GUEST: Daniel Callahan
I’m Richard Heffner, your host on The Open Mind. And this is the second of two programs with medical ethicist Daniel Callahan, co-founder, and for a long time director of the prestigious Hastings Center.
Our theme derives, of course, from his new Simon & Schuster book, False Hopes: Why America’s Quest for Perfect Health is a Recipe for Failure. And our discussion has been focused by my guest’s search, as he puts it, “for medicine that learns how to stop growing, how to stop consuming ever more resources, how to find some finite goals, and then how to stop once they’ve been achieved.”
Well, Dan, we talked a considerable bit about that theme. I wonder if you’d bear with me if I read just briefly from False Hopes. Maybe you’ll recognize some of it. Because I think here you put your finger on the crux of your matter. “An economically sustainable medicine,” and you use the phrase that we’ve discussed, “sustainable medicine,” “will, of necessity, be a medicine of rationing and limits which, however, are willingly embraced for the sake of sustainability and equity. It will aim for a situation in which a society is reached and is willing to accept an adequate but not optimal quality of medicine and level of health, a medicine not addicted to constantly moving forward from adequacy to optimality, much less perfection. That society,” you write, “would then be willing to settle for a steady-state medicine, one that was affordable over time, limited and more circumspect in its aspirations, slow in its growth, and willing to forego possible progress in the name of economic and social sustainability. A sustainable medicine psychologically would be one governed by a closed-life-cycle model of individual life, a closed model in the sense that it would not seek indefinite cure of disease or extension of life, either incrementally or decisively, and a life-cycle model in that it would accept different degrees of health and functioning at different stages of life with the end of life marked by decline and death.”
Now, in all of that, what’s happened to the great American ideal of progress?
CALLAHAN: I think they’re… Let me say, first of all, that if that passage were read, say, in Great Britain, everybody would say, “Yeah, so what else is new? We’ve always done that, with rationing and limits, and we live with the life cycle. We don’t spend a lot on high-tech medicine for the elderly, we don’t spend a lot on low-birthweight babies. But everybody has access, people have security, they don’t worry about paying for healthcare.” So they would say, “You know, that’s…” In fact, I’ve been very influenced by these European models in thinking about this.
The American ideal though has been, first of all, unwillingness to accept any limits, which I think inevitably leads to inequality because people aren’t willing to give up anything to help their poorer neighbor. That’s pretty clear when we’ve tried to reform healthcare in this country. At the same time, it seems to me, we’ve been unwilling to ask, “Well, how much progress are we prepared to pay for? How much really makes us happier and better off than the situation before?” And I think an awful, to me, what we’ve learned, I think, scientifically in recent years, if you really want progress in healthcare you don’t spend a lot of money on medicine; what you spend it on is changing human behavior, looking at social and economic background conditions. Those are the things that improve health.
So it’s not that I want to give up progress altogether by any means. What I want to do is see if we can redirect and look for a more affordable form of progress, but also a progress which is willing to live within some boundaries. Because I think in the end it is a genuine false hope to think that we are going to indeed be happier and happier by getting more medical progress.
I don’t believe there is any absolute correlation in fact between better health and more happiness. All of us know some unhealthy people who are pretty happy, and we also know some healthy people who manage to be unhappy. So to me it’s a kind of mystery what exactly the relationship is.
HEFFNER: Well, let me ask about this business about rationing. How would you ration? What would you ration? Where would you ration?
CALLAHAN: Well, rationing really takes place at a number of levels. I suppose the first… I mean, right now we have rationing in this country. If people, first of all, if you receive money from Medicaid if you’re poor, or Medicare if you’re over 65. You don’t get everything you want. And you have to pay. In fact, with Medicare the elderly pay more and more out of their own pocket. It used to be 15 percent of an annual income of an elderly person went to healthcare, interestingly, when Medicare started in 1965. And now the average is 20 percent. So that’s one form of rationing. The government is giving us a less and less for that particular program. And meanwhile it’s giving less and less to hospitals and clinics and physicians which force them to limit what they give.
HEFFNER: But wait a minute…
CALLAHAN: And, of course… Anyways… So Medicare you see rationing simply by forcing people to pay more out of their own pocket.
HEFFNER: But wait a minute, Dan.
HEFFNER: Are you saying that is accompanied by less and less medical care?
