In Daniel Callahan’s book, False Hopes: Why America’s Quest for Perfect Health is a Recipe for Failure, the author defines “sustainable medicine” in several ways. Callahan generally defines sustainable medicine as creating a level of health that enables a society to function well in economic, educational, and family terms. One of the more specific ways a medicine meets Callahan’s definition of sustainable is through the priorities it follows. Callahan’s most important point is that sustainable medicine will be available to everyone. Next, sustainable medicine will focus on the promotion of public health including disease prevention, health promotion, immunization, and an emphasis on screening. Third, sustainable medicine will offer emergency care and primary care. Advanced technological medicine, followed by highly advanced technology, would be the fourth and fifth priority of a sustainable medicine.
To achieve the definition of a sustainable medicine, Callahan discusses several paradigm shifts involving progress, innovation, and achieving a sustainable technology. Callahan’s idea of a sustainable medicine requires a major restriction on progress and innovation. Because innovation creates new possibilities in treatment and diagnosis, it is one of the major factors in increased aggregate cost associated with innovation. Callahan makes it clear that, “We will have to choose between improving quality by constant innovation and controlling costs. We cannot have it both ways” (95). He acknowledges that a sustainable medicine should curb innovation in research in all but a few instances.
In Callahan’s view, the definition of a sustainable medicine also requires a sustainable technology. Callahan believes there must be a massive shift in perspective concerning progress and innovation. This new perspective would de-emphasize the need to achieve complete risk reduction and to perfect medical techniques. Instead, the emphasis of technology would be to improve the health of the entire population by allocating basic technology to all, in lieu of extensive technology, to some.
Additionally, in defining a sustainable medicine, Callahan emphasizes improving a variety of non-medical factors that affect health equally as much as medicine and an acceptance of the present average life span. Callahan quotes, Theodore Marmor, who states, ” ‘Some of the best kept secrets of longevity and good health are to be found in one’s social, economic and cultural circumstances’ ” (105). Economic, and social leverage, are critical factors that Callahan believes we must attain in order to achieve a sustainable medicine.
Callahan also believes that an acceptance of the present average life span, in relation to progress, would help achieve medical sustainability. Callahan points out that a sustainable medicine will accept death and that people need to be careful not to “…lose the economic advantage of those gains to excessive technology at the end of life” (258). Callahan believes medical resources should be used the most in mid-life and the least for those at the beginning or end of life.
According to Callahan, the ethical problems associated with our current medicine, relate to, and are exacerbated by, the free market. Callahan declares that medicine has been an exceedingly profitable industry and the nature of technology, in relation to profit, requires that technology constantly push its own limits. As a result, innovation becomes the essential factor in perpetuating continuous profit. Ethically, Callahan explains, this constant technological innovation causes a situation in which people begin viewing medicine as “…a collection of knowledge and techniques, to be used and exploited as anyone sees fit” (89). Callahan believes the cost of extraordinary technological innovation could be better used to service the basic medical needs of the population as a whole, as opposed to extraordinary medical needs of a minority of the population. This “exploitation” is an indirect consequence of the free market, and by Callahan’s definition of a sustainable medicine, unethical. The managed-care movement has created other unethical behavior. Callahan points out (in the case of managed health-care in the United States) that economic incentives can, in part, influence doctors diagnostic and treatment behaviors. This response to financial incentives can be viewed as unethical in that money, not patient’s medical needs, dictates what is appropriate or inappropriate healthcare.
