Symposium: Doctors, Drugs and Devices

Too much for that: A social critique of medical technology in late modernity

Stephanie Short, The University of Sydney

Daniel Callahan Taming the Beloved Beast: How Medical Technology Costs Are Destroying Our Health Care System, Princeton, Princeton University Press, 2009 (288 pp). ISBN 9-78069114-236-4 (hard cover) RRP $49.95.

There are two key trends and problems with health care and public policy in Australia in late modernity. While the first is economic and the second relates to medical technology, both affect equity. First, the Rudd Government’s health reform proposals failed to address the funding fundamentals of the Australian healthcare system. The fourth edition of Health Care and Public Policy: An Australian Analysis (2010), co-authored with eminent health economist George Palmer, argues for significant reform of health policy to shift the balance of power towards a more equitable, publicly funded system. In reviewing the major health policy initiatives since the previous edition in 2000, we came to the conclusion that strong central government participation in health affairs is vital to achieve equity in health policy and delivery.

We pay particular attention to the policy-relevant omissions and shortcomings in the Rudd Government National Health and Hospitals Reform Commission (NHHRC) Report (2009). In our view there is a notable failure to question the lack of both horizontal and vertical equity in the financial arrangements that flow from the relatively high proportion of expenditure in Australia derived from private sources as compared with other developed OECD countries. As we make quite explicit, our values are based on the premise that the more fortunate members of society have a strong responsibility to look after, both financially and otherwise, the less favoured individuals and communities.

The second trend highlighted in our fourth edition relates to our false faith in the effectiveness of medical technology—whether devices, drugs or procedures. For example, the NHHRC report failed to address the considerable variation in the provision of many elective surgical procedures (including cholecystectomy, coronary artery bypass grafting and hysterectomy) between geographical areas with similar demographic profiles. As we put it in the book:

Strong central government participation in health affairs is vital.

The effect of technological developments on the practice of medicine and hence on the total cost of health care may be one of the most important problems to be resolved by planners and policymakers in Australia and other countries over the next decade. It is widely believed that the experience of the past 20 years has demonstrated the potential for these developments to place considerable strains on the capacity of all economies to afford them (Palmer & Short 2010, pp. 216–217).

Most importantly, the Commission failed to address the underlying assumption that all medical, surgical and radiotherapy treatments and technologies are effective; an assumption that we shall see is open to question.

TAMING THE BELOVED BEAST OF MEDICAL TECHNOLOGY

Daniel Callahan’s new book, Taming the Beloved Beast: How Medical Technology Costs Are Destroying Our Health Care System, raises similar economic and political concerns, in the US context. Callahan is one of the founders of the field of bioethics. He trained in philosophy and was co-founder of the influential Hastings Center in New York, a non-partisan research institution that has contributed a bioethical perspective to debates about ethics, health care and public policy since the 1970s.

The ethical and policy dilemmas Callahan addresses start with two facts: the increasing cost of health care in the United States and the diminishing returns from same. Callahan contends that the United States needs a cultural revolution in health care; a revolution that will lead to new foundational values.

THE FALSE FRIEND OF ECONOMIC DISCIPLINE IN HEALTH CARE

Callahan opens his analysis with data about the rising cost of health care, including the increasing costs of both new technologies and intensified use of old ones. If this continues at current rates, health care will consume nearly 20 per cent of America’s GDP by 2017. Why is it so? Medical technology saves lives, relieves suffering and is enormously popular with the public—it is also profitable for doctors and a source of great wealth for the medical-industrial complex.

Callahan starts with these economic, and political, facts. The following chapters provide in-depth and valuable critiques of previous and contemporary attempts to tame ‘the beloved beast’—medical technology—including Medicare and Medicaid (publicly-funded health insurance for the elderly and poor, respectively); increased technical and allocative efficiency; evidence-based medicine; information technology; technology assessment; cost-utility analysis (quality-adjusted life years); and managed competition. This is a most useful critique of policy proposals designed to address significant problems in the US health care system over the last four decades.

