BY: DANIEL CALLAHAN, PhD
Dr. Callahan is director, International Program, The Hastings Center, Garrison,
NY, and the author of The Research Imperative,forthcoming this year from
the University of California Press/Milbank Memorial Fund.
People with cancer have good reason to feel relieved when the disease goes
into remission, and good reason to feel heightened alarm when it returns. An
analogy with the cost of health care comes to mind. The 1970s and 1980s saw
an eruption of double-digit inflationary health care costs, an economic disease
of the first order. Then, from 1996-1999, a miracle of remission occurred: The
increase stopped; costs leveled off. Even better, in the HMO movement, which
was credited with the surprising economic stability, a permanent cure seemed
at hand.
No such luck. By 2000 the costs were going up again, from 12 percent to 18
percent, and that trend has continued into 2001. We should now feel the heightened
alarm that occurs when the remission has passed. What happened? The most obvious
message is that the HMOs, even at their nastiest, are not able to hold down
costs. Don't look for a cure in that direction. But there was another obvious
message as well, indicating the principal reason for the cost increase.
The villain turns out to be that much-beloved feature of American health care — its
fine, unparalleled, and endlessly innovative use of technology. Some 40 percent
of the cost increase can be traced to the combination of new technologies and
an intensified use of the old ones; and some 20 percent within that figure
is attributable to pharmaceuticals. The HMOs could not figure out how to deal
with the technological factor. Neither, it seems, can anyone else.
A Touchy Subject
The article by James F. Drane, PhD, that leads this special section ("For
an Ethics of Technology,") deals with one vital aspect of technology: how
and when to draw the line against technologies, or the use of technologies,
that would violate moral values. The other side of that coin, at least in biomedicine,
is the problem of setting limits when the technologies are otherwise ethically
acceptable but incur costs that can create injustice. Those are particularly
unpleasant problems, requiring society to consider denying people the use of
good and helpful technologies because it needs to use scarce resources in other
ways, such as education or job creation.
Unless we hold that any good medical technology ought to be available to every
patient without limits, with no concern for cost and for even marginal benefits — a
wholly unrealistic possibility — then we need to consider limits. The Catholic
tradition has been much better in taking on the limits of technology generally — willing
enough to say no, whether we agree or not — than on setting limits to medical
expenditures under conditions of scarcity. As I have found with some of my own
writings on that subject, limiting technology can be a dangerous topic to raise,
incurring the risk that the writer will be accused of favoring social euthanasia
or promoting a culture of death.
My hope at this point is that the new economic crisis will force us, as a
progress-driven, technology-infatuated culture, to begin entertaining a simple,
but obviously threatening, idea: that the combination of biomedical research,
technological innovation, and market influences must inexorably drive up costs.
Put another way, our love of technological progress and our desire to hold down
costs without setting some limits cannot be reconciled.
A variety of strategies have been entertained over the years to avoid just
that insight. Some people claim that research will eventually lower costs by
curing expensive diseases or discovering inexpensive amelioration. The pharmaceutical
industry has pushed that argument with great vigor. The evidence in favor of
that notion is about as scant as that for the health benefits of its dozens
of only marginally beneficial, but aggressively advertised, products. Others
claim that price controls on drugs, or tough government and HMO buying practices,
can work to control their costs. Price controls might make a difference but
they are unlikely to be adopted in the United States; and government buying
practices have not managed to keep the drug cost problem from erupting in Canada
and Western Europe.
New technologies alone do not drive up costs; the intensified use of those
already in use does so even more. A variety of strategies have been devised
as possible cost-capping mechanisms.
Boost Out-of-Pocket Payments Forcing people to pay more for their health
care through increased deductibles and copayments can make a difference. Everyone
thinks twice when it's his or her own money. But the downside is that, to avoid
spending money, many sick people avoid going to doctors until it is too late.
Use Evidence-Based Medicine This strategy has been stressed for well
over a decade as an effective way to control the use of technology. But it can
never be more than a partially effective tool. Evaluating the medical effectiveness
of every technology is impossible, and impossibly costly, and constant innovation
makes it difficult to keep up in any case. And even when a technology has been
effectively evaluated, many moral and medical dilemmas remain: Should society,
for example, pay for small marginal benefits? Should we spend large amounts
of money to save a few lives instead of the many hundreds of patients who might
be treated more inexpensively?
Learn from Other Cultures Other countries use medical technology very
differently than it is used in the United States. (Great variation exists also
in the way technology is used in different regions within this country.)
But our heavy reliance on technology seems to have little impact on population
health status, when compared with countries that rely on it much less. This
certainly suggests that something is profoundly wrong with our dissemination
and use of technology. But we have yet to understand clearly just what that
is.
Three Unrealistic Assumptions
That failure should by now have convinced us that the technology problem is
much deeper and more difficult to address than previously imagined. Greater
efficiency is of course possible. A better use of market incentives and disincentives
can also make a difference — as long as we don't worry about equitable access
or the needs of the poor. That much said, however, the present cost crisis should
force us to rethink some cherished assumptions and values.
