REVIEWED BY JOHNNY COX, RN, PhD
The Goals of Medicine: The Forgotten Issues in Health Care Reform
Mark J. Hanson and Daniel Callahan, eds.
Georgetown University Press, Washington, DC
1999, 256 pp., $55
For nearly 30 years the Hastings Center has been producing seminal reflection on crucial issues in healthcare ethics and public policy. This volume, one of a series edited by Mark J. Hanson and Daniel Callahan, the founding president of the Hastings Center, continues this tradition.
In 1993 the Hastings Center initiated an international project to focus on neglected elements in the U.S. healthcare reform debate, which was dominated by economics and politics. For four years, scholars from 14 countries explored the goals of medicine and their implications for healthcare delivery, research, and education. The project's final report (previously published as a special supplement of the Hastings Center Report) is the preface of this book. All the chapters are papers or essays prepared by participants in the project.
Quality of care, cost, and access became the parameters of reform proposals. Harry and Louise — the infamous characters in a commercial widely credited with helping to scuttle the Clintons' reform proposal — were not the public's first introduction to the dangers of commercializing healthcare, deprofessionalizing physicians, and medicalizing key segments of life's pilgrimage. Hanson and Callahan invite exploration of intriguing questions: Is medicine necessarily the enemy of aging and death? Is significantly increasing average life expectancy a proper goal for medicine? What is the legitimate territory of medicine, and where is the boundary of healthy medicalization?
These questions raise the "forgotten issues" that must be addressed in current healthcare reform efforts. Without reflection on these fundamental concerns, reform will occur in haphazard ways. For instance, during the past 25 years, revolutionary, grassroots changes have occurred in the ways medicine fashions intimate personal experiences at the edges of life. Mothers resisted general anesthesia and forceps for delivery of their babies and demanded more natural, family-oriented processes. On the other edge, hospice has taken root in America as more and more people seek to approach dying as the final stage of growth within the loving care of family.
Perhaps the taproot issue pertains to the rapid commercialization of healthcare. This book provides the prism of international scholarship through which to examine the impact of transforming a professional service rendered on the basis of need into a commodity exchange conditioned on purchasing power. As one author puts it, "The integrity of medicine itself is at stake."
I hope this text will appear on the reading lists of graduate students in healthcare fields and in the libraries of policy analysts. The writers' erudition will stimulate lively seminar exchanges, but probably will not engage many practicing clinicians. As the next round of debates about reform gain momentum, let's keep the goals of medicine at the center.
Johnny Cox, RN, PhD
Vice President, Mission and Advocacy
Providence Services
Spokane, WA