CALLAHAN: It’s certainly accompanied by a cutting of the corners of medical care. Indeed, it is. If people, first of all, I think all of us can think of, I know sort of near-poor elderly people who, because they’re going to have to pay so much out of pocket simply will not get the kind of ideal care they might like.
But maybe the more immediate example would be the whole managed-care movement in this country, which doctors hate, some patients like, some patients dislike. But managed care is a way of rationing healthcare. People, companies take on programs, and they give their employees the programs. But they all set some limits. They won’t do organ transplants. There are certain things that will not be covered. They won’t cover infertility treatments. That’s rationing. In fact, managed care can’t survive economically unless it rations. I mean, can’t just say, “We’ll give you whatever you want that you think will make you feel better.” And it says, “No, no, no, no, no. You can’t. We’re not going to do that.” And, in short, if you want, every, it seems to me sensible healthcare system has rationing. It has to have rationing, because otherwise healthcare demands and needs tend to be of an unlimited nature. That is, the more, more, more, but…
HEFFNER: How… What is done along these lines overseas? Because you are a great student of what other countries are doing.
CALLAHAN: Well, essentially what’s done overseas, there are different models, but all of them have, all of those countries have universal healthcare, which means essentially that governments tend, they control the budget from the center, if you will, and they set limits on how much money is going to be available for healthcare. And these limits, generally they’ll set very broad limits. I know the British system. That’s the British, they basically give regions a certain amount of money, and they say, “Live within the budget we give you. You all figure out what the details will be.” And, of course, they figure out, “Well, it’s very expensive doing certain kinds of treatments, so we’re not going to give so many of those, and we’re going to spend the money elsewhere.” But they leave out, in short, governments, the governments set the budgets, and then they basically force people to live within the budgets. And if anybody who has to live within a budget has to ration, whether it’s you and I and living within our income, or a healthcare system living within its income.
HEFFNER: How does it work out? Let’s take something like dialysis, which you mentioned in your book.
CALLAHAN: Well, what happens with, when you look at the rates of dialysis for most European countries, they’re significantly lower than they are, fewer people get dialysis, and fewer elderly people get dialysis. Their criteria for accepting people into dialysis start getting higher and higher and higher. They really want a good outcome. They’re going to be, probably discriminate against the old in favor of younger patients.
HEFFNER: Be specific, in terms of age.
CALLAHAN: Well, Britain for a long time had a kind of de facto limit of around 55 for dialysis. It was never a written policy; it was just understood when you went to your primary care physician that he or she was not going to refer you to the specialist who did dialysis. And the patient, I mean, it was all kind of a lot of subterfuge. The patient was basically told, “Well, it’s medically not indicated,” or “We don’t believe that would be effective treatment.” Well, indeed, if often would have been effective treatment. So they covered it up with a kind of medical mumbo-jumbo…
HEFFNER: Why? Why the mumbo-jumbo?
CALLAHAN: Simply because, I think, I don’t believe there’s any politician in the world who’s prepared openly to say, “We’re going to ration healthcare.” So basically what the British did was more or less disguise it with the kind of medical excuses because they thought there would be outrage.
Now, what’s happened, interestingly, in the ’90s is the British sort of publics began catching on to that, and they began demanding more dialysis, and the age has gradually crept up. But there are a lot of other things, open-heart surgery and the like, that you won’t get nearly as easily in Britain as you will here, because they’re just more demanding about who will get in and who will get… And you get a lot of complaints about that, but that’s the way it works in Britain.
HEFFNER: Again, age-directed?
CALLAHAN: Well, age, and… But this would, it wouldn’t be just age. If you had a newborn, low-birthweight baby you would probably find less willingness, much harder to get very intensive, expensive neonatal care for that baby. Or if you perhaps were middle-aged and you had a lung cancer — in fact, there’s been complaints about this — you’re less likely to get aggressive chemotherapy and treatment for your lung cancer at age 45 in Great Britain than you would here. And I think in all of the European countries, they’d never admit it openly, but they all set some limits of this kind.
HEFFNER: Dan, you think that’s easier to accept by others because we’re not talking about profit centers that say, “Not over this age, or not beyond this condition,” and that the person who is rejected for this kind of treatment or this kind of surgery doesn’t have to say, “Well, that means there’s more in the pocket of Mr. X who is the chairman of the board of that HMO.”