Callahan acknowledges all of the obstacles standing in the way of reform: cultural, political, professional and commercial (p. 229). He despairs at the lack of vision on the part of both major parties during the 2008 presidential campaign. He contends that the Republicans, through their support for the privatisation of health care, are unwilling to put pressure on the profits of manufacturers of drugs and devices, or the health care insurers, or doctors. He criticises the Democrats’ approach to universal health care also. This would require budget limits and rationing if it were to be affordable and sustainable, and Callahan claims the Democrats are unwilling to acknowledge this. Why? Because it is politically unpalatable? Instead, the Democrats argue that improved competition will enable them to reduce costs.

Literature is a way of exploring how humans can face illness and mortality.

In Callahan’s view the ‘40-year mantra of increased efficiency and reduction of waste’ is not supported by any significant evidence (p. 23). He refers to reliance on or expectations of increased efficiency as the ‘false friend of economic discipline in health care’ (p. 23). If economic discipline is the false friend, then who is the real friend? Bioethical reflection? Callahan argues that organisational changes alone cannot solve the problem. Rather he argues for a fundamental transformation in our thinking about health care in order to achieve economically sustainable reform. This requires reconstructing our values about ‘progress’ and ‘technological innovation’; and constructing new foundational values. I will return to this proposition.

SO MUCH FOR THAT

Literature is a way of exploring how humans can face illness and mortality— and reading Callahan’s work brings to mind a recent novel that shares his concerns about the US health care system, albeit in a very different way. Lionel Shriver’s striking and memorable novel, So Much for That, describes the life of an American family; a middle class family with health care insurance who saw all their time, energy and savings eaten away ‘for a few good months of life’—millions of dollars spent to extend one person’s life. And as we learn in the novel; in terms of quality of life they were not ‘good months’ at all.

In a recent interview on the ABC’s The World Today (Hall 2010), Shriver said:

This novel took its immediate inspiration from a very close friend of mine who died of mesothelioma, which is the disease that I use in the novel and her treatment cost $2 million. Two million dollars and that’s over the course of a year and three months. Now at the most, the treatment, it was major surgery followed by brutal chemotherapy, which ruined the end of her life, that probably got her an extra three months - maybe. But if you look at how that disease would have been dealt with in the UK, they don’t treat it; they just give you palliative care.

Asked by interviewer Eleanor Hall ‘And do you think that would have been better for her?’, Shriver replied: ‘Yes, I do. I think that her life, the end of her life would have been better. I also think that it wouldn’t have given her false hope in a way that meant that she might have been able to confront what was happening to her’.

Shriver criticises the health insurance system in the United States and argues that President Obama’s reforms, introduced in 2010, will not solve the problems described in her novel. The costs of Obamacare are too great, and health care insurance does not protect the middle class from bankruptcy in the case of health care calamity. And the real problem is that more health care does not necessarily improve one’s quality of life.

THE CULTURAL CRISIS IN MODERN MEDICINE

The challenge for Callahan is ‘moral anguish’, the fact that public benefit will require some private anguish. It hurts to deny people we love and know extra tests, extra care. The trajectory of cancer care stands as a symbol of this anguish. But as Callahan points out, ‘no health care system can provide everything that may save or extend a life’ (p. 231). This is where Shriver’s novel is so vivid. Extra tests and extra interventions do not always mean better care. The ‘technological imperative in medicine’, the belief that all available medical interventions should be pursued has been identified as the fundamental social problem in modern medicine by medical sociologists since the 1970s (Mechanic 1976).

My own empirical research on cancer treatment, conducted in a Sydney hospital in the 1980s, revealed shocking evidence of the technological imperative at work (Short 1985). Doctors presumed that what could be done (with drugs, surgery and/or radiotherapy) should be done. There was a confusion of can and should. And the vast majority of patients complied in a seemingly unquestioning way with doctors’ directives. Some doctors seemed unable to stop active treatment (until the patient could tolerate no more treatment). The more sensitive doctors knew when to stop active intervention, but the vast majority of doctors and patients presumed that what could be done with medical interventions should be done.

