature death, rather than struggling to survive to an advanced age at all costs and without regard to the quality of life.
Callahan advocates a medical care system with a stronger orientation toward preventive medicine and public health, a guarantee of a basic health care package for all, more personal responsibility for health (he thinks victims, to a degree, should be blamed), and more attention to the cost effectiveness of technology. He says we have overemphasized the use of expensive technological innovations in return for only marginal gains and have not concentrated enough on the effective and humane application of what we already know. He advocates placing greater emphasis on the relief of symptoms and the treatment of disability, and less on expensive curative efforts. Although he advocates the assessment of technology and the elimination of fraud, waste, and inefficiency, he doubts that such measures will succeed in controlling costs. Competitive market forces will not do that, either.
Callahan devotes an entire chapter to a discussion of medicine and the market. (Schwartz devotes one paragraph.) He concludes that the market is more likely to increase spending and the use of technology than it is to control these forces, and he says that more government regulation will be needed to protect the public interest. I agree with most of his statements, but I believe his analysis is flawed by a failure to distinguish clearly among the various health care markets and their differing effects on costs. The managed-care market profits from reducing expenditures on medical services and technology, but the markets representing the manufacturers and suppliers of technology and drugs and the owners of facilities for medical services all profit from increasing expenditures. I do, however, agree with him that unregulated market forces will not in the final analysis help us achieve the kind of steady-state health care system we need.
The major impediments to the achievement of a sustainable system of medical care, Callahan concludes, is an unrealistic faith in technology and overconfidence in the ability of medical science to eliminate illness and delay death. We need to realize that perfect health is unattainable, and we must be willing to limit our spending on medical care to keep it compatible with the needs for other essential social goods and services. Callahan hardly mentions the word "rationing" in his book, but the idea is implicit in much of his argument.
The chief difficulty with this book is that Callahan, the philosopher and bioethicist, tells us only what ought to be and not how it might be achieved. He says that the ultimate solution to our health care problems will be found not primarily in reforming the delivery or funding systems, but in changing our attitude toward health and moderating our demands for health services. However, he says nothing about the prospects of such a transformation, nor about the means by which it might be realized.
Schwartz, although starting with the same premise that new technology is the root cause of the medical-cost explosion, reaches quite different conclusions. He begins his book with an excellent survey of the expansion and transformation of our health care system since 1950 and a brief but illuminating description of past and current attempts at controlling costs. He says they all failed, or are doomed to fail, because they are only one-time adjustments and do not attack the root of the problem. He tacitly assumes that the demand for medical services will remain high -- that is, that Callahan's goal, whatever its theoretical merits, is not likely to be realized. However, like Callahan, he dismisses competitive managed care as an effective means of long-term cost control. According to Schwartz,||Increased competition among providers can encourage the elimination of inefficiencies, but competition cannot control the rise in costs imposed by an ever-expanding arsenal of new technology.... Once increased competition squeezes out any remaining inefficiencies in the system, it can produce further savings only when competing providers begin to impose serious restriction on the availability and quality of care offered.
This line of argument brings him to the subject of rationing, one of his central themes. He believes that managed-care organizations will inevitably be forced to limit not only marginal and unnecessary care but also possibly beneficial care that is too expensive. He then explains how a logical approach to clinical-rationing decisions might be made, based on microeconomic theory and the calculation of "expected benefits per dollar."
The trouble with neat formulations of this kind is that there are insuperable difficulties in quantifying the probability of benefit and the value of outcomes in any given patient. As Schwartz himself says, "it will probably be impossible, at least in the near term, to pursue this methodology in any rigorous way." This, however, does not deter him from suggesting that the medical staff of a health maintenance organization might want to apply the principle in a "rough and ready" way to help maximize medical benefits for the resources available. The effects of such explicit efforts at rationing on physicians and patients would be painful, he acknowledges, because "even under the best of circumstances" this approach "cannot yield perfect decisions for all concerned."
We need not worry too much, however, because Dr. Schwartz does not believe that we will have to rely on rationing for the long-term solution of the cost-control problem. In the short run, he sees us "muddling through" with rationing and other imperfect approaches to the problem. In the long run, he predicts that major technical and scientific advances will rescue our faltering health care system by eliminating most of the important causes of illness, extending our healthy life span by another 40 years or so and greatly reducing the need for medical services. He therefore devotes major sections of his book to glowing descriptions of the new science-based medicine that will have arrived by the middle of the next century and will, he believes, render most current expenditures on medical care unnecessary. In this sense, Dr. Schwartz now expects the cause of the present inflation in health care costs eventually to become its cure -- a neat solution to a problem he had often previously described as intractable and controllable only through rationing.