There are different ethical problems, and various ethical pros and cons, associated with Callahan’s idea of a sustainable medicine. Libertarian philosophy promotes the right of the individual and argues that the individual has no duties or obligations to others, and vice versa. Therefore, Libertarians would disagree with Callahan’s emphasis on personal obligation to others, limit on choice of treatment and doctors, and restriction in the free market. Callahan makes clear what moral responsibilities we, as individuals, have to our fellow man in terms of achieving a sustainable medicine. Callahan concludes that we are morally obligated to take care of our own health so we will not burden the health care of others. Callahan specifies that, individually, “I cannot ask of others…that they jeopardize their own health and welfare on my behalf” and “I have no right to jeopardize the health of others in pursuit of my own needs” (273). Callahan states, “…those who pay for healthcare…can make it clear to innovators that they are looking for ways to control the costs of technology, and that they are unwilling to pay for expensive and economically destabilizing innovations, even if these promise some benefit” (110). Callahan is essentially acknowledging the free market must be restrained in the area of innovation, in order for a sustainable medicine to work, and Libertarians are strong supporters of a free market. Overall, Libertarians would view Callahan’s overall means of achieving sustainable medicine as being ethically problematic.
Utilitarians focus on whether one’s actions make everyone better off and they try to choose actions that provide the greatest usefulness. Two Utilitarian credos revolve around sacrificing one’s own utility for the sake of other’s happiness, and, achieving the greatest good for the greatest number of people. Part of Callahan’s required perspective for sustainable medicine, involves forfeiting the right to certain treatments associated with unusual illnesses so that more common medical conditions can be treated, and thus, the greatest part of the population. Callahan repeatedly emphasizes that we need to take better care of our own health, restrain innovation, and stagnate the current life span, in order to achieve the “greatest” healthcare for the “greatest” number of people. Utilitarians would generally view Callahan’s overall goal of sustainable medicine as having few ethical problems.
Kantians believe that our actions should be motivated by a “sense of duty” and the understanding that we should treat everyone with the same respect and consideration we would expect from them. Immanuel Kant’s “categorical imperative” asks that our actions be applicable to everyone (be universal), thereby requiring equal consideration of everyone. Callahan believes our moral motivation in establishing equitable healthcare (one primary requirement for a sustainable medicine) should be “a shared sense of empathy in the community, a common perception that the burdens of illness and disability…should be commonly shouldered” (241). In the case of equitable healthcare, individuals will have a difficult time agreeing on what defines basic “equal” healthcare, in relation to Callahan’s definition of a sustainable medicine. Callahan points out that there is “a conceptual difficulty of specifying a basic level of care health ” and acknowledges that what is needed for one person’s health may not be what everyone views as equal (261). It is difficult to exercise a “universal” rule when so much ambiguity exists within definitions and meanings of equitable, basic healthcare. Due to the definitional problems involved in a sustainable medicine,
Kantians would have a difficult time establishing universal rules for a sustainable medicine.
John Rawls’ believes that all primary goods should be equally distributed, and one of the primary goods he lists, includes the natural endowment of health. Rawls focuses on the obligation of political and economic institutions, and processes, in ensuring resources are distributed fairly. Rawls’ idea of equitable distribution agrees nicely with Callahan’s idea of equitable healthcare, but differs slightly in how fair resource distribution is ensured. Callahan emphasizes the individual’s responsibility, restriction on aspects of the free market, and more, as requirements to create sustainable medicine. However, Callahan also includes a need for institutional intervention. Callahan states that a basic package of healthcare can be provided in three ways, “As a part of a government program providing full care to its citizens. As part of a government program designed to supplement healthcare provided by employers or other private programs. As part of a private, employer sponsored program providing a full range of services” (260). However, since Callahan’s primary emphasis is not on institutional intervention, Rawls may find this ethically disagreeable.
In conclusion, there is a multitude of ethical problems associated with a sustainable medicine. Personally, I am a fan of Rawls. I believe with a few minor adjustments, Callahan’s idea of a sustainable medicine could theoretically work, in accordance with Rawlsian philosophy. However, ethics aside, there is one reason Callahan’s idea of a sustainable medicine could never work in this country. Callahan expects that we, as individuals and businesses, will influence the market in such a way as to achieve sustainable medicine. This kind of influence will never be achieved without severe government regulation, and that will never happen within a true democracy.
Callahan, Daniel. False Hopes: Why America’s Quest for Perfect Health Is a Recipe for Failure. New York: Simon & Schuster, 1998.