May 6, 1998
David Gergen, editor-at-large of U.S. News & World Report, converses with Daniel Callahan, author of False Hopes: Why America's Quest for Perfect Health is a Recipe for Failure.
DAVID GERGEN: Danny, you're a philosopher and an ethicist who spent a long time looking at the medical system in this country, and you've now written a book saying we're on the wrong track. Why?
DANIEL CALLAHAN, Author, "False Hopes:" Well, a couple of reasons. Economically, I believe we've more or less reached a kind of saturation point. The American public is not willing really to see a great increase in taxes to pay for more say Medicare, Medicaid. Employers are not going to let budgets go up indefinitely. We've had a huge crisis in recent years about the control of costs, and I think the message is pretty clear now. We've got to find a way to control costs in the future. So one problem is simply economic. We're spending money at a rate that we really can't afford to spend. We're going to have to stop and level off and really, I think, achieve a kind of a steady state medicine. So that's the economic side. Anyway, the other side is really what are we getting for our money. I believe that modern medicine has really kind of led us down a kind of garden path by really suggesting that we simply spend enough money, if we do enough research, if we organize well enough, we'll one day conquer most diseases and maybe death, itself--not quite say death itself--but at least we'll someday conquer cancer, heart disease, stroke, all the things that cause death. So I think it's misled us kind of emotionally and psychologically, and it sure has created lots of economic problems. So my notion is we've got to really rethink this venture and go in a different direction.
DAVID GERGEN: On the economic side you say we spend more on medicine per capita than any other country and yet we have less to show for it than we should.
DANIEL CALLAHAN: Well, we spend now 14 percent of our Gross National Product, a trillion dollars a year. The next nearest country would be Germany and Canada; they spend about 10 percent of their Gross National Product. We spend literally twice as much per capita as the British, but the depressing part of that is that we have 15 percent of our population that's uninsured. Our death rates are actually worse than--we're number ten or eleven in the world on longevity. We're bad on infant morality. See, we get a very poor return for the money we do spend.
DAVID GERGEN: But it's the promise of medicine and the scientific promise that we can extend life, that we can improve the quality of life, to which you seem to take greatest exception.
DANIEL CALLAHAN: What really struck me--I spent a lot of time looking at other countries, and particularly in Western Europe, and I'm struck by the fact that every country in the world seems to be having some kind of a health care crisis these days. They're all trying to figure out how in the world to pay for the fact that we've got aging populations, constant new technologies, rising public demand, and no matter how they're organized, they have difficulties. I began to think that maybe it is perhaps the very fundamental, deepest values of modern medicine that are really causing us trouble and the deepest value of all is the notion of sort of unlimited scientific progress; that we're just going to get more and more, and healthier and healthier. I mean, in one sense, that's true. Things have gotten better and better. We have a much greater life expectancy now. We are the healthiest people in the entire history of the human race. But the difficulty, of course is that this progress is getting more and more expensive I think in many respects. We've really dealt--we've done a lot of the cheap progress. To use a kind of space analogy we're at the Moon stage. We're off the ground, and we've come a long way, but going further, having come a long way is the trick, and I think--I think at this point we've got to rethink this idea of progress. Can we afford the progress? How in the world are we supposed to pay for all of this? And maybe perhaps there is a better way of spending our money to get a better health outcome than sort of saying just go on and on, more and more.
DAVID GERGEN: Well, you've obviously that about that better way. What do you think it is?
DANIEL CALLAHAN: Well, the evidence is very, very solid now that if you really want to improve the health of a population, you work on public health; you work on health promotion, disease prevention. Most people are really not aware--say during the 20th century we've had an average--the increase in life expectancy has been about 30 years. But the best estimates are that perhaps no more than 20, 25 percent of that is due to medical advances. The rest has come from better sanitation, diet, rising standards of living, more disease prevention. And I think the--given the scientific evidence, that that's the way to improve health, I think we need to invest much more money in research on how to get us to have better healthy--health behavior, how to really work on providing people with the sort of social and economic backgrounds that lead to health, where we're spending the money sort of on rescue, end of life, very expensive technical medicine. And that is--it doesn't get you the return in terms of the investment. And, of course, it in many cases brings a great deal of misery to people. It keeps them alive too long and so forth.
DAVID GERGEN: Well, David Kessler, a doctor who was head of the Food & Drug Administration, now dean of medicine at Yale, the medical school there, believes we're on the threshold of perhaps the most exciting decade of medical breakthroughs in this century. Should we call that off?
DANIEL CALLAHAN: No. I really can't call it off. There's nothing I can say that is likely to stop it. I guess the question is: Is this the best way to spend--I think probably he means that there is a great deal of hope these days in genetic engineering, the possibilities of molecular biology. There are--there, no doubt, are huge breakthroughs, but, of course, this has been said for 100 years now. Science is always on the verge of great breakthroughs. I think the question is: If we get these breakthroughs, will we be able to afford them, or, as I suspect, we'll get a lot of breakthroughs, but they're going to be enormously expensive. We're going to find ways to extend human life, but not inexpensively, so we're going to be backed up against the problem of having a lot of wonderful possibilities, but actually no way of paying for them, or at least no way of providing kind of equitable health care for people.
DAVID GERGEN: What research would you give up?
DANIEL CALLAHAN: Let's take cancer. I would spend a lot less money on looking for new therapies for cancer, new techniques to extend the life of people with cancer--much more emphasis on the behavior of people that might keep them from getting cancer in the first place. Lung cancer is the great killer of men. We really know a lot less about how to change people's smoking behavior than we do about the genetics and physiology of lung cancer. So I would take money away from a lot of the expensive curative stuff we now work on and put it into more fundamental things to get people--help people not to have these diseases in the first place. Or, more generally, I guess I would take money--right now we spend a huge amount of money sort of combating lethal disease mainly by--mainly with new technological innovation. Heart disease is a wonderful example. But it seems to me an awful lot of heart disease is caused by bad health behavior. It seems to me the trick is to figure out how to change that behavior, rather than trying to find expensive ways to maintain the life of people who have had bad health behavior and are now terribly sick, want to be saved, as we all would, but we don't know how to save them inexpensively and often we save them for rather poor lives in terms of the quality of life.
DAVID GERGEN: Is your message then to accept more than we do the natural life cycle which you think we've basically reached and to try to improve the quality of life during the life cycle?
DANIEL CALLAHAN: I believe that it's a mistake just to sort of endlessly try to increase average longevity. I mean, I sort of feel that somebody of my highest white middle class male, sixties--I don't think I need an awful lot more life. I've had a pretty good life, and most people in our society by the time they reach my age, they've had a pretty good life, or if they haven't, they're not likely to get much--likely to get it after age seventy. So I think at that point I could say, look, enough is enough. We've done a terrific job. But let's see if we can improve the quality of life within a kind of finite life span. This--there are so many things we can do in terms of rehabilitation, in terms of osteoporosis, arthritis. There are all sorts of things that sort of pull us--we're alive but we're not terrifically well, and that's where I would place the emphasis. I don't want to live--I know many people that would love to live--if not forever--they would like to be a hundred or a hundred and twenty, but I don't--I can understand that maybe individually but I don't think we, as a society, need to push for that kind of a goal.
DAVID GERGEN: Daniel Callahan, thank you.