Living with Mortality, Part I

THE OPEN MIND
Host: Richard D. Heffner
Guest: Dan Callahan
VTR: 9/15/93
“Living with Mortality, Part I”

I’m Richard Heffner, your host on The Open hind. .,f or many years now. Earlier, I produced and moderated a program series entitled “Problems of Everyday Living.” And my wife used to tell me that people were always able to guess Just what we were encounting in our own lives, what stages of development our children were at, and so on, by noting Just which topics I chose for my on—the—air discussions. Well, nothing changes, I guess. And here, 40 years later, I’m always eager to have today’s guest on The Open Mind, because the great social issues he invariably writes about just as invariably seem to be the personal Issues I and my aging contemporaries are musing about. One of our nation’s most respected and most widely quoted experts on medical ethics, Daniel Callahan is the director and co—founder of the Hastings Center, renowned for its continuing examination of seminal ethical issues in medicine, biology, and the professions. The author of Setting Limits, about what our medical goals can legitimately be in an aging society, and of what kind of life, about the actual limits of medical progress, Dr. Callahan’s newest Simon & Schuster volume, The Troubled Dream of Life, is subtitled Living with Mortality. And I can testify that it impacts profoundly upon those of us who are or who know and cherish those who are pressing now upon or beyond our biblical and biological allotment.

So, Dan, welcome you here today, and ask you, well, you were sitting in the control room before when I was taping a show with Betty Friedan, and Betty was going on about Dan Callahan and the business of allotting resources not to the old or to the growing—old, but to a younger people. And I wonder how that fits into your sense of what it means, living with mortality.

CALLAHAN: I think now for a number of years I’ve been fundamentally interested in what it means to live a life that ends in death. And I see medicine essentially as being an enormous technological struggle against death. So for the past, oh, I suppose, eight or ten years, I’ve been looking at a number of issues which really focus on the question of how far medicine should go in trying to prolong our lives, and what kind of resources we should, as a society, spend on the conquest of illness and of resources we should, as a society, spend on the conquest or illness and disease, and ultimately, I suppose, how we ourselves ought to think about the living or a life and the place of death within that life. So, where in one sense I have spent a lot or my time on apparently social issues such as resource allocation or or health care rationing, I think below those have always lurked the problem or the kind of human anxiety worry about death and medicine’s really essentially fanatical struggle against death which has been the mark of modern scientific biomedicine.

HEFFNER: You know, it’s Interesting to me that you put It that way, which undergirds the other, because as I read The Troubled Dream of Life: Living with Mortality, I asked myself the same question that I asked when I read your other books: Now, is Callahan essentially an ethic or is he essentially an economist? Because it seemed to me that you begin with the problems of limited resources in our country and then move on to the ethical consequences.

CALLAHAN: Well, that’s probably true. I suppose I’ve been drawn to the current health care crisis, which in one sense is a struggle over money and how we allocate money to health care. But I don’t think you can even talk about money ultimately without really asking what we’re spending the money for, what is the purpose of this entire enterprise. And the purpose is really a struggle with our illness, our health, and ultimately a struggle with death. So I think money helps us, money forces us to think, I say it about money itself because we spend money, we like to get money, and of course health care Is an enormous Item in our domestic economy. But the point is behind that great issue of health care lies the question of what we as human beings are to make of our own lives, how much of a focus do we want to put on promoting and keeping our own health, how much as a taxpayer do I want to spend to struggle against cancer and heart disease and etcetera, etcetera.

HEFFNER: But wait a minute. You mix the two together again. Then you immediately ask how much it is to the taxpayer

CALLAHAN: Well, because I think we play different roles. We’re citizens. We spend money on health care. We’re also people who are consumers of health care. And then, so to me the private and the public lives keep overlapping and coming together. When I think of the Clinton administration effort to work a national health care, also think, what is this going to mean for me as a person, how is it going to make a difference in how long my life will be, what kind of resources are going to be available to cope with my own illness. And but at the same time that then forces me to say, “What do I want as a human being from a health care system? What do I want in terms of a good life for myself?” And I think, who’s going to pay for this, too? If I want something, if I might like to live to be a hundred, the fountain or aging, to keep me going on 100, 110, I have to ask who’s going to pay for this. The answer is probably my children or my grandchildren. And then I have to say, “Well, is it fair for me to want to stay alive at perhaps a great burden on them?” So I find it very difficult to keep a sharp line between my private life as somebody who thinks about mortality, worries about dying, and thinks about the kinds of illnesses that may bring me down; and as a citizen who has to pay for this and ask where my private life fits into the life of my neighbors, my fellow citizens.

