What Must Be the Limits of Medical Progress

THE OPEN MIND
Host: Richard D. Heffner
Guest: Daniel Callahan
Title: “What Must be the Limits of Medical Progress”
VTR: 9/15/90

I’m Richard Heffner, your host on THE OPEN MIND.

And my guest is Daniel Callahan, Director of the Hastings Center, renowned for its examination of ethical issues in medicine, biology and the professions.

Now last time Mr. Callahan and I examined the calculus of health care for the aging that he had set forth in his 1987 Simon and Schuster book: Setting Limits: Medical Goals in an Aging Society.

This time, let’s expand our intellectual horizons, turning to his new Simon and Schuster volume: What Kind of Life: The Limits of Medical Progress. Scarcity is still its underlying assumption: the limits we must place on our own felt need or appetite for ever extended, ever healthier lives…because that appetite, in the final analysis, simply can’t ever be sated, but may well ruin us. As Daniel Callahan has written: “Medicine cannot conquer death or old age, but it can bankrupt us trying to do so”.

Mr. Callahan, thank you for staying with me and doing this, this further program. I haven’t gotten any younger since we did our first and discussed what the age limitations are that you would impose upon the availability of certain medical opportunities. But still the question of “can we afford?” is the one I guess that you come back to time and time again. And I wonder whether you’d deal with this question for a moment. If we would pay more in taxes to support this American desire for better and better health and longer and long life, could we…are those resources available indeed?

Callahan: The resources are available. I don’t see us in the sort of classic life-boat situation where you had finite resources and you’re not going to get any more. We are a rich country. We have lost of resources. The question, of course, is whether you can turn the whole country into one big hospital, and spend all of your money, or a disproportionate amount of money on health care. That’s the question that really fascinates me. Thirty years ago, for instance, we spent 6% of our gross national product on education, 6% on health care. We still spend 6% on education; we now spend 12% on health care. The question to me that‘s interesting is, is what is the proper balance? Can you let one area, such as health care really, in one sense, run amok while simultaneously another area, of equally great in national importance, namely our educational system is starving? I mean, so in other words, we’ve got the money, but how do you, how do you want wisely to spend it? That to me is the intriguing question.

Heffner: Well, taking that question then and going back to the…not your first because you’ve done so many, but to Setting Limits, talking here about limiting what the elderly can receive from society. And now you raise your question, the question in this new book, What Kind of Life: The Limits of Medical Progress and you demonstrate that we’re not only talking about the elderly, we’re talking about the medical institution in this country, and the medical profession, and its increased costs for everyone…young and old alike.

Callahan: I have to think probably the problem, the situation of the elderly is going to be our hardest in the years ahead. But we’re having a problem with every age group. We now can spend enormous amounts of money saving the lives of low birth weight babies. I’ve heard of cases recently of one…hospital bills of a million and a half dollars, in one case two million dollars to save a middle-aged person who was in and out of intensive care over a period of many months. We just have this extraordinary capacity to extend life, but it’s a very, it’s a very expensive business. And the question then is how in the world, as we look at what, what…what’s causing this…there are a lot of things. Partly it’s inefficient…I mean we have a wasteful health care system. We probably overpay an awful lot of medical professionals. But eve if…and we have malpractice, which intensifies and makes things worse…but even after you cut through all of that, what we really have is an inherently expansionary health care system, driven by medical progress. We find more and more ways of, of saving life. But they’re usually expensive ways. I mean in one sense, beginning fifty, a hundred years ago, we took care of most of the infectious diseases…polio, typhus, smallpox, things that used to wipe out people by the thousands, and wipe them out at early ages. We made great progress. Now we’re dealing with, with the diseases that are still left. They’re tuning out to be very tough. We apply to those diseases new drugs, new machines, new operations, and what we rarely find is some very cheap, simple way to save a life anymore. We, we…and, and that, that situation, I think, is simply going to get worse.

Heffner: Well, it’s interesting. You compared the costs or the percentage of our gross national product that we devoted to education and to health care and showed how the one expanded enormously, not so the other. Is this because the one – education – is essentially a not for profit, not individually motivated and run area…

Callahan: Well…

Heffner: …and the other is a private, profit enterprise?

Callahan: Well, that, that certainly makes a difference. But, of course, even in the public education…there are profit making elements in education. Certainly when textbook manufacturers, television…

Heffner: Okay.

