The ever-expanding medical system in the United States faces a genuinely serious financial crisis, with costs increasing at a rate about double that of general inflation. The national cost of health care in 1989 was $550 billion.
Energetic efforts have been directed in the past toward eliminating waste from the system, since most Americans believe that good health care would be affordable if the system were more efficient. For example, Medicare has limited unnecessary hospital stays, insurance companies have come to require advance approval for certain operations, health maintenance organizations that can reduce costs have proliferated; yet, these measures have had no significant success in addressing the problem.
In What Kind of Lije: The Limits of Medical Progress, Daniel Callahan, a well-known expert on medical ethics and cofounder of the Hastings Center, the biomedical ethics think tank, tries to look at the health-care crisis from beginning to end, “to carry the problem through from philosophical premises to general policy recommendations,… hoping that the result will add something fresh to the debate.”
Callahan argues that cost-containment programs can provide only a temporary solution to the problem. The public’s demand for the best care that medical technology can provide and the huge growth in the number of health-care consumers offset any gains achieved by cost-containment efforts. This trend is particularly evident among the elderly, a segment of the population that is increasing in number and requires more complex care. Ironically, the very success and popularity of new medical technology defeat efforts to control costs: Successful technology increases the number of people who come for service, ultimately driving up the costs of care.
The solution to the crisis in the health-care delivery system, according to Callahan, is not simply a matter of eliminating waste or improving efficiency. While acknowledging that waste in the system and the enormous profits that physicians and the manufacturers of medical goods make are real and important problems, Callahan says that the ultimate problem lies in the cherished goals and ideals on which the American health-care system is based. The only way to deal with the crisis in health care, he writes, is to change the way Americans think about and understand illness, life, health, and death. Basic questions—”Where are we going? Where should we be going?”—must be raised. Beginning with philosophical premises and ending with general policy recommendations, Callahan attempts “to set forth an alternative way of thinking about health that will lead to the devising of a reasonable and just healthcare system,” one that is “rooted in a plausible understanding of the human condition and… coherent, feasible, and humane in its practical policy implications.”
Callahan calls into question the pursuit of unlimited medical progress, or the assumption that modern medicine must overcome all disease and extend all life. He claims that Americans’ obsession with endless medical progress has led both the public and professionals to deny the unpleasant reality that everyone is subject to aging, decline, and death. In Callahan’s words, “We have found our mortality wanting, and we have tried to modernize it… an extraordinarily expensive economic venture, consuming resources at a rapid and growing rate.” The solution is painful:
People must learn to curb their aspirations and set limits, he warns, or they will be spending more and more on health care with fewer benefits and less satisfaction. Americans must be willing to settle for “reasonable” health, or health “as a means to achieve some positive good,” and accept the reality that illness and death can be postponed but never permanently conquered.
A second cherished ideal Callahan attacks is the American health-care system’s preoccupation with the needs of the individual, rather than a concern for the common good. Focusing on the needs of the individual, or “an unlimited pursuit of individual cure,” has fostered a steady escalation of “needs” and unrealistic expectations. People have come to believe that they “should get what they want and think they need.” Furthermore, the American ideal of equality would extend all benefits to everyone, regardless of the ability to pay, an economic burden the public is unwilling (and unable) to carry. The system has responded by trying to become more efficient, but Callahan contends that the goal of efficiency cannot be met unless the goal of meeting individual need is changed. It is an illusion to think that individuals can all get all they need if only health care is delivered efficiently: “We will never get all we think we need as individuals and will have to settle for something less.” He challenges the Universal Declaration of Human Rights assertion that “everyone has a right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing, medical care and necessary family services.” According to Callahan, the concept of rights has become so overloaded that it has become meaningless, and Americans’ claim of open-ended rights to health care implies that their neighbors (through the government) are obliged to provide for their needs.
It is mistaken to assume that better health and a longer life will result in human happiness, Callahan...
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