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False Hopes: Overcoming the Obstacles to a Sustainable, Affordable Medicine
  1. Richard Ashcroft
  1. Centre for Ethics in Medicine, Bristol University

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    Daniel Callahan, New Brunswick, NJ, Rutgers University Press, 1998, 330 pages, US$17.00.

    Daniel Callahan has for many years been arguing against the technological current of medicine. Equally importantly, he has been a stern critic of the style of bioethical argument which would celebrate new technologies before asking questions about their point, and which would assess technologies piecemeal, rather than as contributions to a larger health and health care context. This approach makes him relatively unusual in bioethics and public policy circles, although names such as Thomas McKeown and Ivan Illich also come to mind.

    Unlike McKeown and Illich, however, Callahan places a strong emphasis on self limitation by consumers as much as by providers of health care. His explicitly moral challenge to the “demand side” of health care expansion is powerful, taking a stance where most analysts would prefer not to tread—the evaluation of “consumers' choices”. In this he shares some common ground with those, such as Alan Williams, who advocate the “fair innings” argument. Positions such as Callahan's and Williams's are the obverse of the usual rationing argument, in that they place a duty on health care users to restrict their own demand, where most advocates of rationing would restrict the types of services supplied.

    With those who argue for the necessity of rationing, Callahan presents us with the hard facts of expansion in health care techniques, rapid rise in health care costs, longer life (but greater morbidity as the life lengthens), and the focus of medical and commercial interest on high-technology, high-cost medicine. His argument in this book is that this trend is not likely to reverse and that we must therefore decide, as a society, what we want medicine to do—that is, what we think medicine should be for. He argues that to wish medicine to seek to defer death indefinitely is both inhumane and impossible to realise. As long as this is the case, he points out, so much of our medicine will be aimed at prolonging life for as long as possible, even to the point of intolerability for many of its “beneficiaries”. Meanwhile, little or no attention is being paid, at least within medicine, to the question of what this prolonging is for—what makes the life to be prolonged go well. Quality of life concepts hardly begin to address this issue. Long life is an instrumental goal, not an end in itself.

    Given this, Callahan argues persuasively that scarce health care resources should be diverted towards preventive medicine, public health, and what we might call “running repairs”. This has been advocated before, of course (McKeown is a good example), but Callahan courts controversy when he insists on promoting personal responsibility for health, rather than system responsibility for health care. His arguments here are well worth considering, given that “desert” is a frequently applied informal test for access to health care.

    Callahan's book mainly addresses the problems of the rich world, but within that context his arguments apply equally to the UK, Europe and the USA, because he avoids looking at specific health care systems or state arrangements, concentrating on the ethical arguments. This is a strength, but it brings a weakness with it: he makes a wealth of policy suggestions, but the realpolitik of how these are to be translated into societal goals and social and political institutions is not addressed at all. The flip-side of this is that there is no discussion of how we got here: the motor of change is apparently taken to be “technology” as such—rather than, for instance, social and economic interests at a variety of levels. But in a lengthy book such as this, perhaps it is too much to ask that a chapter or two on the “political economy of health” could be added.

    This is, all things considered, an excellent book, which deserves to be read not only by academics and students but also by the general public. It is clear, and very well written, and, I believe, largely correct. Following the responses to this book promises to be fascinating.