HEFFNER: Well, clearly, Callahan is able to make that distinction. And to keep the two going. I shouldn’t say, “Make that distinction.” To bring them together and to keep both questions going. Do you think the rest of us are? Has your struggle over the past years – and each or your volumes has, In a way, addressed itself to this same question – do you think the rest of us are capable of looking at whether we have a wild death or a tame death, as you write? Whether we’re going to extend our lives as far as they can be extended in a decent fashion, and not say, “That’s what we insist upon, never mind Callahan’s economic considerations?”

CALLAHAN: My impression is that there really are two levels here. Most people have not really given a lot of thought to their own mortality or to the American health care system or to some of these larger issues. I think people put them out of mind. They don’t like to look at them. They’re not happy subjects to talk about particularly. I find them fascinating, but I discover a lot of other people who prefer to run from them. But I think when people are pushed a bit, when they really sit down; they are ultimately interested in these matters. They are capable of thinking about these issues. And as much as we might like to avoid it, we do think about our own death. Our friends die, our relatives die, our parents die. We know that someday we are going to be in that position. So my own experience in talking with people is they, you, begin with a certain amount of resistance, a certain amount sometimes even hostility raising these difficult Issues, but if one can talk in a sensitive, sympathetic way with people, you find it’s there. Below the surface it’s there, and people are, generally speaking, glad to talk about It. It depends how they talk about it, but they’re glad to talk about it.

HEFFNER: Dan, if we could wave a magic wand and say, “Presto! The resources of this nation, of this globe, will be multiplied many-fold, and we needn’t talk about who is going to tax whom, where the money will come from. We have the resources,” could you then address yourself to the troubled dream of life and the limits of life and living with mortality? Could you set the economic consequences aside and think as a person concerned with the necessity for death and…

CALLAHAN: I’ve tried to do just that, because I think the issues are quite separable. Thirty or ‘10 years ago we worried about death but we didn’t worry about resource allocation and the cost of health care. So we’ve actually had the experience doing that kind of thing. I guess I believe that even if we had unlimited health care resources we would still face the problem of death. Modern medicine is not going to conquer death. As I sometimes say, it pushes death around, it maneuvers it, and it can outwit it for a short time, but death ultimately with triumph. And there’s nothing the health care system ultimately can do about that. It’s always, it’s fighting a kind of rear—guard battle, It’s sometimes a successful battle, but in the end death triumphs. Now, suspect our ultimate question is how do we begin thinking about our own lives. We begin sort of inside, if you will, thinking, “I’m going to live a life. I’m going to get sick, I’m going to age, I’m going to die at some point. Medicine can make some difference here, but in the end I’m going to have to face the same ultimate problems that all human beings have had to face.’ And at that point we have to ask what does that mean, what kind of a life should we want to live, what kind of a death should we seek. And medicine though makes an enormous difference. Modern medicine changes the nature of this problem. Even if you know that death will triumph in the end, we know that death maybe postponed by modern medicine. We know that death can provide some comforts, palliations that earlier medicine could not do, So medicine, and also I suppose modern medicine changes our notion of mortality. I think the ultimate problem with the modern medicine, we know we’re finite, we know we’re limited, we know we’re going to die. But medicine doesn’t quite buy that. Medicine thinks, “Well, maybe we can…” It doesn’t come out and say it, so to speak, but It really kind of wants to say, “Look, maybe if we’re smart enough or spend enough money, we really can do something about death.” I think that’s the kind of secret promise of medicine. And scientists in a way have pushed medical science. They all say, “We maybe we can’t beat death, but you know, maybe we can beat everything that kills us. Maybe we can get rid of all the causes of death. We need not die of cancer or heart disease or stroke or Alzheimer’s. Surely you’re going to die of something or other, but none of these nasty diseases.”

