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[ JBEM Index / Volume 5 / Number 2 ]

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Book Review

What a Secularist is Saying About Medical Limits

What Kind of Life: The Limits of Medical Progress by Daniel Callahan (Simon and Schuster, 1990), 318 pp. $19.95.

This new book, following its earlier sibling, Setting Limits, by the Founder and Co-Director of the Hastings Institute is at long last a sane voice amidst the cacophony of medical flirtations with aspirations for infinity. Callahan persistently argues for limits to our faith and hope for the efficacy of medical science. He is one to know, and in this book he contends for the priority of "care" over "cure" in medical economics. Hand in hand with this, Callahan is consistent in rebutting the "right to cure" mentality, often parroted today.

Callahan pleads for us to accept "a more modest standard - sufficiency not perfection" (p. 120) and asserts that the best success for medical enhancement have come when groups, rather than individuals have been targeted. He calls for the use of principles of technological assessment, and research prioritization (Chapter 6). His thesis is that medical ethics (as well as medical economics) will be on better footing if we reverse the nascent priority by restoring the preference for communal medical needs over an individual and rights-oriented approach. Callahan's most direct statement of purpose deserves to be heard in his own words:

"My goal in this book is to show that we have a more difficult problem on our hands, that the standard nostrums of neither right nor left will any longer suffice to cope with the problem before us. that problem can be directly stated: The very nature of medical progress is to pull to itself many more resources than should rationally be spent on it, often more than can be of genuine benefit to many individuals, and much, much more than can be socially justifiable for the common good. The power of medical progress feeds off of a potent dynamic. There is the force of technological advancement, ever ingenious in finding new ways to improve and extend life, many of them as attractive as they are expensive. The combined force of that dynamic has resulted in an explosion of health care costs." (p. 21).

The Christian will welcome this, although Callahan's entire book includes little reference to biblical, or even religious (only one reference to God, on p. 228) considerations. Yet, he reaches many of the same conclusions being discovered by biblical medical ethicists. It is nice to have such a clarion call by a noted and secular author. He does evidence that lack of biblical mooring in a few instances. For example, he does believe that the government should provide base-line care for all citizens, but restrict its tentacles so as to be under no mandate to provide all procedures, even the top of the pyramid procedures for each individual. Still, we might be more comfortable with an even further diminished role of government than he advocates. Further, he does recommend a universal health insurance plan (p. 219) as well. He also has a good discussion on euthanasia, but at a few points, left the reader wondering. Notwithstanding these lapses, one feels quite at home with Callahan in terms of medical ethics.

A few quotes will reveal how close he comes to affirming some of the conclusions of this journal. At one point he says, "We might wonder whether our ultimate problems with healthcare are not moral rather than practical, more about our chosen ends than our managerial means" (p. 261). Also, (on p. 34) Callahan says, "We have lost our way because we have defined our unlimited hopes to transcend our mortality as our needs, and we have created a medical enterprise that engineers the transformation." Earlier he'd articulated, "The deepest thrust of this approach, however, is to pursue the idea that we cannot solve the allocation problem without doing that which is most resisted -- deciding what is good for us as a society, not just as individuals" (p. 28).

Callahan states his contention as follows:

"I argue that the ideal of meeting the individual need for cure and the faith in efficiency as a way of making that possible are mistaken. It is not simply that they are impractical as goals, which is one way they are wrong. More fundamentally, they are goals that fail to take account of inherent human limitations. They thereby run the risk of deluding us as individuals about the possibilities of our lives, and of severely distorting a balanced pursuit of societal well-being. Our present system of healthcare is faulty, but not just because it is chaotic and poorly designed. It is faulty because it seeks the wrong ends" (pp. 29-30).

Moreover, the reader must hear Callahan as he critiques medical salvationism.

"Let me try to articulate that reigning vision. It consists of three major ingredients: a broad, limitless definition of health; a highly subjective notion of individual need, one captivated by the diversity of personal goals and desires; and a strong view of human rights, in particular the right of individuals to have access to adequate healthcare. It is a vision that sees health as an unbounded good, that allows the one to make in principle as much demand on the help of fellow citizens -- in the name of his or her rights and their obligations -- as is required to meet those needs. It is a wonderful vision, but it is seriously flawed. It is collapsing under its own weight, and it will not longer suffice to provide the foundations for a healthcare system" (pp. 33-34).

The criticisms of this book which I'd offer are few. One of the slight irritations is the too-frequent repetition of major themes. Yet I would rather have the author err in this direction than in being too short. Also, the weak point of the book seems to arrive in Chapter 7 as the author seeks to "Devise a Political Strategy" to implement his recommendations. Not that his was entirely wrong, but I was unconvinced as to the likelihood of any possible implementation. Again, it is disconcerting to see so little divinity or theological reference in a matter so close to theology. Hopefully many will profit from this, especially medical and political leaders. One more fine feature of this book is the set of appendixes which would aid anyone making a public presentation on these topics.

[ JBEM Index / Volume 5 / Number 2 ]

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