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Taming the Beloved Beast: How Medical Technology Costs Are Destroying Our Health Care System

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First of all, a disclaimer. I have worked with Daniel Callahan (some years ago) and with the Hastings Center which he helped found. I have also reviewed (in another place) an earlier book of his, False Hopes: Why America's Quest for Perfect Health is a Recipe for Failure. His main thesis in both books is that we soon have to radically rethink the goals of medicine.

In this new book Callahan argues that the profligate use of medical technology is the chief culprit in the upward spiral of costs. When we evaluate medical technology based only on its impact at the individual level, all the incentives push us toward using the technology. We must evaluate medical technology against its population effectiveness.

In my review of False Hopes I argued that prior to this fundamental reform of medicine we must first achieve fundamental health care reform, including payment reform, before we can bend the curve of medicine more toward public health priorities.

This new book convinces me that I was wrong. We can't wait. We need to start talking now about the ends of medicine in terms of the common good. The next 10 years while we debate health care reform will be decisive.

Another reviewer tries to separate medicine and public health into two realms: one devoted to prevention the other to treatment. I once heard a dean of a very good medical school make the same distinction: medicine is responsible for the individual patient's good; public health if for the common good, or the health of the public.

This is a very common, and very wrong, distinction, as Callahan's books have long argued. Medicine is also responsible for the common good, the health of all of us together. More than this Callahan argues that we cannot hold medicine responsible for this task until and unless we determine what we mean by the good or full life. Callhan asks that we face the reality of death and the end of life when caring is what matters, not another heroic intervention.

I have watched friends my age (73) die in hospice centers when it came time to throw in the towel, and for my friends and for myself, accepting death is part of what is meant by the full life. I had another friend of the same age, a physician, finally decide to have back surgery for chronic pain despite the evidence of its dubious effectiveness and he suffered coronary arrest and died several days later. This occurred in one of the nation's premier teaching hospitals where my friend taught.

Callhan's book is the best book around for reviewing all of the various dimensions of health care reform, beginning with Medicare. He has a remarkable knowledge of the vast literature on Medicare reform and also is up to date on what's occurring in health care systems in the Western democracies as they struggle to control spending. I also have studied the health insurance schemes of Germany, and the tax-financed National Health Service in England, but Callahan's information is up-to-date, informed, and pertinent to the U.S. because it shows how all of these systems are faced with the huge pressures that medical technology is placing on medical spending, and are all systems are trying in various ways to cope.

I plan to recommend this book to every one who wants to try and grapple with the next 10 years as we move toward systemic reform. It is encyclopedic in its coverage of the vast range of topics, and its final chapter, where once again he returns to why public health and its population perspective is so central to the evaluation of medical technology and medical practice, should be read by everyone in public health.

The first reviewer's analysis of this book is a caricature of the importance of Callahan's achievement. Callhan's real message is that when it comes to health together, or health status, we must sooner or later decide what we mean by a full life and a normal life span. Public health, no less than medicine, needs to face this challenge.

We all need to ask ourselves, how much health together is enough and how do we get to that "enough"....with more and more enormously expensive technology or by eliminating health disparities by extending effective primary care to those who today are without coverage, or by reforming primary care for those who have coverage to preclude expensive testing that is accomplished more for the economic health of hospitals and clinics rather than the patient?

This is a very important book on the health care debate by an expert who has written many important books on the ends of medicine.

Yep. Just academic blabbering. The author, despite his academic accolades, makes a common mistake. He is confusing the two fundamentally separate aspects of health care. One is care for the sick -- this is called Medicine. The other is prevention of disease -- this is called Public Health. Of course, he is right in the sense that Public Health has the potential to save far more lives than Medicine. He is also very much right that Public Health is woefully underfunded. That is because saving statistical lives is different than saving actual real people, and people generally don't relate to it very well. The two parts of health care are largely different endeavors. A real cancer patient is unlikely to take much satisfaction in the fact that smoking cessation is decreasing the rate of lung cancer death in the population. She will continue to seek the best medical care she can get, and who is to say that this is less important than building a bigger house, buying more clothes, or whatever else?

It makes total sense for the US to create a true health care system (not just health care industry). The system would put in true economic incentives for healthy behaviors. Make smoking even more expensive! Tax low nutrition value foods! Encourage physical activity! Find a way to tax sedentary behavior! Make all true preventative care, e.g., vaccines, cholesterol management, colon cancer screening, etc., free for all!

It is nonsensical to measure medical care by mortality statistics. Sure, the US population may have the largest fraction of obese, diabetic individuals with osteoarthritis, reflux disease, liver inflammation, and so on. Is that a failure of Medicine or is that a failure of Public Health. Obviously, it is the latter. Yet, it is Medicine that gets the blame and we hear again and again how it we're not getting the value for the spent dollar. No argument there, but the logic is wrong.

Public Health expenditure should be recognized as its own priority! Blaming Medicine for failures of Public Health is no different than blaming NASA or the National Park System. Evaluating Medicine by Public Health metrics is fundamentally flawed.