Research Will Solve the Problem The first of these assumptions I have
already mentioned: the belief that research will eventually lower costs. No
serious evidence indicates that this will happen. What's worse, there are strong
initial suggestions that the new genomics coming on line will do even more to
raise costs than the traditional pharmaceuticals. Progress costs money, and
progress in the development of therapies for the chronic diseases of an aging
society will be even more costly.
Respect for Life Requires Constant Innovation The second assumption
is that a respect for the sanctity of life requires biomedical progress and
constant technological innovation. Progress and innovation save lives and reduce
suffering, don't they? How can we morally deny them to people who need them?
The mistake here is to assume that only a total warfare of medicine against
death and disability can have moral support. But that is a false, excessively
secular, view of the goals and purposes of medicine. A decently long life and
a minimizing of pain and disability are more reasonable goals that do not require
the infinite spending of resources. Many of the worst health care problems in
the United State do not, in any case, stem from a shortage of advanced technology.
Instead, they reflect poverty, a lack of access to even low-cost technology,
and a failure to provide inexpensive public health measures.
Rationing Is Wrong The third assumption, closely related to the second,
is that any setting of limits on health care or technology — rationing, that is-would
be wrong.
Liberals hate the idea of rationing because they know that its results would
almost certainly be inequitable; the rich would buy their way out of any rationing
scheme. Moral conservatives hate rationing because it could cost lives (as if
the present system of de facto rationing does not already do so). Wesley J.
Smith has made a name for himself with his book Culture of Death, which
argues that, under the baneful influence of bioethicists, American medicine
is letting people die right and left, either through an indifference to the
sanctity of life or because of a desire to dispose of the burdensome.
Both liberals and conservatives are wrong. Unless liberals are prepared to
sacrifice other social goods by devoting all available money to it, health care
cannot be made completely egalitarian. Still, a two-tier system need not be
unjust as long as those in the lower tier receive decent and adequate health
care (which does not mean flying to Switzerland, as the rich can do, to find
the world's best cancer specialist). And unless conservatives are willing to
put up with unlimited taxes and a deification of improved health as the end
point of a decent society, there must be some limits.
Four Conditions for Limits
But limits make sense and can be just only under four conditions.
Universal Access The first is that that there be universal health care,
guaranteeing everyone a decent package of health care regardless of ability
to pay. Our present mixed system — market-oriented medicine and a (tattered) safety
net in the form of Medicaid — has shown itself incapable of providing a basic
foundation of access to health care for all. If society is to impose limits,
it must do so according to some kind of centralized system that can set minimal
standards of care applicable to everyone and provide the money to pay for it.
An extension of the Medicare program, relatively efficient and relatively popular,
would do that job most effectively, though it would have to add a prescription
drug benefit, which is now lacking.
Public Participation The second condition is that any limit-setting
plan must involve public participation. Creating a national commission, with
a representative mix of the population, might be one way to do this. However
the plan is formed, though, it must persuade the public that the limits thereby
established reflect their values and priorities, not those of distant
bureaucrats or technical experts.
I would stipulate only one important bias in any system of universal health:
It should take a population approach to health, not one that gives priority
(as is now the case) to individual health. A population approach would seek
to understand the main general causes of poor health in the country, the probability
of coming down with various diseases, and the behavior roots of unhealthy lifestyles.
The first question in setting minimal standards should be: What will promote
the best health among the largest number of people?
Appropriate Goals The third condition would be to institute a national
dialogue on the appropriate goals of medicine and health care. I would focus
the discussion by using age groups as the main categories: children and adolescents
(1-18); mid-life adults (19-64); and elderly (65+). What does each age group
need to flourish, to carry out the social and individual tasks appropriate for
it, and to feel that its basic needs are being met? If we had a population health
perspective underlying a generation-based allocation system, our health care
system would be best positioned to help people go from birth to old age and
death.
A Concern for Economic Implications The fourth condition is that research
policy be reoriented in the direction of technological development with an eye
on cost implications. At present, both the public and private sector carry out
research with no visible interest in the economic implications of the research.
As for the private sector — and the pharmaceutical industry in particular — its
very purpose is to turn a profit. It is indifferent to cost as long as there
are buyers, no matter how inequitable the pattern of their purchases. In the
public sector, the National Institutes of Health (NIH), which is focused more
on basic research, has never made the cost implications of research a serious
consideration (though Harold Varmus, the former NIH director, called attention
to the problem in 2000, his last year in office). While it will not be easy
to either determine the cost implications of new technologies in their early
developmental stages or to put in place incentives that encourage health care
organizations to resist paying for those that are too expensive, we must make
the effort.
A Fateful Choice
We Americans love technology and expect it to get better each year, whether
it involves our automobiles, computers, or medical care. If America made no
technological progress in health care over the next 20 years, but simply better
distributed what is already available — while simultaneously improving public
health measures — the results would be stunning. That is not going to happen.
But if we could get it into our heads that technological progress now directly
conflicts with our ability to pay for good health care and our access
to it, we would see that it is as much a source of trouble as it is a source
of improved well-being. That simple insight would be the beginning of wisdom.
As matters now stand, it seems impossible for most people to believe that
something seemingly so good, so productive of past and present benefits, could
be harmful. Unless that belief changes, nothing but endless struggle, growing
injustice, and missed opportunities to move in other directions will be our
fate.