FALSE HOPES - Why America's Quest for Perfect Health Is a Recipe for Failure by Daniel Callahan, Simon & Schuster, New York, 1998. 330 pp,$24, ISBN 0-684-81109-X
Daniel Callahan, cofounder of the Hastings Center and the Director of its International Programs, takes on the entire medical establishment--doctors, nurses, hospital administrators, medical researchers, and pharmaceutical and medical technology companies--all of whom he believes are united in a relentless pursuit of unlimited medical progress, stopping at nothing short of the conquest of all disease and the indefinite extension of life spans (see last month's review of Schwartz' Life Without Disease - The Pursuit of Medical Utopia).
The Hastings Center is an avant-garde institution where any idea can be explored (see "Duty to Die" in the HHK column in this issue of the Journal). Callahan, as the president of the Hastings Center from 1969 to 1996, must be taken seriously. In the preface, he presents his political leanings, aligning himself with the Clintons in their quest for healthcare reform. He bemoans the fact that no plan made it through Congress--not one bill, not a single reform. Callahan is even more appalled that at the next presidential election, both candidates all but ignored the issue.
Initially, the reason he takes this stance is not clear. However, he soon points out that the universal, if poorly financed and often corrupt, healthcare systems in China, Southeast Asia, and in much of Latin America, are turning to the marketplace and accepting privatization as their new gospel. He finds it most unsettling that the popular, well managed, equitable health care systems of Western Europe have begun to unravel in the post WW II welfare state. These systems, beset with rising costs, are high on the budgetary hit lists of political leaders who are looking to the marketplace to reduce public benefits, thus securing their own future.
Callahan realizes that if everyone is having a problem, and all are looking for answers, there must be an underlying basic issue. Almost all healthcare reform efforts assume that the solution lies in better organization and financing. Callahan then observes that no matter how much money is spent and no matter what the health gains may be, they never seem to be enough. Conventional solutions do not address the real problem. No matter how much progress, they always seem insufficient to meet the "needs" of the day.
The most cherished and celebrated aims, commitments, and values of modern medicine are beginning to give us trouble. But challenging these ideas, Callahan reflects, is not new. Rene Dubois in his 1954 book Mirage of Health questioned the then imminently anticipated total conquest of disease and stated this would not happen, not soon, not ever. In the 1970s, theologian Ivan Illich, British physician John Powles, American physician Rick Carlson, and British professor of social medicine, Thomas McKeown, each showed in a systematic way that there is no clear correlation between population health and medical care. Carson boldly predicted the diminishing impact of physicians and hospitals on health by the year 2000.
Callahan emphasizes that "A serious transformation will require taking money away from the acute-care sector, including research into the cure of many lethal diseases, and using it instead on prevention research and massive educational efforts designed to change health-related behavior." Callahan asserts that sustainable medicine will do the following: give priority to preventing and treating diseases that afflict the many rather than finding cures for diseases that effect the few, improve the quality of life for the elderly rather than extend life indefinitely, and focus on primary care and public health measures that benefit society as a whole rather than satisfying the health needs of individuals.
Callahan as an ethicist explores topics and issues on which to base future dialogue as well as change the direction of the debate. But he doesn't give us the final answer. He does point out that many Americans are bypassing traditional physicians and hospitals and are going to alternative medicine practitioners whom they pay from their own pockets. According to some estimates, these visits exceed those to traditional practitioners. This demonstrates that patients will pay for what they perceive as valuable.
However, Callahan's prejudices outlined in the preface, may prevent an objective extension of the excellent ground work he has developed. He might also have mentioned that the current debates in Britain and Europe include proposals for a significant transfer of costs from the national health systems to the individual through major co-payment plans, not only for office visits, but also for hospital stays in some instances. That may not be politically correct, but it would be a giant step toward what is economically correct for our patients.
Del Meyer, MD