Public benefit will require some private anguish.

Callahan does not seem to grasp or accept this proposition—that the technological imperative lies at the heart of the culture of modern medicine. The sociological proposition is that the public’s faith in health care and its efficacy may be misplaced. This is ‘the cultural crisis in modern medicine’ referred to by John Ehrenreich and colleagues (1978), Ivan Illich (1976), Thomas Szasz (1977) and medical sociologists in the 1970s.

Lionel Shriver’s novel evokes this cultural crisis perhaps more vividly than any of these academic texts. Lionel Shriver, the novelist, suggests the problem, and the solution, rests with each of us—and those around us—as we make health care decisions. More care is not necessarily better care. Is the aim of health care really only to save or extend a life? Possibly, the technological imperative is the false friend of modern medicine.

Callahan, the bioethicist, identifies an economic crisis in US health care and offers a political answer or solution in the form of new public policies. He argues that only a government-regulated universal health care system can offer the hope of making health care affordable for all. However, Australia has a universal health insurance system, and it has not solved the problems.

TOO MUCH FOR THAT

Will health care in Australia in late modernity exhibit different cultural values? Surely the health care system in Australia needs to change too. However, it is not clear that it can be driven entirely, or even largely, on the ‘demand side’ by consumers making different decisions. It is extremely difficult to refuse interventions—perhaps how and when they are offered also needs to change, and this is on the ‘supply side’. And we need to understand how and why, by whom and in which contexts well-informed health care choices are more likely to be made. This is the subject of my current research with colleagues in Australia and the United Kingdom on the social experience of health care in late modernity. We are chasing answers to questions that have puzzled me since the 1980s. And we are chasing them sociologically; through field work, in-depth interviews, and surveys. Our working hypothesis is that cultural capital (Bourdieu 1984) empowers holders to stand as more equal partners in the process of deciding on treatment. Cultural capital may in general be associated with greater ‘personal efficacy’, and more informed health care choices. Is ‘health care capital’ a subspecies of cultural capital of relevance here? We shall explore whether and if Bourdieu’s notion of ‘cultural capital’ can assist us to shine further light on this fraught field of ethics, health care and public policy. Are health care judgments related to social position? To have or not to have a hysterectomy, an MRI, an experimental cancer drug? We shall see.

REFERENCES

Bourdieu, P. 1984, Distinction: A Social Critique of the Judgement of Taste, Routledge, London.

Ehrenreich, J. (ed) 1978, The Cultural Crisis of Modern Medicine, Monthly Review Press, New York.

Hall, E. 2010, ‘US author scathing on Obama health reform’, Transcript of interview with Lionel Shriver, The World Today, ABC Radio, 19 May [Online], Available: http://www.abc.net.au/worldtoday/content/2010/s2903664.htm [2010, Oct 16].

Illich, I. 1976, Medical Nemesis: The Expropriation of Health, Random House, New York.

Mechanic, David 1976, The Growth of Bureaucratic Medicine: An Inquiry into the Organisation of Medical Care, John Wiley, New York.

National Health and Hospitals Reform Commission 2009, A Healthier Future for All Australians – Final Report, Australian Government, Canberra [Online], Available: http://www.health.gov.au/internet/nhhrc/publishing.nsf/Content/nhhrc-report [2010, Oct 9] .

Palmer, G. & Short, S. 2010, Health Care and Public Policy: An Australian Analysis, Palgrave Macmillan, South Yarra.

Short, S.D. 1985, ‘The war against cancer: A sociological study of cancer treatment’, New Doctor, no. 35, pp. 2528.

Shriver, L. 2010, So Much for That, HarperCollins, Melbourne.

Szasz, T. 1977, The Theology of Medicine, Harper and Row, New York.

Stephanie Short is convenor of the ARC-funded Health Governance Network, HealthGov, and Professor in the Discipline of Behavioural and Social Sciences in the Faculty of Health Sciences at The University of Sydney.