Callahan: …manufacturers. I mean the education system has its for-profit side as well. Not, not quite as extensively, or as drastically as medicine. But, of course, why…one reason there is profit in medicine is that people want it. They want this progress. They…and indeed…

Heffner: Wait a minute, wait a minute…why…

Callahan: …we’ve given is a very high prestige.

Heffner: …why are you equating progress with profit?

Callahan: Mainly because first of all it, it costs a great deal of money to do the investment in research in the first place, to give us the medical advances we have. A lot of that is driven, of course, by a desire for profit. We have many…pharmaceutical companies and other technical manufacturing companies who want to make as much money as they can for their shareholders by medical advances. We as a public are…we like those medical advances, too. We’re willing to pay an awful lot for them through our taxes, or our employers pay for us, or we pay for it out of our own pocket. And the net result, of course, is you have a, you have a wonderful system in one sense where you have people trying to make money, people like us who are trying to stay well. It’s a kind of marriage made in heaven to drive up costs.

Heffner: It doesn’t sound like heaven to me. But it does drive up the…

Callahan: It does, indeed. Right.

Heffner: …does drive up costs.

Callahan: Indeed it does.

Heffner: Do you think there’s any remedy that you see in that configuration?

Callahan: Well, there, there are a number of possible remedies, and the question is which ones would be tolerable and which ones will the American people put up with? One thing, of course, we can do, we could try to do, is limit profits, hold down the salaries of physicians and nurses and others. Very difficult to do. That’s now done to some extent in some of our federal programs. But I suspect in the end we’re really going to have to, to change some of our appetites. We’re going to have to, I believe, have a more modest division of the future of medical progress. We’re going to have to live with some limits ourselves. We’re going to have to accept our mortality more. In short, I think one is going to have to dampen some of the fire underneath all of this, and the main fire is, of course, our desire to be healthy and to live long lives. And that’s, I think, at the heart of…the profit exacerbates things…it intensifies the complications and obviously the costs in our system, but, but all of that rests on a very fundamental human need to stay alive, and that’s…it’s the combination, I think, it’s the real…so we’ve got to start, we’ve got to work at the practical side on the profits, but meanwhile also work at this basic fire.

Heffner: But in the meanwhile it seems to me that no one is talking about working on the profits. No one is talking…

Callahan: Oh, well, the government certainly…certainly the federal government has worked hard…in the Medicare program it’s established some limits of reimbursement to hospitals whether for profit or non-profit. It’s…

Heffner: Appropriate in your estimation?

Callahan: Yes, appropriate. And they’ve made, they’ve made some difference. But unfortunately we don’t, we don’t have a very well organized system and what monies that’s being saved in one area is usually being more than made up for in other areas where we don’t have similar controls.

Heffner: You mean within the medical…

Callahan: Within the medical, within the medical…community…moreover, of course, American physicians, like Americans generally, hate government, hate government interference so they fight every inch of the way. Naturally and the manufacturers fight every inch of the way against these controls and regulations. But one…so there…and we’re…in the near future we’re going to probably see a better balance between what specialists in medicine are paid and a physician who carries out expensive…complicated surgery is paid, probably four or five times what a physician who simply talks to you for the same length of time is paid. That’s going to be changed, too. So there’s certain things you can do by government regulation. It’s been argued that companies which purchase an awful lot of health care in this country can draw some lines; they can simply refuse to pay as much as they have. Of course, then their employees scream and complain about all of this. But there’s, there’s things we can do. Now the problem is we haven’t, unfortunately, learned how to do them very effectively. We have not learned how to manage our costs, mainly because we still have a mixed system. We have a system where you do have a role for government, but you still have a very powerful role for competition and profit and money-making. And we’ve tried somehow to bring these two together, but the net result is a kind of utterly chaotic situation. Compare our situation, for instance, with Canada. In Canada you have central government control…they have what they call “global budgeting”, namely, they decide on a certain amount of money to be spent for health care and people have to live within that limit. You, as an individual patient have to work within the government system. You can’t buy health care outside of that system. That works very effectively to control costs. The problem, of course, in this country is we tend to hate government. When you go to Canada it’s very clear that the Canadians are much more willing to let government have a large role in their lives. They mutter and the doctors there complain but they put up with it in the end. Americans get absolutely outraged at the idea that government is going to come in and tell you how you can practice medicine, what treatments you can and cannot have, what machines your hospital may or may not buy. So I…part of the problem in our country, is our national character works against us. We believe in choice, we believe in progress, we believe in things always moving ahead. We hate government. It’s a terrible, it’s a terrible mix if you want to run an economical health care system.

