Medical writer Daniel Callahan discusses medicine in America.
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GUEST: Daniel Callahan
I’m Richard Heffner, your host on The Open Mind. And my guest today is Daniel Callahan, co-founder, and for a long time director of the prestigious Hastings Center, and author now of Simon & Schuster’s compelling, if at times quite unnerving, new volume, False Hopes: Why America’s Quest for Perfect Health is a Recipe for Failure. Now, please don’t get me wrong. It’s an important place to be, particularly for those who are quite so long in the tooth as I am now. But I should indicate that intellectually Dan Callahan and I have been here before in years past. Indeed, just think of the titles of various Callahan books we’ve discussed: What Kind of Life: The Limits of Medical Progress, Setting Limits: Medical Goals in an Aging Society, The Tyranny of Survival and Other Pathologies of Civilized Life. Which is why I want to begin our program today by asking Dan Callahan what personal, philosophical, psychological, perhaps theological imperatives lead him in the rather singular direction his writings have taken: a continuing revisionist, and quite negative, assessment of the medical establishment’s pursuit of unlimited progress that he characterizes as “nothing less ambitious than the conquest of all disease and the indefinite extension of lifespans.”
Clearly my guest has a personal fix on these matters different from that which informs most contemporary medical thinking. And I want to begin today by asking him just what it is. Dan?
CALLAHAN: Interesting question. Many people have tried to pin me down as to where my interests in these issues come from and why I’ve gone in the direction I do. I think, well, let’s see, at this point I’ve worked in the medical field, in and around it, for about 30 years now. And I think I came into that field really very much the outside or the amateur. I got interested in how it operated. As a child I had spent a lot of time in hospitals, and that probably hung over into my adult life. But I got interested in medical ethics toward the end of the 1960s. But as I spent more time with this establishment looking at this world, a kind of new world, I really became uneasy about what seemed to me the general thrust of it, which was, it seemed to me, sort of to have unlimited horizons, or, if not, if medicine never said its purpose was sort of give us immortality or conquer death, it acted, in fact, as if that was the goal simply by targeting any and all lethal diseases, any and all sources of suffering for eradication. And I began to wonder if that was really a sensible goal, whether, in fact, medicine had to learn better to live within some boundaries and limits, and whether really the drive to conquer everything from the beginning of life, the death at the beginning of life to death at the end of life really made any human sense.
HEFFNER: Why? Isn’t that complaining about the American way?
CALLAHAN: It is, indeed it is complaining about the American way. And, of course, I spend a lot of time in Europe with the healthcare systems there, and their very different attitude toward these matters. They understand old age and death are a part of human life. They certainly spend money struggling to relieve the worst symptoms of this, but there isn’t a kind of a crusade, the kind of obsession with unlimited hopes and expectations that you find here.
And why we’re this way, I’m not sure. One of the really first distinguished American physicians, Benjamin Rush, really was somebody who talked about medicine. He saw medicine conquering not only the problems of the body, but he thought medicine would ultimately deal with “human vice,” as he put it. And so we have rejoiced our dead in a very optimistic vein. And of course Thomas Jefferson was a great believer in science. We’ve got that tradition going. So we have a lot of things in our culture that have pushed us that way.
To me, the problem is, the first one, and I think there’s a kind of philosophical problem there: How far should medicine go, what should it aspire to? But of late it’s obvious that it’s created an economic problem too. We’ve reached the kind of stage where it’s getting harder and harder to pay for all of these wonderful things that we’d like in the name of health.
HEFFNER: But, Dan, when you say “philosophical problem,” that’s what I wanted to get at first. Where does Callahan come from philosophically, theologically, psychologically, that makes Callahan feel this is a problem? Because I think if you scratch most of the people on the streets outside of the studio, they’d say, “Well, of course we’re going to and want to conquer illness.”
