What Price Better Health?

GUEST: Daniel Callahan, Ph.D.
VTR: 1/22/04

I’m Richard Heffner, your host on The Open Mind. And as I’ve had reason to say quite often of late, by way I suppose, of summing up my own life’s work, essentially I’m a teacher. One might say even in this broadcasting role, though on a larger scale here than in a traditional classroom.

As a teacher I seek mostly to open my own mind and the minds of my viewers to the ways my guests can best set forth and elaborate upon their thoughts about the seminal issues of our times.

And I don’t usually challenge those views except for the sake of clarification. But today is different. Today my Open Mind guest is once again Daniel Callahan, philosopher, ethicist, co-Founder and long-time Director of the prestigious Hastings Center, renowned for its continuing examination of ethical issues in science and society.

This time I’m really going to challenge my old friend and his new book for the University of California Press “What Price Better Health: Hazards of the Research Imperative.”

Indeed, given how counter-intuitive his title seems to me, at least, I’m going to push Dan Callahan very hard to tell us in the most specific terms, chapter and verse, if he will, just what the downside could possibly be of America’s ever growing support of better health and the ways to achieve it. Dan, you’re on the spot.

CALLAHAN: Well, I’ll give you one downside right away. We have very rapidly rising health care costs, going up 10% to 15% a year for the past few years. The number of uninsured is increasing all the time. About 50% of this cost increase comes from new technologies and technological innovations introduced into the system.

So it’s great to have these technologies, they do change and improve our life, but they’re beginning to create an economic fit. So that’s for openers.

Beyond that, I’ve gotten fascinated with the whole research enterprise and our love of research in this country and our belief that we, we have to have unlimited medical progress. And I’ve come to think that like a lot of things that are good … I, I suppose I’ve been fascinated by things that are good that have their bad side for much of my life; I think biomedical research does have terrific benefits, but it also carries with it an awful lot of temptations. And I’m kind of interested in exploring what the temptations are. What I call the “shadows” of this enterprise.

HEFFNER: Temptations. Why do you call the “shadows” temptations?

CALLAHAN: Well, I’ll give you … I’ll give you … let me start with a simple historical example. It was …one of the great debates over the past century has been on the use of human being as research subjects in medicine. The scientific community argued for decades and decades that they simply couldn’t, people were simply too dumb to be asked to write the research, that you had to sacrifice a few lives to save other lives.

And then, of course, along came the Nazi doctors who did all sorts of terrible things to people, in the name of medical research and then we had abuses here in the fifties and sixties of medical research. And in every case the defense was “My gosh, we, we have to circumvent moral rules because what we’re doing … mainly saving lives … relieving suffering is such an ultimate good that, that it’s worth paying the price.” And the great revolution in that field was … really came out of the Nuremberg Trials when it was really determined that it was no longer adequate to have human beings used as research subjects without their informed consent.

That was to say a doctor cannot work on you, do research with you unless you say “Yes” and that is a hard and flat rule. And even if you … you know even if the researcher says, “But I could save thousands of lives, if I could just do this research.” And still the rule is not without my permission. So right away, there’s a shadow side.

Now we, this issue has been debated a hundred years, and yet still there are abuses. There are still people getting research done (on them) without their permission. Still people dying of research where they have not been adequately told what the results would be. So that … that sort of … it’s a long chronic illness and again, that’s what I call a research imperative … “My gosh, we are doing good things, therefore we have to break a few eggs to make an omelet” kind of stuff.

HEFFNER: But, Dan, I, I … when you mention that you have to make … to make an omelet you have to break eggs …I, I couldn’t agree with you more in your hostility toward that. Suppose I said everything you just said, “Yes, indeed.” And indeed I can.

CALLAHAN: MmmHmm.

HEFFNER: Then, where are you left with this matter of the research imperative? Because you have said yes to Callahan’s concern about informed consent. You’ve said yes to Callahan’s concern about human beings as the objects of research. You’ve eliminated that. Then were are you?