Heffner: What is your own estimation of the benefits of this continuing expansion of medical research? Continuing expansion of medical efforts to cure us, rather than just to take care of us?

Callahan: I, I begin…I think that we’re beginning to get some unhappy consequences of this forward progress. What we’re really seeing, first of all, not…we’re seeing high costs, which we can’t manage. We’re also seeing people becoming, I believe, rather ambivalent about medical care. People who are increasingly fearful of dying at the hands of contemporary medicine. It’s wonderful that we have these very elegant intensive care units, but none of us want to spend our last days in those units, with tubes coming our of every orifice. Nor do we look forward to the prospect that if our lives might be saved in one of those units, only to discharge us to a nursing home where we might spend another ten years demented or unconscious or curled up in a fetal ball. I think people are beginning to really get a little wary about medical progress. And, well, yes, we all want to be kept alive, but my gosh, maybe the price for being kept alive by modern medicine is too high a price. So there’s a powerful move…people signing living wills, leaving instructions when to stop all of this medicine, and I…what I see is something analogous to what happened with environmental issues. I believe beginning 10, 20 years ago we began to see that an awful lot of our so-called technological progress, automobiles and factories, really did harmful things to the environment…pollute the air, the rivers and the like, and we began to get a little bit wary of some of our progress. Particularly as it impacts on the environment. Health and medicine though were kind of…that was different. Now health only does good things, doesn’t do anything bad. I think in one sense health care and medicine are joining the rest of the world. We know that medicine can do great things for us. We know that it can do some harmful things. It can keep us alive, but it may only keep us alive as a physical wreck and that’s not terrific, I think.

Heffner: But Dan, is there any indication that what you see as a potential shift is really taking place as of yet?

Callahan: Not in any very, very powerful way. People still want desperately good health care, and they still want those…in the end they still want those intensive care units, even with the risk of machines. But what I’m seeing is the straw in the winds that I wasn’t seeing three or four years ago. I’m seeing a younger group of physicians coming along who would like to see medicine return to a much more fundamental orientation on primary care rather than highly specialized, technological care. What we have in this country is a rather strange system, which has been heavily dominated by the technical specialties. The glamour lies in organ transplantation, intensive care units, neonatal, sort of everything that we connect with modern medicine. That’s the symbolic…But when you ask what really does help people’s health, it’s much cheaper things. It’s health promotion and education, prevention…it’s having a doctor that you can go to who’s simply a primary care physician. It’s having good emergency rooms, it’s having things at a much more simple level. And we‘ve created this enormously complex system, that not only scares many of us out of our wits that we’re going to spend our last days in that system, but that also begins to…we, we spend so much in relationship to what we’re actually getting for that money. That’s the…there’s a big discrepancy there. We’re spending more and more money, but we’re getting, we’re getting poorer and poorer results. I mean…we now spend more money on health care than any nation in the world, more per capita, more in general, yet we have 35 million people who have no health insurance. And that’s crazy. I mean how…we can end up with that result?

Heffner: Well, we were talking before about England and dialysis. And there, I gather, whatever developments there are, there’s just simply a governmental limitation.

Callahan: Well, there’s a limitation on dialysis. There’s a limitation on open heart surgery, there’s a limitation on…

Heffner: Age limitations?

Callahan: Well, it’s interesting. What they do in England…it’s not formal…the government doesn’t have regulations about age, but it is understood that there is an age limitation. That if you’re beyond the age of 55 or 60, you will not get dialysis, you will not be referred by your primary care physician to a dialysis unit. You will not get open heart surgery beyond a certain age. You will not have access to the very expensive diagnostic procedures. This is kind of unwritten. It’s sort of developed as a practice in England where every…the doctors understand that’s the general rule, but they don’t write it down…but it works enormously effectively. Now, of course, in every…many people think, “Well, this is terrible”, but what the English have also…that you are guaranteed a primary care physician in England, you’re guaranteed a great deal of basic medicine, that you’ll never get turned away from an emergency room in England. What they take away at one level, they give back at another, and the net result, when you say, “How long do people live?”, in England they live exactly as long as they live in the United States. (Laughter)

Heffner: How, how do you figure that, Dan? How can you explain that?