CALLAHAN: Well, I think in my own case, I was once a religious person, Roman Catholic upbringing. But I really left that nearly 30 years ago, and I don’t consider myself a religious believer of any kind at this point. But after I left that religious world, I then moved into the world of medicine and science, which had these grand aspirations. And I began to think, “My gosh, this is like a religion too.” I had been in one kind of dogmatic, absolutistic religion, and I found myself in another world which seemed to have many of the same traits. And I think, if I was skeptical of the one earlier, I became skeptical of the other later. And I suppose in great part I did not… I think many Americans, and certainly our scientific establishment, really buys the old Enlightenment view. I mean, “Science is going to save us, can overcome nature and all boundaries” and the like. And I simply never quite warmed up to that particular kind of faith. And I do see it as a faith. And I began to think, “My gosh, this faith does give us many things, and wonderful benefits. On the other hand, it’s also generating lots of problems which people are reluctant to admit.”
HEFFNER: It’s so interesting to me that you say this “old-fashioned” or this “older enlightenment notion.” To me it seems that the Enlightenment notion is the new one, and that you have, in a sense, returned to that old-fashioned religion.
CALLAHAN: Well, in a way. Except I don’t believe the old-fashioned religion, first of all, part of that old-fashioned religion was one of the sources and contributors to modern Enlightenment science. I don’t think there is such a dichotomy as many now think. But I’m also trying to return to some of the earlier roots of medicine itself. I mean, up until about the Eighteenth Century, medicine did not take as its task the conquest of death. In fact, medicine couldn’t do much about death. Medicine was all about care and comfort and helping people deal with the fact that they were limited, finite people with limited bodies. And so, on one sense I’m trying to also return medicine to some of its own roots, because I think particularly in an aging society we have a, we really have to find a way to come to grips with the facts that we are going to get sick and die, so I want to take medicine back some. But I’m not sure, I’m not sure… It seems to be quite interesting, in fact. I would say most modern religious believers accept the enlightened notion they want to conquer death and disease as much as anyone else. So I guess I don’t quite accept the notion that I’m returning to the old. It’s more discomfort with the new, if you will. I’m not sure what’s better, but…
HEFFNER: You used the expression “sustainable medicine.” You are looking for a sustainable medicine. And perhaps that’s more the key to what this book is about and to what everything you’ve written in recent years is about.
CALLAHAN: Well, in many, in the past few years I’ve spent a lot of time reading about and talking to people as part of the environmental movement. My organization, the Hastings Center, now includes the environment as one of its issues. And I got very attracted to the idea of sustainable development, which is really a central notion for environmentalists. Namely, we have to have a planet which is going to be able to keep human life going for future generations. Not only keep it going in terms of basic natural resources, but in terms of beauty, the environment, a whole lot of things. And it seemed to me, and partly to do that we have to really give up the notion of unlimited growth. The environmentalists say we can’t have unlimited growth if we are to have a sustainable environment. I began to think, “Gosh, that’s an interesting notion. I wonder how it would work of applied in the field of medicine.” And I decided it might make sense. It would, at least gave me a way of thinking through some of my discontents and uneasiness. And then could we imagine a medicine which would begin to more or less level off, plateau, which would not, would begin to have more modest drives and ambitions, and thus be affordable. I mean, I think part of the problem now, we’ve created a kind of medicine that’s become increasingly difficult to pay for, and every country in the world is having this problem. Every country is sort of struggling with how in the world are we to keep up with the new technologies and our aspirations. And then you’re saying we can’t. I mean, we’ve got to find a way to cut things off, level things down a bit. And that’s sort of what I’m after.
HEFFNER: Dan, would it be unfair for me to ask you at what end do you begin? Where do you begin? Do you begin with the search for an economically feasible, in terms of our resources, an economically feasible medicine? Or do you begin in terms of a philosophically, psychologically acceptable-to-Callahan approach?
CALLAHAN: Well, I think a little of both. I think we have to try to relate the two. It’s pretty clear to me that countries can deal with the economic… There’s one nasty way you can deal with the economic problems: you just make people pay more out of their own pocket, and at some point they won’t have money, and that’s one way to control the cost of healthcare. But I think that’s a nasty way. So what I’m looking for is a philosophical way, if you will, of thinking about healthcare and health, which will somehow allow us to not only be more satisfied with the kind of healthcare, but also by limiting some of our aspirations and keeping the whole thing under control.
