Book Review
Prophet or Dreamer?
Ethicist Daniel Callahan says we need to end our love affair with technology if we are to control health care costs.
Book review by Charles R. Meyer, M.D.
Prophets have always been a bit scary. Illustrated Bibles frequently depict them as wild-eyed, robed men shouting into the wind. Many of those Biblical prophets, like Jeremiah, scared people with their predictions of doom or, like Daniel, with their depictions of visions. Whether truth or hallucination, the words of prophets are always troubling, discomforting the comfortable and unsettling the settled.
The writings of Hastings Center ethicist Daniel Callahan have such an unsettling effect. In What Kind of Life and The Troubled Dream of Life, he urged medicine to look at the limits of its power to heal and cure. In his latest book, Taming the Beloved Beast: How Medical Costs are Destroying Our Health Care System, his predictions about health care costs in this country, while not apocalyptic, are dire enough to make Jeremiah nod knowingly.
Although not exactly calling it a pit of vipers, Callahan has harsh words for health care in the United States, calling it “individualistic, scientifically ambitious, market intoxicated, suspicious of government, and profit-driven.” Throttling the relentless expansion of this system is particularly difficult given our attitude toward technology, which Callahan believes is the primary cause of the upward march of health care costs. We love our technology in all fields but especially in medicine, as 34 percent of Americans believe that “medicine can cure any illness if they have access to the most advanced technology and treatment.” Convinced that life is priceless and no cost should be spared to preserve it and swayed by marketing that says technology works wonders, the public expects research to keep pumping out advances that will be implemented in the daily delivery of medical care even to the point of “curing” death. “Death is then not something that only happens to bodies from biological causes; it no less comes from the absence of technologies to stop it,” he writes. This thinking encourages the pursuit of marginally beneficial treatments.
Often, doctors don’t need much encouragement to order such treatments. Prompted by the “gee-whiz” of new devices and by the lucrative fee-for-service payment structure, more physicians are entering high-tech specialties such as radiology and cardiology. The result of public and physician attitudes is more bucks funding more machines.
Yet Callahan contends that we aren’t getting our money’s worth. Health outcomes in the United States are inferior to those in countries that spend a fraction of what we do on technology. Callahan likens health care in the United States to a Rolex watch—we pay more for high-end when a basic Timex would do.
He explores proposed methods to curb the spending on that Rolex, including eliminating waste, assessing clinical effectiveness, and establishing national and state budgets. In each analysis, he rejects these techniques as cost-control strategies destined to fail. Instead, Callahan says we need to move from the present “infinity model” of “unlimited medical progress and technological innovation” to what he calls a “finite model” of health care “that understands the necessity to shape health care goals that are affordable, accessible, and sustainable.” Callahan means we need to decide that we can’t have it all, that there are limits to what we should be able to have done to us when it comes to medical care and what we should want done to us, “Our individual definitions of a full life should not be the norm for a national health policy.”
He personalizes what this means for himself. “I believe I have an obligation at our moment in history, and at my stage in life [age 79] to make use of as little expensive technology as possible, using only that technology that will do me significant good and not just add a few more months of life. I therefore resist heavy diagnostic screening to turn up asymptomatic problems, and no less resist follow-up treatment of the low-probability ‘better safe than sorry’ variety.”
He realizes that this will require a wrenching change in our values. “Whether Americans can be brought to think differently about health, to expect less and to settle for less, and to be willing to forgo some health care they might like, or even need, for the sake of the public good, takes a utopian, or maybe a counter-utopian elixir of hope and imagination. I see no plausible alternative,” he writes.
Prophets are frequently dreamers, and Daniel Callahan is one as well. He imagines Americans abandoning better-for-me in favor of better-for-us. Taming the Beloved Beast is tough, certainly utopian, but possibly prophetic talk not from a demagogue yelling on a street corner but from a thoughtful ethicist asking us to re-examine our values in order to tackle the health care costs that threaten to bury us. MM
Charles Meyer is an internist and editor in chief of Minnesota Medicine.