But how realistic is this utopia? There is no doubt that sophisticated new technology, genetic science, and molecular medicine will bring dramatic improvements in the prevention, diagnosis, and treatment of disease. Yet the consequences of these advances are hard to predict, and I suspect many experts will hesitate to go all the way in endorsing Schwartz's predictions of a life without disease. In any case, we will have to wait a long time to see whether he is right -- too long, for most adults now alive.
As public and medical professional dissatisfaction with the present health care system mounts, I think it becomes increasingly unlikely that our country will be content to wait for either of the long-term solutions proposed in these books. We are not going to moderate our expectations for medical care or our enthusiasm for new medical advances to the extent that Callahan's "sustainable medicine" would require. Neither will we accept the kind of rationing that Schwartz says will be needed for economic survival until the prophesied ultimate triumph of medical science brings us a life without disease. Most citizens want a substantially improved health care system now, and I believe they will soon want to hear public discussion of proposals for achieving that end. When the debate begins -- as it surely will in the near future -- these two books will doubtless provide informative background, but they are not likely to be of much help in generating practical new policies.
Reviewed by Arnold S. Relman, M.D.
Copyright © 1998 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
Callahan (What Kind of Life: The Limits of Medical Progress) here advocates a "sustainable, steady-state medicine" that stops consuming ever-more resources yet provides affordable health care "equitably accessible to all." High-tech medicine's pursuit of the eradication of all diseases and unlimited progress are no longer viable, he contends in his farsighted, visionary manifesto. Callahan examines the obstacles?social, financial, political?facing his modest agenda for medicine, but he nevertheless feels it can be accomplished through a combination of improved public health programs, emphasis on greater personal responsibility to alleviate such conditions as obesity and heart disease and a drastic reallocation of resources away from acute care toward massive preventive and educational efforts. While much of his thoroughgoing analysis seems directed primarily to medical professionals and policymakers, his clearly written prescription will open a dialogue among health-care critics and reformers, establishment defenders, holistic healers and the public.
Copyright 1998 Reed Business Information, Inc.
Medical ethicist Callahan (The Troubled Dream of Life, 1993, etc.) proposes a new way of looking at the nature of medicine that sharply challenges traditional beliefs in progress and perfectibility. At the Hastings Center in 1992 the author initiated a four-year project, The Goals of Medicine: Setting New Priorities, in which research groups from 14 countries addressed questions about the future of medicine. This book is a parallel project. If Callahan had a bumper sticker, its message might well be ``Enough Already,'' but slogans aren't his weapons of choice. His forte is critical analysis, which he applies rigorously to the values of modern medicine. In his view, faith in limitless progress and the drive to dominate nature (through expensive high-tech procedures and the attempt to conquer death), and expansion of its domain into social problems such as teenage pregnancy and drug abuse make modern medicine neither socially equitable nor economically sustainable. Callahan proceeds to define a sustainable and equitable medicine and its implications for health policy: The focus must shift from individual health improvement to population health improvement through a comprehensive system of primary care medicine oriented to health promotion and disease prevention. Further, the drive toward total risk reduction and medical perfectionism must be curbed. And finally, efforts to overcome death must be replaced by the goal of improving the quality of life within a limited life cycle, i.e., the average life span now attained in developed countries. Not only must research rein in its goals and promises of ever-improving life, but patients must lower their demands and expectations. In brief, sustainable and equitable medicine means decent care for all, not state-of-the-art care for the few. Callahan is a powerful presenter of ideas, anticipating challenges and providing persuasive arguments, and his controversial thoughts on the future of medicine are sure to stimulate discussion among health-care policymakers. --
Copyright ©1998, Kirkus Associates, LP. All rights reserved.With millions of dollars going into continuous research, the medical establishment has vested interests in promoting the idea that all diseases can be overcome and unlimited progress is possible. Not so, Callahan declares. Instead, he argues for a "sustainable" healthcare policy to meet basic needs and contain costs.
Copyright 1999 Reed Business Information, Inc.