Now, at this point it becomes very difficult, because I think there is probably always going to be a fundamental strain in human beings who will want more, we don’t want to die, we don’t want to get sick. And how we manage that aspiration on the one hand over, again, sort of the reality principle on the other, which is you can’t have everything, we’re not going to be able to, we’re probably not going to get immortality, we’re not going to conquer all suffering, and we’re going to have a lot of high costs that we can’t afford. So balancing these two seems to me the great challenge for medicine in the future.
HEFFNER: Challenge. Do you think we can meet it, given who we are?
CALLAHAN: I suppose what I’m hoping for is, as time goes on, the economic stresses of medicine become more and more evident. We’re going to see these stresses with the Medicare crisis, which is predicted after about the year 2010 when the Baby Boomers retire. And I would hope that the economic pressures force us to say, “My gosh, maybe we’re working with the wrong model, the wrong vision of medicine.” Perhaps we have sort of tried, we’ve tried to work without any boundaries or sense of limitation whatever, and that’s clearly, at least if nothing else it’s unaffordable, and maybe also it’s generating some false expectations and hopes about medicine. I think one of the problems with modern medicine, it’s not just that it’s created economic problems, but I think it’s made it harder for us to come to grips with the fact that we are mortal creatures. And how we do that, I think earlier generations, they did it because they had to do it. I mean, medicine couldn’t save their lives, and they developed rituals and a culture for dealing with limits and mortality. But modern medicine has sort of thrown that out the window. It just says, “No, you don’t deal with mortality; you try to get rid of it. You conquer it. You don’t make sense of suffering; you try to eliminate suffering.” And I think that’s created all kinds of, a kind of spiritual malaise, if you will.
HEFFNER: Well, wait a minute, wait a minute. You talk about suffering. But my understanding from reading your most recent book, False Hopes, is not that you look to do that, that you want to alleviate suffering, but it is the philosophical or theological point at which you get caught: the life everlasting, the refusal to accept the end of life. Not the pain that goes with it.
CALLAHAN: Not the pain, actually. But I really would look for would be some way to really improve the quality of life within a kind of finite lifespan. I think now the tendency is to keep pushing, pushing, pushing, giving us all longer lives, conquering all those diseases that shorten life. Where I would like to see a quite different notion of progress, namely the fact that we accept the fact that we are going to live maybe 75, 80, and that’s going to be the average, but we’re going to really live better lives than we did in the past by focusing very much on pain and suffering and disability, things that kind of ruin the lifespan for an awful lot of people.
HEFFNER: Yes, but, you know, I introduced the program by talking about the nervous-making quality of false hopes. And it’s quite clear, as I look back at the transcripts of the programs we’ve done before, I’m aware of the fact that now I’m that much older, I’m that much closer to the point at which, I’ve probably passed the point at which my friend Dan Callahan would say, “Enough already. Heffner, you’re off on your own. We’re not going to devote our resources, our medical resources to you; we’re going to devote them to your grandchildren, which is only fair.” And that makes me scared.
CALLAHAN: Well, let me distinguish, as we philosophers like to say. I don’t want to abandon anybody in old age. I want to say, “Look, beyond a certain age we probably should be less and less interested in finding cures for the lethal diseases, less and less interested in getting you from 85 to 95. But we never want to abandon you. We want care, comfort, good social and economic support in old age, access to emergency care if you need it, but perhaps a diminishment of: A) a lot of high-technology medicine toward the end of your life; and B) a diminishment of research efforts to find ways to keep extending life.”
But here’s where I return to the old-fashioned medicine, that is the medicine of care and comfort. That seems to me fundamental and indispensable. The question is: Do we need to carry it to sort of endless technological warfare against death, you know, even in old age? And it seems to me that’s even possible. I mean, conquering death and old age is a hopeless task. We’re going to die of something or other. But what it seems to me we can certainly live better lives as older people. But my own impression is most elderly people, they’re not worried about where they’re going to get a heart transplant or open-heart surgery. I mean, they’re really worried about are they going to have economic security, a certain dignity in the community, will their sort of basic human needs be taken care of. I don’t think they’re sitting around worrying about where they’re going to get the very best, most modern technology. Now, I might be wrong on that point, but that’s at least my impression.