CALLAHAN: That’s one area. I’ll use some other examples. The pharmaceutical industry justifies its high drug prices on the grounds that they are saving lives. That they have, they have a moral obligation to constantly find news drugs and treatments to save lives. And that’s the argument they primarily use for their high prices.

The problem, of course, is there are a lot of people in our country and throughout the world, particularly with AIDS, who can’t afford these drugs. They are dying because of their inability to pay for the drugs. So I, I find it just ridiculous that the pharmaceutical industries can talk about saving future lives, while people are dying here and now because they will not make their products available at an affordable price.

HEFFNER: That …

CALLAHAN: That’s … they claim the research imperative is that future lives are more important, in a funny way, then the present lives.

HEFFNER: But, Dan, then I say yes again to Callahan …

CALLAHAN: Right …okay, I’ve got a few areas here, all right.

HEFFNER: Very important areas, because I couldn’t give a hoot in hell about the profits of the pharmaceutical industry. Let’s make …

CALLAHAN: MmmHmm.

HEFFNER: … let’s nationalize …

CALLAHAN: Right.

HEFFNER: … the pharmectical industry or pharmaceutical research …

CALLAHAN: MmmHmm.

HEFFNER: … we’ve eliminated the profit motive.

CALLAHAN: Yeah.

HEFFNER: Then the research imperative … what’s the matter with it then?

CALLAHAN: Well, I guess then, then the problem is deciding what you ought to work on. The argument sometimes of many scientists or their supporters is that they should be able to work on anything they want because they’re going to benefit us. And I guess I think … can think of many things that would not be of benefit to us, but their claim that they’re going to do us good; they’re going to satisfy our individual needs, it seems to me, it gets pushed too far. And sometimes they, in order to do the research; they begin trampling on a lot of important values.

HEFFNER: Yeah, but let me ask this. In that matter … when … since Callahan has already eliminated the profit motive, has already eliminated experimentation on human beings. Already eliminated the problem of consent, what difference does it make, except perhaps in the area of dollars. Is that your concern?

CALLAHAN: No, my concern really is … I suppose … there are two; one concern is simply call it the somewhat lower level of cost and price and peoples giving freely and having choice.

A higher level is where is research going to take us? What kind of a world is it going to create for us? Do we, in fact, want to improve human intelligence, human memory? Do you want to double average life expectancy?

HEFFNER: Do you know anyone who would say “No” to those questions?

CALLAHAN: [Laughter]

HEFFNER: That’s what I really meant.

CALLAHAN: Well, there are plenty of people who would say “No” to things.

HEFFNER: Why?

CALLAHAN: If they thought about it. I think we …

HEFFNER: Why?

CALLAHAN: Well, I, I suppose first of all … to me it’s a very fundamental, philosophical question is what really makes people happy in life? And, and I think that an awful lot of the hype that comes from what science is going to do for us in the future, or the miseries it’s going to relieve of us, or the better lives it’s going to give us, really does not encompass a careful reflection on what, in fact, does make people happier or to me, more importantly what leads to a good society.

And I think an awful lot of the research that goes on in this country may satisfy individuals; may make them happy, but it is not necessarily creating a better society. And I guess when I look at medical research, my question is, “what will give the overall society better health?” And then I get moved in the direction of public health, doing things that help the most people. Much more primary care, much less high tech genetic medicine; much more low tech ability to visit a doctor inexpensively to get inexpensive drugs and so forth and so on.

So it’s a… I feel I should start with a question, “What do we really need in this world?” As far as I can see, we certainly could use some better health, but I don’t see the greatest problem, at least in developed countries, as a health problem. Our greatest problem is social … is jobs, social violence, the fact we’re … the social evils that seem to be greater than biological evils.

HEFFNER: Again … yes, yes, yes, yes.