CALLAHAN: Well, the interesting, the United States really, we do have a very powerful for-profit medical sector. And it’s been growing in recent years. An awful lot of the, I believe the majority of managed-care organizations are now for-profit. And there’s no doubt that they’re interested in a financial bottom line. I mean, they want to, in the old expression, “Do good and do well at the same time,” but doing well is critical, and there’s no doubt that, I mean, at least the accusation is that you really do get somewhat less good care with for-profit organizations because they’re, they can’t make any money if they give you everything you might want, so they will cut the corners.
Now, interestingly, part of this story, the European countries that are having trouble with their healthcare systems are tempted to go in this for-profit direction, to create a market sector to sort of take the pressure off of government, force people to spend more out of their own pocket, encourage entrepreneurs to sell to people. But this is because the European countries are finding it hard to live within their budgets.
HEFFNER: Well, of course, I read with, I think, considerable care, Callahan’s Chapter number Seven: Can This Marriage Succeed? Medicine and the Market. And I’ll be damned if I know really enough about what you think to be able to sum it up. Let me ask you to.
CALLAHAN: Well, let me put it this way. The phenomenon worldwide is that when governments, and at least the phenomenon of the ’90s, is when governments are faced with financial pressures, they very quickly begin thinking, “Can they privatize, can we get this problem off our back in some way?”
HEFFNER: That’s the Thatcher/Reagan approach.
CALLAHAN: That’s the Thatcher/Reagan. But it’s also the Chinese, the Chinese have turned very heavily to the market, and Vietnam, and the rural areas. A lot of the Asian countries, the Latin American countries, heavily gone in that direction. None of them have dismantled the public sector, but they have diminished it, and they have forced people to go outside of that sector to buy out of their own pocket, and from people that make money off of medicine. This has come about because of the economic pressures.
Now, to me, the real question is: To what extent can we go that direction without doing real harm? And, of course, if you know market enthusiasm, and this is kind of faith too, if you just let things be economically free, supply and demand will sort of take care of our needs, and everybody will get what they want. Well, that’s, to me, a messianic belief with no very solid foundations, but it’s out there. And I think the question is, I believe some market mechanisms and strategies can probably be helpful. Competition, perhaps. Economic incentives and disincentives. I mean, we’ll charge you less for your insurance policy if you don’t smoke. Well, that’s an economic kind of incentive. So some of it, I think, can work.
So, to me, the interesting question is: How much market can medicine take without losing its soul, so to speak? And secondly, how is it going to be regulated? Because I think most responsible observers say you’ll never get a perfectly free market in healthcare, namely, where people simply will get whatever they can pay for. It has to be regulated and watched by government, because you will get corruptions. And there will be poor people who simply can’t afford it, and they need some kind of protection. So the question is: What’s the good balance between the sort of government safety net for healthcare on the one hand, and the private sector trying to make money on the other hand? And that’s the big question around the world.
HEFFNER: You think in the area of preventive medicine have more of a shot at privatization?
CALLAHAN: Well, the difficulty is preventive medicine is not very attractive to people who want to make money off of healthcare. I mean, what do you, what’s, the ideal way you make money, I suppose the perfect model is you get some chronic disease and you have to take pills for the rest of your life, 20, 30 years, or 10, 15 years of pills. You don’t get cured; you sort of get half-cured. And companies make a lot of money off of supplying you for the rest of your life. Prevention does not bring any profits. It’s not a profit sector. It’s not like selling pills or expensive machines. And that’s why they’re very little attraction to it as an area for the commercial side of medicine. I mean, I think that’s the… The problem, as I try to catch in the book, is that, interestingly, the scientific evidence indicates that if you really want to improve health you do good public health services, health promotion, disease prevention. That’s where the evidence is going. The culture, however, is going in the market direction. So they’re heading, it’s a shame that just at the time we’re really seeing the importance of the public-health perspective, the market has become a powerful force. Why? In great part because the market, people have been attracted to the market in the ’90s in the US and a lot of places, but also because there’s a huge amount of money to be made off of people’s desire for health, and particularly on women’s health. That’s the companies, basically they have, they make their money by constantly innovating and giving you… They love it when you say, “More, more, more,” because they like to give you more, more, more.
