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Ethicist Callahan: 'Set Limits' On Health Care

Dec 10, 2009

For decades, ethicist Daniel Callahan has argued that expensive medical care be parceled out carefully – essentially rationed – for elderly patients. Now, at 79, his quest to stem late-in-life spending is coming face to face with his own mortality.

Twenty-two years ago, the co-founder and president emeritus of the Hastings Center, a nonpartisan bioethics research institute in New York, wrote the highly controversial book, "Setting Limits -- Medical Goals in an Aging Society." It made the case for limitations on care based on age – a topic that recently provoked intense, if sometimes hyperbolic arguments during the health care debate -- and against the provision of extraordinary, expensive medical procedures for people who have already lived a full life. But recently Callahan himself underwent $80,000 worth of treatment for a heart condition.

That drew a rebuke from blogger James Pinkerton, a fellow at the New America Foundation. He called Callahan a hypocrite for having the expensive heart procedure.

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Callahan laughs off the criticism, but notes that his experience is indicative of the difficulty in trying to contain medical costs. After a period of dizzy spells, he fainted last summer, and his cardiologist insisted he go straight to the hospital. The doctors diagnosed a ventricular tachycardia, or rapid and irregular heartbeat that starts in the ventricles, and performed a seven-hour ablation procedure that burns off tissue causing the problem. Before he knew it, Callahan had received $80,000 worth of treatment.

When he asked, his physician didn’t even know the price tag. That’s why, he says, decisions can’t be left to individuals and their doctors.

“I want Medicare to determine what benefits it will make available, based on costs and other considerations, and then simply not pay for those that don't pass their tests,” he says. That doesn’t sound especially incendiary – except that Medicare isn’t supposed to consider cost and the health overhaul bills in Congress bar the program from using the results of comparative-effectiveness studies to decide what to cover.

His new book, "Taming the Beloved Beast – How Medical Technology Costs Are Destroying Our Health Care System,” critiques costly pharmaceuticals and medical devices that Callahan says drive costs ever upward. “Our whole health care system is based on a witch’s brew of sacrosanct doctor-patient autonomy, a fear of threats to innovation, corporate and (sometimes) physician profit-making, and a belief that, because life is of infinite value, it is morally obnoxious to put a price tag on it,” he writes.

He has written or edited 41 books and amassed a host of professional honors, but Callahan also has plenty of critics. Dr. Kenneth Prager, professor of Clinical Medicine at Columbia University Medical Center and director of clinical ethics for the hospital, said he considers efforts to limit who gets treatment “unethical and arrogant.”

“I have patients that I’m sure would be considered to have an awful quality of life who are taken care of and loved by their families and to whom every day is of inestimable value,” Prager said.

Callahan, however, continues to believe that after people have lived a reasonably full life of, say, 70 to 80 years, they should be offered high quality long-term care, home care, rehabilitation and income support, but not extraordinary and expensive medical procedures. He rejects the effort to find a medical remedy to every condition. (Of erectile dysfunction, he says, “You get old. That’s the way it goes, guys.”)

Callahan, who received a Ph.D. from Harvard in philosophy, became interested in medical technology in the 1960s after a seven-year stint as editor of Commonweal, an independent opinion magazine for lay Catholics.

“That was the era of all sorts of technological breakthroughs -- ICUs [intensive care units], organ transplantation, dialysis, the contraceptive pill -- most of which began raising ethical problems of one kind or another,” he says.

In 1969, he and psychiatrist Willard Gaylin founded the nonprofit Hastings Center in Garrison, N.Y., the first center devoted to bioethical research. It now has a $3 million budget and a staff of 30, including nine research scholars, as well as 170 international fellows.

He has little faith that political leaders will set limits he deems necessary. Calls to cut waste and inefficiency have been made for decades, he says, to no effect. “Liberals believe in progress and are heirs to the enlightenment,” he says, “and conservatives want individual choice.” Neither address the heart of the problem.

Callahan spoke recently to Beth Baker for Kaiser Health News. This is an edited excerpt of his remarks.

Q. It’s your contention that we cannot rein in health care spending without tackling the technology piece -- drugs and medical devices.

A. With 50 percent of the annual [health care] increase coming from technology costs, it seemed to me that was a crucial element. Secondly I was interested in how American medicine reflects American culture. America is a culture that loves technology.

Q: Would you say, then, that American culture is the main thing driving technology costs upward, rather than financial gain?

A. It’s a lot of things. Patients love it and expect it. Everybody likes their doctor to talk to them, but if the doctor merely talks to them, they get a little suspicious. Doctors are well-paid to use [technology], companies are making billions of dollars selling it. Another feature that doesn’t get picked up is the focus of the media on medical technology.

Q: It seems it’s not only cost that bothers you.

A. Cost is a symptom of a deeper problem. We have an “infinite progress” model. Nothing is ever good enough. The standard of care is raised higher and higher – but death always wins.

The National lnstitutes of Health is always giving priority to the most lethal diseases – cancer, heart disease, strokes. Things that really make you miserable like mental health [problems] or arthritis don’t get nearly as much money. The fight against death has been a very central part of American medicine. It’s a weird system where you get saved from heart disease at age 65, treated for cancer at age 75, and then after that end up with Alzheimer’s at 85 – this is progress?

Q. What are some of the most egregiously expensive things?

A. A lot of people in health care make an awful good living, particularly if you’re a specialist – you can make up to $1 million a year. We pay much more than any other country in the world.

As far as technology, with Avastin, for colorectal cancer treatment, the costs per patient can run up to $80,000 for which you get an average of 1.5 months additional life. We also have an excessive amount of screenings and MRIs.

[A spokeswoman for Genentech, the maker of Avastin, says a study submitted to the Food and Drug Administration showed that patients using Avastin plus standard chemotherapy had a five-month improvement in median survival compared to those using chemotherapy alone.]

Q. What are the implications of your views for research funding?

A. First of all, we could really have a good national debate on what our priorities should be. We don’t spend enough money on education, particularly primary and secondary education. NIH is a particularly blessed agency getting a steady rise in budgets, with bipartisan support. Why are we spending all this money when we don't know how to teach math to kids very well?

Secondly, we would look much more carefully at the consequences. Research drives up health care costs, it doesn’t reduce [them]. The argument in Congress for years has been if we cure these diseases we’ll save all kinds of money. Well, that’s not happening. And even if we cure cancer, diabetes and heart disease it would make something like a 10 percent difference in overall health care costs.

FDA tests for safety and efficacy -- they don’t deal with cost at all. We could have every manufacturer of drugs or devices release an economic impact statement. The drug company would say, ‘Our marketing shows it’s going to affect 10,000 patients, and this is what it’s going to cost the health care system.’ That would force companies to begin to think, ‘Could this cost less?’ I also suspect it would change the priorities of the research. The difficulty now is that a drug company, with these very expensive drugs, can make a pretty good profit even if they don’t have a lot of patients, and even if people go bankrupt buying their product -- which a lot do.

Medicare is going to run out of money shortly, and we’re finding more and more expensive ways to keep people alive. So we have to find ways to set some limits.

Beth Baker is author of "Old Age in a New Age -- The Promise of Transformative Nursing Homes"

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