Callahan: Well, I explain it because it’s; it’s been known for a long time that if…that one reason people get desperately ill and sick is that they don’t take care of themselves. They have not been properly educated in good health behavior. They have not…they don’t have a physician that they can turn to when they begin showing either minor symptoms that might turn into serious symptoms, and in other words, it’s been known probably for a hundred years, that if you emphasize good primary care in medicine, the simplest kind, you get a terrific result at a comparatively low cost. But we’ve been so beguiled by the technological advances, and the drama of medicine that we put our money into a lot of other things, and we neglect the primary care level. And an enormous amount of Americans don’t have a primary care physician. Lots can’t get in emergency rooms, and…so what happens if you don’t have a physician you can go to? You wait until you’re very sick, and then, then you get your care. But at that point you need…you’ll have a heart attack and need…open heart surgery…whereas if they had caught you 10 or 15 years earlier they would have changed your diet, and you would have had a physician work with you to get your weight down, and you would not have had that heart attack. And that would have been a lot cheaper.

Heffner: Well now, is the point you’re making now what you directed yourself to in the title of your book What Kind of Life: The Limits of Medical Progress? I mean is that…

Callahan: Well, in part…

Heffner: …the trade-off?

Callahan: The trade-off…what I’m looking for and what I would hope we would get in the health care system is really a better balance between the length of…emphasis on the length of life, and the quality of life. We have a medicine that has been very oriented toward saving life, and saving life by whatever expensive technology it takes to do that. Meanwhile, we have neglected really working on the quality of the life of people saved. We’re very poor on long term care, and nursing care, particularly for the elderly. We’re very poor on the health promotion and health education. And it seems to me we’ve got to find a better way to balance all of this and to have a kind of moderate, rounded health care system, not the one we have now, which is terrific. If you, if you have…need a liver transplant, you can probably get this in the country, but if you, if you just need to see a doctor for some minor complaints, and you’re poor, you can’t get that. That makes no sense. And I want to…somehow we…our system is going off, all over the place, and it needs to be rounded. And I think part of the key, though, is we have to limit our appetite for the constant medical progress. There we want always, we like these dramatic organ transplants. But I think they’re misleading us, and they’re really doing us some very significant harm because they’re distracting us from more fundamental things that can be done…that will have…well, actually a much better public…at least public outcome.

Heffner: And how do you feel about those who would participate in denying that the most important thing was continuing to breathe, and feeling instead…in our other program when we talked about the aging…I’ve lived, not enough years, but I’ve lived a good number of years, and I’ve had a good life, perhaps, and now I want to turn it off rather than suffer as I do because those doctors have kept me alive and kept me alive and kept me alive. How do you feel about fostering the efforts, on the part of those who say “Enough already, I want out. I want to get…

Callahan: I, I…

Heffner: …off the stuff”.

Callahan: …think that’s terribly important. But I make a big distinction. I think it’s terribly important to, so to speak, to allow people to die and let them die by disease. I mean that is to say, if you don‘t want to be treated, and you tell the doctor, “Stop”, the doctor should stop. If you tell your family, “If I’m unconscious some day, I want you to tell the doctor ‘Stop’”…that’s very important and needs terrific…much more support than it’s getting, much more education. But I, I, I’m very resolutely opposed to doctors killing patients who ask to be put out of their misery, and then there’s a strong…

Heffner: Wait, wait, wait a minute, Dan. You say you’re against doctors “killing patients who asked to be put out of their misery”.

Callahan: Yes.

Heffner: You’re against patients getting out of their misery…

Callahan: I’m not…

Heffner: If the only way they know how to do that is to ask the doctor for an injection or pills or…

Callahan: Well, first of all, I think it would only be in a tiny minority of the cases that that would ever be necessary. I believe contemporary medicine can relieve pain and suffering very significantly, so that a doctor can…you don’t have to go out of this life in absolute suffering…there would be some minority cases, but, but doctors for the most part can control pain and suffering. So when you ask a doctor “relieve my suffering”, he doesn’t have to kill you to do so. I think he can medically manage you.

Heffner: But the suffering can be of different kinds.

Callahan: The suffering…

Heffner: …psychological…

Callahan: …sense of meaninglessness and this and the like. But here I think the hazard is, I really see a danger in changing the medical profession into one that could directly take life through active euthanasia, say, or assisted suicide, and a profession whose, whose traditional purpose has been to save and preserve life. So, I’m, I’m worried about that move.

Heffner: Yeah, but you’re, you’re pushing the medical profession to abandon one of its traditional strong points and that is to keep researching, keep finding these magnificent technological ways to preserve life. You find that somewhat now, anathema.

Callahan: Not “anathema”, but, but it needs to be done much more carefully. We need to…I mean I don’t want to stop research, but I want to do…we want to ask what the research…are we really going to get a good result? Are we going to make people happier, are we going to do them some good? Or are we merely going to preserve a body, keep a body going so that a patient will say, “My gosh, why did you doctors get me it he situation? Get me out of it”.