HEFFNER: Well, that leads me to the question of how much of the unsustainable quality of American medicine at this time is a function of enhanced, whipped-up, advertised, public-relationed more-more-more attitudes by the drug companies, by the makers of medical technological machinery, etcetera. I mean, how much of a role has been played by the profit sector?
CALLAHAN: Well, the general estimate… Let me go back a step. The general estimate is that over the past few decades about somewhere between 30 and 40 percent of the increased cost of healthcare are really due to new technologies and technological innovation and a more intensive use of technologies. And there’s no doubt that that has been fueled in great part a by very aggressive sector which sells drugs, which sells and develops drugs, sells and develops machines and the like. And, of course, not only then increasingly now promotes it directly to us through magazines and newspapers and TV. Of course, they say your physician, you have to consult your physician. So I think it makes a very significant difference, and when this pressure is missing in other countries it’s a lot easier then to cope with. Many physicians I know, I asked physicians, “What do you think about this advertising?” And I get a mixed answer. Some say, “Well, I guess it’s good. Maybe I wouldn’t have known about this as much as I might. And I don’t mind my patients coming in with ideas.” But others say, “You know, my God, they’re coming in, they want all these things, and whether it’s good or not. And a lot of them say it’s not worth the hassle. I just give it to them. But I don’t believe it’s going to do any good. It probably won’t do… If it won’t do any harm, and they want it enough, I’ll prescribe it.” But they think it’s probably enormously wasteful in many cases, and it does lead people to have kind of excessive expectations about medical benefits which don’t happen.
HEFFNER: Well, along the lines of excessive expectations, aren’t those the lines that you’re most concerned about?
CALLAHAN: I am. Exactly right. I think we have a situation where we… I don’t, in a funny way, I don’t want to blame the companies altogether, because I think this is a kind of conspiracy with the public, likes this sort of thing. I mean, the public, it’s not as if the public is sort of in their heart of hearts unwilling. They eat it up. They’re as interested in better health as the companies are in selling them better health. So it’s a kind of conspiracy of both parties, if you will.
HEFFNER: And you’re saying your medical friends, or at least some of them, think this may be to some extent a key to better health?
CALLAHAN: Which, well, no. Let me, I wouldn’t say they feel, well, in some cases they say, “Sure.” The patients are getting information which is useful to them, and sometimes actually it’s useful to me, because I wouldn’t have paid as much attention. But the more common theme I hear is that this is putting enormous pressures on us to give people things that in many cases won’t do them very much good, but they’re desperate, they’re eager, they’ve been sold, and I think many, I would say the balance, at least the ones I talk to, feel that this is not very helpful.
HEFFNER: Dan, how did this come about? Because it came about so quickly.
CALLAHAN: I suspect the companies really, really got onto something that has probably been known as a kind of underground truth for a long time, which is: Doctors like to keep their patients happy. And doctors are very responsive to patient desires. And I think this has probably always been the case. But suddenly they say, “My gosh, you know, we can sell things if we build on this desire of physicians to please their patients.” And it gives us a sort of a different psychological way into the doctor-patient relationship. And they were absolutely right. It sure does.
HEFFNER: Was there no change in government policy that brought this about?
CALLAHAN: I don’t think it’s a matter, you know, I don’t think there’s any change in government policy. I think the main requirement always with drugs is if you’re going to sell them you have to say what they’re good for, but you have to list all of the contraindications and the potential harms. And as long as they do that, and of course you’ll notice most of these ads will have a big, big type about all the benefits, and then they’ll have a lot of small type about all the potential things you should think about. As long as that’s taken care of, then there’s no problem on the part of the government. It’s a matter of free speech and, I suppose, the market in operation.
HEFFNER: Would you do something about it?
CALLAHAN: Even if I could, I don’t have the faintest idea what one could do about that. I suppose the first thing we’d need, which I don’t think anybody has, we’d have to really do some very good studies about whether this is harmful or beneficial. All I know, I mean, me talking to a bunch of physicians, or them talking among themselves, doesn’t prove that it’s doing harm or good. So until, if we had really solid evidence that you were really getting some bad health outcomes, if people were turning to stuff they read about and sort of twisting the arms of their doctors to get things that weren’t helping them, or even harming them, then you’d have a better basis. But right now it’s just a lot of stories. But I don’t know what the challenge would be.