Now, so I think medicines enormously ambivalent about this. And this infects us too. So to me part of the drama of the present situation is the interesting movement back and forth between resource allocation. A lot of scientists say, “Give us more money.” My gosh, we’ll really radically extend the human lifespan.” Well, when they talk that way, that makes me think, well, maybe I have to rethink this issue of my lire and death and my mortality. So I see this interesting interaction between the social and the medical level and the personal, and they, so to me it’s very tough to just talk about it personally when I think about what medicine is going to do this. It’s possible, but it’s not, I don’t think it’s wise to try to think just as a totally isolated person who is not part of a particular society or culture or health care system. And they all make a difference about the way we think about our private lives, I think.

HEFFNER; You mean the medical profession which has been lured into thinking that maybe it can do more and more lures us in turn into thinking that..

CALLAHAN: Oh, It absolutely does. Medicine is really itself an expression of the larger scientific progress oriented culture. We are part of a culture that believes that scientific knowledge is fundamentally the way to real truth, that that knowledge can be translated into medical technology which is going to improve our lives and keep us alive for a longer period of time. And not only Is medicine of course caught up in that wonderful dream, but we as citizens are. We spend an enormous amount of money on health care research in this country. Doctors endlessly complain about the excessive expectations by the public. People really believe there are miracles out there. And they go to doctors and the doctors turn out to be rather human, they don’t have resources, skills, or the knowledge available to cure certain cancers and certain forms of heart disease. But they say, the patients, then, “My gosh, we can do it all.” And the doctors say, ‘We really can’t.” But, I mean, at the same time though, doctors, sort of, as researchers, say, “Give us more money, another ten years, we’ll do something about this terrible disease.’

HEFENER: Well, in all honesty, in all fairness, hasn’t that been true?

CALLAHAN: That has indeed been true. It’s been one of the wonderful; one success story of science and the scientific method, medicine is a wonderful example. The problem although, medicine’s got a kind of interesting problem. That is to say, if one of its goals is to deal with the problem of death, which it certainly has been at least for a couple of hundred years now, or to deal with aging, another fundamental struggle of medicine, it’s an infamous struggle. To me it’s a little bit like the conquest of outer space. The possibility of medical progress is endless and infinite. We can push death back to 100 on average, or 110. But then you can say, “There’s 200, 300. And it runs, I suppose with outer space you can say, “We’ve put a man on the moon, we have done all sorts of other things.” But we know that however far we go, we can always go farther. So the ultimate question to me, or at least the most interesting, vexing question is, if no matter how far you go there’s always further you can go, how in the meantime do you live with the limits we have now, the present possibilities.

HEFFNER: But Dan, you see the consequences of what you’ve just said, surely, that you talk about a seemingly, not realistically, but seemingly limitless future In my time, in my children’s time, In my grandchildren’s time, How could I not make the assumption that if they push the boundaries to 80, to 90, to 100, to 110 — and you, yourself, say, “Sure, we can do that” – how could we possibly Incorporate into our thinking what you would like us to incorporate into our thinking? Isn’t it futile, futile quest on your part?

CALLAHAN: (Laughter) Well, it’s probably futile in getting people to face up to some of the puzzles and paradoxes and tangents. We’d like to be hopeful about these matters, and there’s a lot of reason to be hopeful. But I think there’s some important realities. First of all, there is the question of the allocation of resources. It’s harder now to conquer death than it was 50 years ago, in part because we’ve made great progress. We’ve dealt with infectious disease. We’re left now with the diseases of aging. Cancer, heart disease, and stroke are still the main killers: They are tough, they are very tough foes. And my own guess is they are not going to be anywhere near as easy to conquer as typhoid. And so that’s a practical problem.