HEFFNER: You know, I daresay I think you are a little bit wrong on that point. As I get closer to the end, and as I have, as I’ve had recently, bouts with things that scare me, physical things that scare me, I realize the notion of comfort is not comforting enough, the notion of relieving pain is not comforting enough. And since I vote much more powerfully, much more frequently than my children do or my grandchildren probably will, do you really think that I’m going to be able to face up to what it is you’re saying to me, given that fear?
CALLAHAN: I suspect it will be hard. Interestingly, a study came out recently, sort of a survey of elderly and what they’re prepared to put up with in old age, and what they’d like. And it turned out the study found that most people would prefer to have longer lives at lower quality rather than shorter lives at high quality, which I must say is a shock to my fleece. But I don’t think that’s the right set of priorities, but I can understand it. And I perhaps will see in my own case when I get something serious, will I grab like everybody else. But I guess the question, the way I like to put the question, this is maybe the way I would feel and you would feel, but I’m trying to stand back and say, “What’s good for a healthcare system? What’s good for a society?” And giving me or you lots of expensive stuff at the end of life, A) maybe there are better ways to get health and health promotion, disease prevention might have given you a better life that such that you wouldn’t need these. But also you would really have to think of it, it’s our kids that are paying for this after all. That’s the way our Medicare program works. It’s the current taxpayers who are paying for the elderly. And at what point are you going to say, “I can’t keep putting this on my kids, or on the younger generation, to let me go on and on and on at high cost.”
HEFFNER: But, you know, there’s one part of the equation that I think you leave out. And it surprises me. And that is going back to old Samuel Gompers. What do you want? You want more. You want a bigger pie, as well as a larger slice of the pie. But the important thing is a bigger pie. Why aren’t you putting your emphasis upon more and more in terms of our resources? You say, you’re acting as though, and maybe you’re correct, there are finite resources. Maybe the environmentalist model is the wrong one.
CALLAHAN: Well, I mean, there is a difference. Because with the environmental model we really are dealing with the material world, and resources actually can run out in some absolute sense. It’s certainly true with healthcare systems as…
HEFFNER: You’re talking about natural resources.
CALLAHAN: Natural resources can run out. With healthcare systems, as with, I suppose, school systems or anything else, you can just let the budget keep go up and up. I guess there, right now we spend 14 percent of our gross national product on healthcare, more than any other country in the world. The Swiss and the Germans are next, and Canadians are now 10 percent. But we don’t get a good return for that money. The English spend half as much per capita as we do and they get equally good health outcome. So you’ve got one question. We can let the budget creep up, but probably a lot of it’s going to be wasted, inefficient. If we, simply we know that by looking at other countries.
The other question though is, how do you, I guess I’ve been fascinated the question, how do you think about a balanced society. One thing that’s fascinating about the British national health system is that it has to do, all of the different parts of their society supported by government have to compete directly with each other. So you have healthcare competing with schools, competing with welfare, competing with defense. In our country we’ve sort of let healthcare have a kind of runaway. We’ve let it go up and up and up. We haven’t let school, and actually we spend 14 percent of our gross national product on healthcare, six percent on education. Thirty years ago they were about the same, six on each. But we’ve let healthcare go up despite the fact that health, people’s health is getting better. And there’s, to me, the funny paradox of medicine. However much we spend, nobody is satisfied. I quote in my book a wonderful physician who died some years ago, John Knowles, distinguished physician, who said, “Doing better, and feeling worse.” And when you think about it, think of our, I don’t think anybody would say our education system is so terrific that it doesn’t need more money. Why do you let that one stagnate in terms of spending, and the one, health has gotten better. We ask, however good our health is, we say, “No, we always want a little more than we’ve got.” And this goes on and on and on. And that’s the problem I’m trying to deal with.
HEFFNER: Yes, but, Dan, when you write about, you quote John Knowles correctly. When John Knowles sat at this table, years ago now, in fact, the last time just before he died, I experienced the impression of a great optimism. When we talk together I experienced just the opposite. John seemed to be one of those people who would say “More and more and more” when he was heading the foundation, when he was running Mass General.