CALLAHAN: But …

HEFFNER: No, no, no … no, no, no …

CALLAHAN: All I want to do is to say, “Look, the research enterprise is often presented as this pure, clean, unadulterated, wonderful thing, and you’ve already agreed, “Well, there are some problems.” That’s, that’s all I want to say.

HEFFNER: But then let’s …

CALLAHAN: And I want to pursue some of those problems.

HEFFNER: But then let’s handle the problems.

CALLAHAN: All right.

HEFFNER: Let’s …

CALLAHAN: Well we can’t get rid of them … let’s go back a bit.

HEFFNER: Yeah.

CALLAHAN: The issue of human subjects could be dealt with International Rules and Regulations.

HEFFNER: Right.

CALLAHAN: We’re not going to get rid of the profit motive. Not the least chance in the world, and much less in the United States … that we’re going to get rid of the profit motive. And I don’t think we would necessarily want to get rid of the profit motive in any and all respects anyway.

But there’s no … the possibility of actually controlling the profits of the drug industry, at least in this country, are nil. Total inability over the years in Congress to set any kind of price controls established. The Bush Administration even now in the new Medicare legislation has been very … came out very favorable to the drug companies. They are a very powerful lobby and unfortunately we live in a society that loves the market. That loves profit. And so I … we’re stuck with that one, I’m afraid.

HEFFNER: How …

CALLAHAN:

HEFFNER: …how could say that? How could you say we’re stuck with that. Yes, that’s were we are now.

CALLAHAN: Well, we’ve had two hundred years of it and it’s, it’s part of our culture, it goes back very far and you can trace it right back to Thomas Jefferson, in fact … the great individualist. In fact the great lover of the affluent life. And, it’s right in our history, deTocqueville talked about the American drive for money and profit. He said “Americans talked about two things … money and religion” … really struck him.

HEFFNER: Dan, if we had this discussion in 1932 …

CALLAHAN: MmmHmm.

HEFFNER: …perhaps I could be a little more sympathetic …

CALLAHAN: MmmHmm.

HEFFNER: …but changes have taken place in our nation; a great sea change …

CALLAHAN: Yeah.

HEFFNER: … every time at the end of the program when I told people where to write; and I tell them “FDR Station”, my voice goes up. In fact we have in the past had, had great social movements where changes have taken place. We’ve, at least temporarily …

CALLAHAN: MmmHmmm.

HEFFNER: … driven from the temple the money changers …

CALLAHAN: Some

HEFFNER: … well, from you …

CALLAHAN: Well we haven’t done it from the pharmaceutical or the medical (GARBLED); and in fact that’s getting far worse than it used to be.

HEFFNER: Well, let’s do something about that.

CALLAHAN: Oh, I’d be happy to do something about it, but nobody in Congress has figured out how to do anything about it, and even in the Democratic Administrations, they don’t succeed.

HEFFNER: But you see …

CALLAHAN: I, think it’s very deep. I mean … I, I guess the problem is that there’s in certain parts of our culture that are so deeply … I mean freedom is far more important to us than justice. I’ve been interested to go to Europe where they have universal … every country has universal health care, they take it for granted that we should take care of our fellow citizens when we get sick.

Americans have never taken that for granted and that’s why we have such a large number of uninsured. And I guess what to me is very distressing is … it’s been around for such a long time; it is deeply inbred. Now I agreed very much that there are social movements that have changed things.

I think in my lifetime and your lifetime, Civil Rights, Feminism, Environmental movement; great social changes. But I must say, we haven’t made nearly as much progress with the profit motive. And I think we’ve not made nearly as much progress in, in really trying to think through the problem of Universal Health care. And I think if we’re going to think through that problem, we’re going to have to think through the problem of rationing and limits and how we’re going to actually fairly distribute the care we want to give everyone.

HEFFNER: It’s seems to me and it always has when we’ve talked together …

CALLAHAN: MmmHmm.