But let me go on to my second point. At the same time, even If we get. us up to 110, what are you going to do about death? At 110 you’re going to eventually have to face this problem of death. We may change the years. Three-hundred years ago people had to worry about death at 30 or 40 which was the average life expectancy, Now we can worry about it at 80, 90, 100. But at some point this same old problem that’s been there forever reappears. In a new guise perhaps, but ultimately we’re going to die. And all we’ve done, we’ve changed the length of our life, but we haven’t changed the ultimate problem of how we live within the limits of a body that is going to die. That’s…

HEFFNER: But in the meantime, Dan somebody is sitting out there watching this, and saying, “Callahan is the guy who 50 years ago said, – ‘Look, sure they’ve extended the potential for living beyond the biblical three—score and ten, but at some point they’re going to have to come to an end, at some point you’ve got to die.” Well, the person watching outside says, “Okay, but Callahan said that 50 years ago, he said it 100 years ago. Others said it 400, 200 years ago. In the meantime, If they can push those boundaries, I want to see what’s going to happen with my grandchildren, my great—grandchildren, my great-great-grandchildren.” You can’t win this battle, can you?

CALLAHAN: You can win, if my aim was to stop all medical progress, I couldn’t win it, and I wouldn’t want to win it. What I would like to do, though, is get people to be more sober about the nature of this progress. First or all, recognize that the amount of money as citizens — here we go back to the question of our role as citizens -— we’re now spending 14 percent of our gross national product on this wonderful effort to keep us alive and in good health. Fifty or 100 years ago it was one or two percent. So it’s become an enormously expensive venture, and It begins then to Impinge on other things. My effort to keep myself alive or you alive by modern medicine may be taking money from the needs of schoolchildren for better school. I happen to see it that way. So we really have to ask, partly because the cost of the progress exponentially starts to rise. It was cheap early, now it’s going up. So as citizens we’ve got to worry about the economic place of this great effort.

Secondly, we have to ask, and of great concern about keeping people alive longer is a large number of people are alive but not in very good health. One of the great paradoxes, or I suppose unhappy aspects of the extended lifespan is it has been accompanied by an increased burden of illness. Death rates have gone down, but sickness rates, or as they call them, “morbidity rates” in medicine, they’ve gone up. More people, in short, are sicker now than was the case 50 years ago, in part because people simply died, but now we keep them alive, but not often well. So you’ve got another complexity here. And in any case, finally you hit that age 110 and death Is here, and you’re back to the same ultimate human situation.

HEFFNER: Dan, is it true that it is essentially the last year or the last months or the last weeks of life that cost so much, talking in an economic term?

CALLAHAN: That is really, that’s really misleading. What we know is, from Medicare expenditures, money spent on the elderly, about five percent of people take about 30 percent of the resources. And those five percent are people in the last year of life. So we have one statistic that shows us. But that really doesn’t prove very much. We really don’t know whether the people who died and took a lot of money were known to be dying in advance, we don’t know whether the money was wasted. In the long run, probably the greatest burden right at present of health care costs, say, on the elderly, is not the high—tech cost in the last year of life; its the overall burden of cost to the elderly, which includes long—term care as well; So that figure is quite misleading, I think

HEFFNER: Dan, what informs your attitudes toward this question? What essential? Who is Callahan?

CALLAHAN: I suppose I sometimes thought, well, as I argue about these issues with people, I see the world very simply divided into two categories; there are those who are full of hope and optimism, and give us more, more money and by gosh we’ll beat death as we’ve beaten everything else; and those who I suppose take a more tragic view of life, who really think, yeah, you an make progress, but progress usually comes at a cost, you can push death around a bit, but death is going to get the better of you. And I suppose my problem — I’m trained as a philosopher -— is saying, “Well, how do we, what’s the proper stance toward life?’ I tend, in many ways, to be an optimist. But about questions of death and mortality, then I, you know, I’ve got to cede the face that I’m limited, our resources are limited. And how do I learn to live with my limitations and not simply entertain fantasies of triumph and conquest and of getting rid of death? So, and I find an awful lot of these struggles seem to get down to people who have a sort of tragic strain within them, and people who are optimists. And one goes back and forth. And sometimes I switch roles myself.

HEFFNER: But no one’s a greater pessimist than I am, and no one has a greater sense of the tragic than do, much to the consternation of a lot of people I know and live with. But I find it so difficult to comprehend how you can make any kind of assumption about the potential of spreading these ideas, when Indeed the councils of, not despair, because you’re not despairing, you’re warning. You’re saying we’re going to have to deal with this, so let’s deal with it now. Those who Pave seen science, if you will, push back the frontiers that in terms of time indicated when we had to be concerned about a tame death or a wild death or facing death. I guess I come back, and there’s no sense in beating that dead horse, to the notion that there’s no way in the world in which given the very things you’ve said, you’ve talked about the frontiers being pushed further and further back.

