Reviewed by Kenneth R. Foster
By Daniel Callahan; Princeton University Press, 2009; 288 pp.; $US 29.95; ISBN 978-1-4008-3094-7
The barbarian is at our gate, in the person of 79-year-old Daniel Callahan. Or so many readers of IEEE Spectrum will feel after reading this provocative book on technology and health-care costs by the famed bioethicist and cofounder of The Hastings Center, a bioethics think tank in Garrison, N.Y.
Callahan addresses a big and seemingly intractable problem: the unsustainable level of spending on health care in the United States, which presently accounts for 16 percent of the country’s gross domestic product—far outstripping education (6 percent) and defense (5 percent). Worse, health-care costs are rising at twice the level of inflation. Such spending, if allowed to continue, will strip resources for many other social goods and will bankrupt businesses and individuals.
Technology is the "beloved beast" that accounts for about half of this increase, often in the form of high-tech treatments for people nearing the end of life. Consider the 59-year-old cancer patient who received a 43-hour operation to remove a tumor, at a reported cost of US $300 000 (excluding surgeon’s fees), but died four months later.
The problem is not easily solved. Indeed, Callahan argues, it lies at the "irreducible core" of modern medicine—the belief that patients and their physicians have the right to choose treatments based on their own individual notions of medical necessity, notwithstanding the costs of such choices to society.
Callahan favors a "population-based" health policy, which translates into age-based rationing of health care. The goal, he says, should be to enable people to achieve most of the satisfactions of life: education, career, travel, family, and so on. Older people should be treated well, he says, but not heroically. Resources should be directed where society would benefit the most: toward the young (so they can help sustain society in the future) or to even out inequities in the levels of health care across the population.
Even Callahan seems pessimistic that the political system is able to implement his suggestions. Proposals to ration health care are politically toxic in the United States. Cries about "death panels" nearly derailed the plans of the Obama administration for health-care reform—and that was when the critiques were based on nonsense. What politician would support a plan that denies high-tech care to elderly Aunt Millie? But health-care rationing is coming, in one form or another. Indeed, it is already here, in the denial of all but emergency care to tens of millions. Callahan bravely says that we should choose a sensible way to do it now, rather than let a failing health-care system do it by default in the near future.
About the Author
Kenneth R. Foster is an IEEE Fellow and professor of bioengineering at the University of Pennsylvania.