HEFFNER: … that there is still something more fundamental in your opposition to this kind of activity …

CALLAHAN: Well, it’s not opposition, it’s that I want it to be thought about in a more careful …

HEFFNER: Okay.

CALLAHAN: … nuanced fashion. I’m not against progress. I’m a beneficiary; I’m alive because of lots of progress.

HEFFNER: Yes, but it seems to me that you might not say progress is marked by the fact that you or I … that we’re still living. You seem …

CALLAHAN: Well, I can see some of the benefits of it. But I’m really asking the question, what is the overall benefit for us as a society with these developments?

HEFFNER: You mean that you and I are still around?

CALLAHAN: Well, that’s one part. Okay. You and I are still around. But, but actually there are a large number of scientists now that are trying to double life expectancy and do even more. Now I don’t think that’s going to be any great social benefit. It’s not going to solve any of our contemporary problems. I don’t know of any problem we have now that would be solved by having people live twice as long as they do.

HEFFNER: I, I guess you feel instead that it will exacerbate …

CALLAHAN: It will exacerbate … oh, absolutely Yes. We’ll obviously have problems of job mobility … where young people … how do you get into the system, if you’re going to have to wait years and years? We’re going to have a large problem, basically … obviously … even the people who are in pretty good health are still going to have bad health. You’re going to have years and years of providing health care.

And I guess the question to me, which I can’t answer, obviously … would people actually be happier and better off if they had another 30 or 40 years. And that’s …I, I … I look at my own peers and people older than I ask, “Hmm, do they … how long a life do you need to live to have a happy life?”

And as far as I can see, if you can make it to 70 or 80 thereabouts … you’re, you’re not going to have incrementally more and more happiness just because you live one more year.

HEFFNER: Which is it? 70? Or 80?

CALLAHAN: Well, I, I … it’s interesting …

HEFFNER: Or 90?

CALLAHAN: I think, I think … I see things that are … 80 seems interesting … there are a lot of medical data … but things really begin changing around 80 for most people. There are always … I mean there are always the 95 year old guy in the Boston Marathon. But for most people things do really begin to decline after 80. Namely, they don’t necessarily die, but, but, you know, their hearing gets bad, their eyesight gets bad, they have to urinate more frequently; they don’t have the lung capacity they once did. Frailty begins …and you see all the signs …

HEFFNER: And suppose the medical people say, “Well we can fix this …”

CALLAHAN: Well, that’s exactly …

HEFFNER: … and fix that.

CALLAHAN: … that’s exactly what they do say. And …

HEFFNER: Then …

CALLAHAN: But then I still want to ask the question: a) is that a good way to invest their money. I do start with the question … when I look at our present society, I see all sorts of social problems. I ask the question, will any of them be solved by improving longevity? And my answer is “it’s hard to see it”, other than you and I might like it; and many of our fellow citizens. But, as a social benefit it seems to me it’s going to create problems, not solve problems.

HEFFNER: What would you do then, given that point of view … what would you do then to avoid the, perhaps unfair of me to call it “waste” of our resources on keeping the 78 year old fellow going. Once, once in our studio …

CALLAHAN: MmmHmm.

HEFFNER: … when we were talking about this, I said, “okay, I’m 68 then …

CALLAHAN: I know.

HEFFNER: … and do you want to tell the hospital to turn me away …

CALLAHAN: No.

HEFFNER: … instead of “wasting” resources?

CALLAHAN: Well, I, I don’t … I understand by “waste” namely doing something that really needn’t be done if you did things better … so let’s put it that way … waste in the health care system … do you have a treatment go to success if it’s not benefiting the patient… I’m all in favor of … let me say two things here … I’m worried about the future of our Medicare system, whether it can keep growing in size and expenditures, particularly as the Baby Boom generation retires and the number of people under Medicare gets larger and larger. That’s one problem. The other problem is what do you do with the individual elderly patients?

HEFFNER: And it all comes down to individuals.