CALLAHAN: An analogy that I’ve found helpful here is the environmental movement. Fifty years ago we felt we had total free use of the environment. We didn’t worry about polluting the air or the water or misusing our resources. Some people did, but if you go back even further. We’ve changed our attitude toward the environment. We now recognize that, sure, people need incomes, we like technological progress. But they do things to our environment, and we’ve become a little wary about what happens to our environment. We recognize that we are limited in our resources. We recognize we have to live on this globe, and that’s the only globe were going to have. And we’ve changed our attitude toward the environment. I see something like that, and what we’ve given up is a kind of optimism. “Oh, well, science and technology can deal with any pollution that comes along. We’ll just put things up in the smokestacks. And if technology does bad things, technology can clean up those bad things.” I think we’ve got a more fundamental pessimism. This is the kind of wariness that’s seeped much deeper with the environmental issue. My gosh, we have to be very careful. We have to, in fact, not kid ourselves that we’re going to find technical fixes for a lot of these environment. We’re going to have to change our way. I think medicine has reached that point as well. I think the very fact that I, when I first began working in the field of medical ethics, say about 30 years ago now, most people welcomed IOU. But my gosh, It would be wonderful if you really got sick and you’re critically ill and they’re going to put you in an ICU and they’re going to do these wonderful things to keep you alive. I see something happening which is sort of a change, which is, do I really want to get in those, what do they, is what they do in those units really going to do me good. Is it real progress, maybe, to keep me alive for another six months but in a terrible state? There’s a kind of wariness about all of this which I see very much like the environmental wariness, and that’s what’s to me changing. We still want the progress, but we know it comes with a price tag. We know that in the end we’re not going to transcend ourselves, though we can push things up.

HEFFNER: Yeah, but Dan, you use, which is your right to do, a kind of straw man here, or woman. You say, “Keep me going for another six months.” Suppose it’s another six years. Suppose it’s another 16 years. Who makes these decisions? One of the things about the medical people you’re talking about and whose actions you to some extent deplore, is that they were even-handed. We’re going to use every mechanism at our disposal just to continue life. And others are going to have to make the decisions about: What are you going to do about life? How long is that life going to last? Otherwise, you’re putting the decision for saying, ‘No, he’s only going to last six more months, so don’t put him in the ICU,’ in the hands of someone. Who?

CALLAHAN: Well, it depends on what we’re going to ultimately do here. As taxpayers we’re going to have to decide how much our federal programs, how much they’re going to invest in health care, the conquest of disease. So we as citizens who elect our representatives, that’s one way we do it. We increasingly, of course, do it through our employers who give us health care benefits and provisions, or increasingly now force us to make, pay more out of pocket for this, So ultimately these decisions, I think, become social. They’re partly determined by our general cultural attitudes, whether we think it’s a great thing to invest In health care or whether we think it’s a great thing to fight death, or whether we think it’s important but maybe there are other things out there as well that we have to balance off against that. don’t actually deplore the fact that the doctors do this. But we’ve all accepted this myth that science can really transform our human condition, and to a great extent it has. The question is how far and at what price. And just when you begin —— here I switch back to the mode of citizen — how much do we want to spend on this? How much do we want to tell our representatives to spend on health care? We’re going to be having a huge debate I or some years now in our country about that matter. And at that point we’ve got to ask what I want as a person in my own life and what I sort of think is going to be good for us collectively as a community. And they may not be the same.

HEFFNER: Well, I think that’s the point at which we end, because we’re getting the signal that it’s time to end. And I ask you to stay where you are so we can go on to a second program and I’ll get you to answer the question as well as to ask it.

Thanks, Dan Callahan, for being with me today. And thanks, too, to you in the audience. I hope you join us again next time too. And if you’d like to share your thoughts about our program today, please write: The Open Mind, P.O. Box 7977, FUR Station, New York, NY 10150. For transcripts, send $2 in check or money order.

Meanwhile, as another old friend used to say, “Good night, and good luck”