HEFFNER: Of course, this isn’t just advertising, “Ask your doctor for a prescription.” We’re now talking about over-the-counter.
CALLAHAN: Well, over-the-counter too. I think though, to me, the side I like least about it is that it is, in order to get people to be interested in these things, you have to do two things. First of all, you’ve got to promise relief of something. And secondly, but even more fundamental, you’ve got to get them scared in the first place. There’s terrific number of ads these days about getting cholesterol screening put out by companies that have drugs for high cholesterol. But, of course, you have to get everybody nervous, very scared, say, “Gosh, maybe I should think about that.” And, of course, one line of advertising these days is, “Even if you’ve never had any heart trouble, by gosh, we’re all subject to out-of-the-blue heart attacks. And maybe you’d better go in and get your cholesterol checked. And if you get your cholesterol… Well, it turns out we’ve got this wonderful drug.” So I think part of our health problem is we’re excessively nervous, we’re too nervous about health in this country. We talk about it too much. It’s interesting, again, in the European countries, they don’t have big health sections in their newspapers. In fact, I was recently in Europe and I asked about, I said, “What kind of…” I was, I said, “What kind of publicity has the new drug Viagra for erection problems?” And one person said, this was in the Czech Republic, and he said, “Well, you got about like this in the paper.” I said, “What about evidence that Tamoxifen, which really helps in breast cancer?” “Oh, had about that much.” And then I said, “Well, at least here in New York got first page of The New York Times.” But they don’t play it quite that way in other countries. And I think partly because health is a concern, has to be a concern of all human beings, but we’ve escalated this concern to a level well out of sight from everyone else.
HEFFNER: You’re not ready to say that there is just plain and simply a basic, insoluble conflict between the physician’s oath to do no harm and the marketplace’s oath to make more money?
CALLAHAN: Well, I believe there could be, if… I think it’s a soluble problem, but it takes an awful lot of vigilance on the part of the doctors. On the one hand, they have to have an awful lot of internal discipline and self-regulation. And I believe, on the other hand, we require some government regulation to make sure that the market does not get too powerful a force. And as it will unless somebody is watching it and setting some limits.
HEFFNER: Dan, we have two minutes left. You’ve written these various books, the most recent, and I think the most compelling, False Hopes: Why America’s Quest for Perfect Health is a Recipe for Failure, is quite compelling, and frightening. What’s your prediction, as you look into the future, about what we are going to do? Are we going to give up false hopes? Are we going to modify them considerably?
CALLAHAN: I guess, if I were utterly realistic, I would say as Americans we’re probably going to continue muddling along. We’re not going to come out with any very clean, clean solution. We’re going to have a large number of people like myself who are going to be much more pushing the changing of behavior and lifestyle approach over against expensive medical technologies. But our culture is not, is so wedded to a scientific, technological approach that it’s… I can’t imagine that changing very much, and I try to think of the Baby Boomers and others, and they’ve got that, they still have that. So I suspect we’ll continue muddling along, and maybe the sort of things I’m trying to promote will make some difference. But I don’t know. It’s an uphill battle against American culture.
HEFFNER: Well, that culture now is aided and abetted by the advertising that you were talking about, but the freedom the drug companies and the technologies feel in pushing their wares.
CALLAHAN: Well, I think in great part, I mean, I think we have a funny combination of circumstances. On the one hand, we have liberals who believe everybody should be able to make their own life choices and the like, and not have government interference; and then you have the conservatives on the right who believe in the market who more or less say the same thing, “Let people be free. Let us advertise to them. Keep government off our back. Let everybody make free choices.” You got the left and the right converging here, and that in itself though seems to be one of the great problems and great obstacles to a sustainable medicine.
HEFFNER: Well, Dan Callahan, if I make it into the eighties, my eighties, you’ll come back and we’ll talk about rationing again. Meanwhile, thanks so much for joining me today on The Open Mind.
CALLAHAN: And thank you.
HEFFNER: And thanks too, to you in the audience. I hope you join us again next time. And if you would like a transcript of today’s program, please send $4 in check or money order to: The Open Mind, P.O. Box 7977, FDR Station, New York, NY 10150.
Meanwhile, as another old friend used to say, “Good night, and good luck.”
N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.