CALLAHAN: it’s not all waste. It seems to me that the fundamental question, which we wrestle with a lot with other people is “what actually counts as waste?” I mean is by-pass surgery for a 90 year old who is otherwise in good health and will continue in good health … is that a waste?

I’d say on the one hand “no”; I think for the individual it’s not a waste and it’s not a waste of doctor’s time to perform the procedures. Whether we can afford a trend in this direction when the Baby Boomers retire, that’s a separate kind of issue. But I don’t consider it wasteful. An awful lot of medicine, particularly … an awful lot of medicine these days sort of gives us marginal benefits at a very, very high price.

Now, I’ve been interested recently in looking at new heart technologies. We’re about to get an artificial, implantable heart and defibrillators … very expensive stuff, which basically gives people maybe a few more months; maybe a few more years of life, but at an enormously high cost. Now the question is “is that a waste of money?” Well, it you have heart disease, it’s not a waste of money. But if you’re paying your taxes for that you might think, “well there are better things to spend money on in our society than $300,000 … and some of these procedures cost $300,000 and they’ll add three months of life. Is that a good way to spend money? I don’t …

HEFFNER: Dan, how are you gong to deal with this? And I’m not quarreling with you now.

CALLAHAN: Well, I, I … it’s interesting …I’ve spent a lot of time in Europe and I’m fascinated to see how the Europeans do this because they do … everybody is guaranteed health care in Europe. And the way, and that means government control. Governments run the health care system and basically they control in great part by … what the economists call the “supply side”. They limit available technology, they limit hospital beds. They make people pay a fair amount of out-of-pocket …in universal health care, that’s a little sneaky side. In Italy about 30%, Israel around 35% … when you go to the hospital, you pay 35% of the bill yourself. They do it mainly by government controls. But that’s Europe and people will accept things happening … government doing things that we would never tolerate.

So I think if we have universal health care, it has to be controlled by the government and the way to control it, of course, is that they will simply turn off the spigot on certain new procedures, new technologies; they will be much more … they might say “we’re not going to spend $300,000 to give somebody another three months of life”. They might say, “we just can’t do that”.

HEFFNER: What about old procedures, like dialysis, for instance.

CALLAHAN: Well dialysis is a wonderful case … it had been a legend for some years … that’s older and sicker. When dialysis first came in, in the early 70s, the expectation was it would cost about $400 people would be actually the beneficiaries. Well, as time has gone on, it’s a billion dollar … I don’t have any … it’s many billions of dollars now. Most of the … the largest number of people now are older people on dialysis, people over 70. And the doctors often find this … the doctors who provided … in fascinating discussions with because they say, “Look we have lots of patients we don’t think it’s a good idea to put them on dialysis … they’re not going to live very long, they are in misery, and they need the dialysis. On the other hand life on dialysis is very unpleasant also. But we can’t say ‘No’. If they want it and the government is going to pay for it, however useless we think this treatment is …

HEFFNER: Would you say “No”?

CALLAHAN: If I were in their position I would probably wimp out and say, “Okay”, I would go along with the patient. But that’s the side of me … the doctor at the bedside has to think about these matters differently …

HEFFNER: You’re not in that position, you’re …

CALLAHAN: I’m not in that position.

HEFFNER: … you’re the social philosopher?

CALLAHAN: Well, I … I suppose I’m trying to think from the perspective of society. Namely, is that, again, to me, the interesting question is “what else might we better spend the money on?”. We live in New York City, we’ve got all sorts of schools that are falling down. Dialysis you can get full coverage by the Federal government if, if you have failing kidneys. And you can be right next to a high school that can’t afford text books. That’s seems to me a bad set of priorities.

HEFFNER: Therefore I have to repeat, what would you do, Dan?

CALLAHAN: I would, if we could do it, I would have universal health care.

HEFFNER: Okay.

CALLAHAN: I would have the government control the price of drugs, I would have government limit a fair number of procedures in order to …

HEFFNER: Like dialysis.

