Daniel Callahan, Taming the Beloved Beast: How Medical Technology Costs Are Destroying Our Health Care System (Princeton: Princeton University Press, 2009), 267 pp.
Reviewer: Christopher Libby
In Taming the Beloved Beast, Daniel Callahan, senior researcher and president emeritus at the Hastings Center, synthesizes his long-standing concern for the relationship between technology (the “beloved beast” of the title) and the goals of medicine with his more recent engagement with healthcare economics and policy. He argues that adequately controlling costs and equitably distributing medical care in the United States requires a healthcare system that limits the use of technology and is highly regulated by government.
Like a plethora of other commentators, Callahan identifies cost as the primary problem plaguing the U.S. healthcare system. For some time, annual healthcare cost inflation has fluctuated in the 7-12% range, and it is expected to remain in the 6-7% range indefinitely. Inflation at this level will continue to drive up the health portion of the GDP to about 19.5% by 2017, a significant increase over the 2007 level of 16.3% (1). And like many of his contemporaries, Callahan identifies cost inflation as a worry in large part because of how it affects access, as rising costs exert downward pressure on employer provision of healthcare benefits, and individuals find themselves either without insurance or paying out-of-pocket for a significant portion of their healthcare.
Callahan argues that realizing a sustainable healthcare system will require cutting healthcare cost inflation in half from the current level of about 7% to a level of 3-4%. (39). He judges that the path to achieving this goal is steep, indeed, as he devotes chapters 1-4 to questioning the sufficiency of regnant proposals for reigning in costs. In wide-ranging discussions, he argues that neither popular ‘tactical’ attempts to manage costs at the point of delivery (e.g., evidence-based medicine) nor ‘strategic’ proposals for healthcare system (re)organization have proven sufficient. Likewise, canvassing a number of empirical studies, he contends that market competition, a favored solution of many economists and political conservatives, “may work locally here and there,” but it is “too untested, too speculative in its potential national impact, and too great a gamble to ever be depended upon to reliably control costs” (92). As Callahan explains in chapter 5, the difficulties here are driven by the highly commercialized character of American medicine. This is seen, for example, in the ways the medical profession has become a ‘hand-maiden’ of medical industry (142), which has fostered the ‘medicalization’ of health, and incentivized entrepreneurial behaviors among physicians.
In chapters 6-8, Callahan develops his constructive vision of healthcare reform. Curtailing technology costs is the linchpin of healthcare reform, as new and intensified old uses of it constitute about “50% of the annual increase of health care costs” (1). Limiting technology utilization is easier said than done, however, as it will require a transformation of the ideals that drive modern medicine: the dominant individualistic, utopian, Enlightenment perspective contends that biological suffering “is an inherent evil; that death is intrinsically wrong and should be the main enemy of medicine; . . . and that endless medical progress should be pursued” (7). As those familiar with his work will know, such ideals comprise the ‘infinity’ model of medicine; here, he identifies it as the archenemy of a healthcare system that aspires to control costs and ensure access.
Our infinite medical aspirations need to be replaced by a ‘finite’ model of medicine that shifts emphasis from individual good to the communal good and that recognizes the need explicitly to limit access to technology. In such a ‘population-based’ health policy, the most important aim is not to stave off death at all costs, but, rather, to help a person achieve a ‘full life’, characteristically achieved by one’s late 70s. Resource allocation priorities thus properly shift from the elderly, where intensive interventions are often of marginal benefit, to the young, where technologically intense treatments are more justifiable, even, in some cases, acute, low probability treatments. But those in later old age (81+) “need to be put on notice” that if they “want the same level of technological care they received in their earlier years, they will simply not get it” (192). In seeking to situate this model politically and institutionally, Callahan is clearly more impressed with European healthcare systems than the “present public-private mix” that “has demonstrated its incapacity to curtail costs for over 40 years” (209), and advocates a government-dominated system that provides universal access while consciously seeking to control costs and oversee technology utilization.
The virtues of Callahan’s argument are multiple: it is written in an accessible manner and should garner a wide readership; it seeks to unite often disparate, if conceptually related, fields of inquiry; and it has the potential to spur deeper reflection about the nature of healthcare and the proper shape of healthcare policy. For theologians, in particular, the commitments latent in his population-based health policy resonate with and provide possible intimations regarding how one might envision cashing out in practice a commitment to the common good, and his embrace of a finite model of medicine solicits reflection on the spiritual challenges and dimensions of proper end-of-life care.
While the virtues of the text are great, there are important elements of the argument that merit further development or more extensive discussion, a feature in large part no doubt due to its aspirations to comprehensiveness. For example, many are unlikely to find compelling Callahan’s dismissal of competition, as his discussion of empirical studies is overly cursory. However one might be disposed to regard competition, it hardly seems sufficient to devote less than a page-and-a-half to canvassing seven studies on the relative favorability of HMO competition. Similar worries attend his discussions of tactical schemes for controlling costs, as several are discussed and evaluated in only four to six lines of text each. Finally, those unfamiliar with Callahan’s ethical commitments, especially, are likely to find his discussion of a full life insufficiently attentive to the elasticity of the term and to its variability according to race, class, and gender. None of the foregoing should be taken to constitute a rejection of Callahan’s argument in this text. Rather, these are invitations for him to develop aspects of his work more fully. Given his prolificness, we should not have to wait long.