Heffner: Well, but…

Callahan: Now…

Heffner: Having gotten them in, how about getting them out, at their request?

Callahan: Well, I, I think the way to get them out is, is when you tell the doctors to stop, they stop. When you say you don’t want the operation, you don’t want the dialysis, you don’t want the organ transplant…you don’t get it. You want out of the intensive care unit, you get out of the intensive care unit. In other words, the doctor, the doctor tries to do for you what you consider is your own welfare. So I am…but I am drawing the line…the doctor…when you say “Doctor, give me an injection, I want it to end now”. I’m saying, “My gosh, I think that’s socially dangerous. That’s a road we don’t…we shouldn’t go down in our society”.

Heffner: Dan…

Callahan: And we don’t have to, either.

Heffner: …the business of a patient’s autonomy. Forget the business about euthanasia…how keen are you…I think of our program with Max Lerner recently…he’s very keen on the doctor within each of us, and the power and authority that doctor within each of us should have. What’s your own fix on that?

Callahan: Well, I, I’m very strongly in favor of autonomy. I want to manage my health and my medical life as well as I can.

Heffner: Do you know enough to? Particularly in this high-tech age.

Callahan: I will, of course, have to depend heavily on doctors. But increasingly I think it’s my right to ask doctors to inform me of my choices, to make known the options that are going to be available to me, to tell me if I get the operation what are likely to be the outcomes. If I don’t take the organ transplantation, what’s…how much life do I have left and what’s the quality of life? I think we’ve reached a time when we can, we can insist that our doctors educate us, inform us, give us very real choices.

Heffner: Yes, but if we’re talking about people who don’t head up an institute devoted…

Callahan: Yes, I know.

Heffner: …to the very questions that you’re dealing with, are we individually sophisticated enough to be able to hear even the doctor who’s willing to share with us?

Callahan: I, I believe so. Doctors…they need a lot more training in doing this and it’s not easy. I think the problems aren’t the technical level. I think the problems are at the emotional level. Right now, for instance, doctors are still very poor in talking with patients about the possibility of their dying and asking them what choices they have. It’s not because the questions are technically difficult, it’s rather that there’s an enormous reluctance on the part of doctors to raise issues of this kind. And, of course, patients aren’t exactly enthused about talking about these matters, either. It’s the emotional barriers that I think are the really difficult ones. And doctors aren’t well trained to do this, and the subject is still…if it’s raised, it’s often raised much too late, when somebody is already in a critical condition. It’s not raised back in your, in your doctor’s office when you’re in good health, or…I would make it part of an annul physical, that a physician would say, “Alright, now let’s think about the possibility that next year you might get critically ill and what we’d want to do about that situation”. We don’t do that, of course, but that’s that would be the better way to do it.

Heffner: I took the bit myself once when I ended up in an emergency room, laying there on a stretcher for 17 hours, presumably with a heart attack and said, “The hell with this, I’m getting up and going home”. I realized afterward what a damn fool thing it was…

Callahan: Yes.

Heffner: …because I didn’t know enough to know whether that was safe enough. But your idea of education, I think, means education of the people, too.

Callahan: The education of the people…

Heffner: …not just the doctors.

Callahan: It has to be done together. They’re really education of the physicians about how to talk to you and me as lay people; education about us as to what medicine can and can’t do. And I suppose in a funny way, we’ve got to…I think doctors and patients have got to learn…be educated together to learn how to talk with each other, and it’s…we sure don’t know how to do it now very well.

Heffner: Dan Callahan, reading What Kind of Life helps us, I think, know better about what to do. At least it raises an awful lot of questions. I’m not so sure I’m happy with the answers, but thank you for joining me again today on THE OPEN MIND.

Callahan: Thank you.

Heffner: And thanks, too, to you in the audience. I hope you’ll join us again next time. And if you care to share your thoughts about today’s program, today’s guest, today’s intriguing subject, please write to THE OPEN MIND, P.O. Box 7977, FDR Station, New York, NY 10150. For transcripts send $2.00 in check or money order. Meanwhile, as another old friend used to say, “Good night and good luck”.

Continuing production of this series has generously been made possible by grants from: The Rosalind P. Walter Foundation; The M. Weiner Foundation of New Jersey; The Mediators and Richard and Gloria Manney; The Edythe and Dean Dowling Foundation; The New York Times Company Foundation; The Richard Lounsbery Foundation; and, from the corporate community, Mutual of America.