A Review of the book False Hopes: Overcoming The Obstacles to a Sustainable, Affordable Medicine

Daniel Callahan, co-founder and until recently the Director of the Hastings Center, continues here his quest, embarked on in his earlier Setting Limits, What Kind of Life and The Troubled Dream of Life, to redirect public understanding and expectations of medicine and healthcare. We are near crisis point, Callahan believes. The US system of healthcare is both the most expensive and the least fairly distributed of the western world. (41 million people without health insurance is morally unacceptable.) We cannot continue our current rates of spending on healthcare; the costs and the expansive delivery of healthcare in the western world are neither sustainable nor equitable. Tinkering with the system, however, will not sufficiently alter the strain upon the system from expensive new technologies, ever-increasing consumer demand and an ageing population; nor does tinkering address the problems of distribution. Instead, we need to rethink what medicine is, what its purposes are, what kind of value and of how much value health is. False Hopes endeavors to aid us in that rethinking of medicine.

Callahan’s inspiration for his new model of medicine is the environmental movement’s talk of ‘sustainable environments.’ Callahan proposes a ‘sustainable medicine,’ ‘a medicine that in both research and health care delivery aims for a steady-state plateau, at a level that is economically affordable and equitably available, and also at a level that is no less psychologically sustainable, satisfying most--but, of necessity, not all--reasonable health needs and expectations’ (p. 26). In short, what is required is a change in the demands we make for our healthcare, a change that is premised upon a more fundamental change in our attitudes, a change in our ideals with respect to medicine. Innovations in technology coupled with a growing affluence (in the western world) has led us to expect medicine and healthcare to continually ‘progress’ towards higher tech interventions at continuously lower costs. But this is a false hope, Callahan argues. We ought to expect medical progress, to be sure, but the future benefits of medicine are not likely to accrue to the general populace, but rather to a wealthy few, future benefits are likely to be more expensive than past medical achievements, and the future benefits of medicine are not likely to be unambiguously good. For example, who are the mostly likely to benefit from advanced techniques of genetic intervention? How expensive is genetic therapy likely to be? Would it be an obviously good thing to tweak the ageing gene so that we are able to live to be 120-140 years old?

Callahan, thus, maintains that we must give up the ideal of unlimited, ever advancing, rapid medical progress and replace that ideal with a ‘sustainable’ medicine. The consequences of failing to turn from ‘progressive’ to ‘sustainable’ medicine are significant: the economic stress upon the national economies of developed nations created by providing health care, the psychological costs of a growing medical perfectionism which tolerates no risk and no imperfections, the expansion of medicine to address all human needs, the skewing of medical priorities with the marginalization of the caring function of medicine, and the ever widening gap between the rich and the poor.

True hope lies in sustainable medicine. Sustainable medicine requires, first of all, that we ‘live within the boundaries of nature.’ The natural life cycle, thus, acts as a norm for healthcare. Rather than continuing our attempts to extend life expectancies, we should respect nature’s tutelage that a decent life can be lived and end at the age of 75. Why spend money on research aimed at extending the life-span? Why invest significant healthcare dollars in treatment of the aged, already at or beyond their natural life-span? There are natural barriers to be heeded at the beginning of life as well. Attempts to improve the prospects for low-birthweight (below 500 grams) are likely to be most expensive while offering little real hope. Finally, a sustainable medicine will recognize our natures as the complex, multifaceted creatures that we are, will, thus, recognize that perfect health is not the only human good and not the greatest of human goods.

Callahan recognizes that the shift to a sustainable medicine is more easily accomplished in nations with more communitarian approaches to public health. American individualism and the dominance of the market model of medicine make it more likely that European nations with their longer traditions of ‘solidarity’ will harness the creeping imperialism of market medicine. The American emphasis upon personal responsibility, on the other hand, may better lend itself to corralling expansionist expectations of medicine.

False Hopes is a wise and provocative challenge to the practice of medicine in the developed world. Christians appropriately worry about the corruptive effects of the market upon the practice of medicine and about the ever widening gap between the medical have and have-nots. Callahan presents us with good reasons to settle for less when more might be achievable. CBHD

Article appeared originally in Ethics & Medicine: An International Journal of Bioethics 17:1 (Spring 2001).