CALLAHAN: Like dialysis, in order to keep everybody … make the universal health care possible. I don’t think we can have universal health care unless we’re prepared to say “no” to a lot of things.

HEFFNER: Well, I guess that’s the key point.

CALLAHAN: But see that’s the hard part for Americans, for Americans to buy. The whole managed care which got a lot of complaints in the 80s and particularly the 90s. Managed care was holding down costs in the middle of the 1990s and they were doing it by means that a lot of people objected to. First of all by saying … you have to go to your primary care physician to go to a specialist. Doctors had to get their procedures approved with the insurance company. All of that stuff got shot down and the control of costs which came in in the middle 90s all faded away and it went right back up again. Because they got legislative pressure, legislators said, “My God, you can’t … how can you say no to these … you’ve got to give these people. But this is America, unfortunately.

HEFFNER: And yet you probably have to say more and you’d have to say that the answer to your question, “What price better health?” would be … any price whatsoever on the part of most people.

CALLAHAN: Well I think that’s, that’s very much the case. In fact I always … I think one of the worst things I’ve heard over the years is people who say, “you know, I basically agree with you, that makes a lot of sense. But if it’s my wife, my spouse, my girlfriend, that’s different.” Well to have a nation where everybody wants it all to be different with themselves and their loved ones, you can’t have a European health care system. I think they better understand over there that if you want to have a fair and equitable system and everybody has decent access to, you can’t put your wife and your loved ones first. They are on a par with every other citizen.

HEFFNER: But you also don’t think we’re going to do that in this country.

CALLAHAN: It’s very hard to be optimistic. I mean again, the Democrats … or some of the candidates are talking about … and George Bush is sort of getting nervous about that issue. But its … after watching this for fifty years and every … every ten years … “oh, we’ve got a huge crisis in health care … something’s got to happen now.” Well, we seem to be happy muddling through a crisis rather than actually engaging in any serious reform.

HEFFNER: We just have a couple of minutes left …

CALLAHAN: Yup.

HEFFNER: You do spend a lot of time abroad.

CALLAHAN: Yes.

HEFFNER: How successful are other countries?

CALLAHAN: They’re far … well, a) they’re much better … they’re much more successful on cost of health care, they spend less per capita than we do and less as a percentage of their gross domestic product.

They’re also better on the outcomes. People live … America is not at the top of lists of longevity, there are a lot of countries … Canada’s a lot better off than we are. So they basically get better health outcomes at a lower cost. That’s the simple story of the European health care. So, by almost any index, we, we have a poor health care system.

HEFFNER: And what’s the difference there? What’s the missing ingredient? Private enterprise?

CALLAHAN: The missing ingredient is that we have a system which is very heavily a private system, a private health insurers, private … and a lot of people who believe very much in the market as the way to run things. And George Bush is right at the top of the list these days.

HEFFNER: Don’t you think that the answer then … since the answer to your question “What Price Better Health?” is in this country … any price … that we’re going to take the profit out of medicine.

CALLAHAN: Well, I think that’s … that’s about the most Utopian thing I can think of to say in this world given the fact that we have failed for at least a century to, to do this and it is getting worse, not better.

HEFFNER: You think that it will be easier to say only so much … in terms of what price.

CALLAHAN: Oh, no. That’s going to be equally hard, too. The difficulty, I think, with the American health care system is it’s very hard to imagine any sort of semi-reasonable solution that will be successful. Even the market people … people who believe that we should make much more profit-oriented private enterprise … they’re not going to win either. Because we don’t want to go that far, on the other hand we don’t like the government either so we won’t go in that direction. So we end up with the worst of all worlds.

HEFFNER: Well, Dan, when we’re in our nineties, we’ll keep talking about this. Thanks, Dan Callahan for joining me today. 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 $4.00 in check or money order to The Open Mind, P. O. Box 7977, FDR Station, New York, New York 10150.

Meanwhile, as an 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.