CALLAHAN: I suspect that’s probably so. But I would also, but I think he was pointing to just, nonetheless, an interesting phenomenon that we want more because we are never quite satisfied. Very interesting study by a younger colleague of his, Arthur Barsky at Harvard Medical School, psychiatrist who really looked at, studied people’s actual health status 30, 40 years ago, and their subjective experience in getting people recently. Same questions that were asked 40 years ago: “Are you in good health?” And so forth and so on. And then he measured their health, and he found that people these days are, in fact, far better health than on average than, say, 40 years ago. But they think they’re worse off than they, they feel worse now. And so I’m sure that John, I mean, he was an optimistic, lively kind of fellow. But he pointed to a funny paradox in our system. Why is it that people think they’re worse off now than they were 40 years ago? And I think because we keep raising, we’re never satisfied. It is more, more, more. Let the standards go up. And, of course, we’ll always be unhappy that way.
HEFFNER: Well, as an ethicist, and a philosopher, let me ask you this question: Do you see the possibility that if more and more people saw what you see and fought more, as you would have them fight for what you call “sustainable medicine,” do you think that would have an impact upon our other ways of looking at ourselves, our future, our potential for doing the things that you want us to do in terms of war and peace, in terms of welfare, in terms of caring for each other?
CALLAHAN: I really can’t honestly say, yes, it will lead in that direction. I think what I, I mean, first of all, I think the scientific evidence indicates that if you take a public-health health-promotion approach you have a much better chance of getting a healthy population than spending a lot on medical care. So, in one sense, what I’m looking for, and I think others are looking for, a sort of a fundamental way to change our living and health behavior so that we’re less dependent on technology to bail us out and rescue us at the last minute, which is the tendency of the American healthcare system. I guess I would like to see lots of aspects of our American life less dependent upon technology, more of a willingness to somehow live a more modest life within some kind of natural boundaries. And here I think the environmental movement has something to teach us. I mean, it’s really saying, unless we learned how to live simpler lives and become less obsessed with constant growth and economic development, we’re not going to have much of a planet 50 years from now. And I guess I want to say this is probably true in a lot of other aspects of our lives.
HEFFNER: Well, when FDR said, “We have nothing to fear but fear itself, unreasoning fear, to be sure,” wasn’t that part of that American can-do that has enabled us to make, in many areas, the progress we have made? And I repeat the other question, or the prime question for me. Taking your limited approach, your approach of recognize the natural limitations upon human life, won’t we then, in all likelihood, be less able to think in terms of limitless futures in many, many, many social areas?
CALLAHAN: Well, first of all, it seems to me that, in many respects, we have learned to live within boundaries. I have a few examples. When I was growing up, you probably remember the automobile of the future is going to go 150 miles an hour. Popular Mechanics. We were going to have these wonderful, engineered highways. Well, we pretty well learned our children and grandchildren are going to live somewhere around 55 and 65 miles an hour. We’re not going to have a supersonic jetliner for everybody going around the world. And sure we’ve begun to see some of the practical limits to some of our aspirations. With automobiles we in fact are going about the same speed as when you and I were children. But they’re safer now, the quality is higher, they’re more efficient, and it seems to me that’s the… I have a few pictures in my mind of areas where we have learned to more or less level off, and we still find ways to express our desire for progress and improvement. Automobiles get better. They don’t go any faster, but they get better in lots of other ways. And it seems to me that’s part of the environmental message too. But if we want a decent planet we’ve got to give up the notion of unlimited growth. Let’s see if we can function on, put our focus on trying to have a kind of bounded live that is richer and fuller and that doesn’t depend on the notion of always of more, more, more, because more, more, more, first of all, doesn’t make us as happy usually as we think it will because we get there and it’s the next stage and we say, “Oh, gosh, we’re not so great after all, so let’s go on.” So it’s, we’ve got to change our psychology. And I think there are models around of people who have done this kind of thing.
HEFFNER: Well, you know, the great influence in my life still, the World’s Fair of 1939. And so I still think in terms…
CALLAHAN: Well, that’s when I first saw television.
CALLAHAN: I went to that World’s Fair also. Yes.
HEFFNER: There it was. And the thought of a limitless future. But look, I’ve just gotten the signal this program has ground to an end. Not ground, but is at an end. Stay where you are. We’ll do another program, and it’ll be on next week. Okay?
HEFFNER: Thanks, Dan Callahan for joining me today on The Open Mind.
And thanks too, to you in the audience. I hope you join us again next time also. 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.