Better solutions needed.

False Hopes Daniel Callahan Simon & Schuster $24, 330 pp.

Universal Health Care Pat and Hugh Armstrong The New Press $24, 143 pp.

In just the time since this review was commissioned, Viagra has assaulted the nation, and the media have heralded a new generation of cancer drugs - smart bombs which only target cancer cells, based on genetic research. Politicians have seized upon managed care as a political horse to whip in the coming elections, and the pharmaceutical industry continues to prepare a boutique of designer drugs to accommodate the inexorable aging of a self-obsessed generation of baby-boomers. Meanwhile, almost 15 percent - over 40 million people - of the U.S. population have no insurance of any kind, and convenience stores brim with home-made posters announcing fundraisers for various victims of various maladies.

Having looked serious health-care reform in the eye four years ago and blinked, the United States is now receiving exactly what it asked for: health-system changes driven by the private sector. These changes - in all their ragged, inequitable, and profit-driven trappings - have left many citizens uneasy. Depending on one's definition, over 80 percent of the population (or double the number five years earlier) now receive their care through some form of "managed-care system" - where choice of doctors and access to services are limited in exchange for reduced rates and a supposedly predictable budget. The possibility - and in some cases the reality - of managed-care companies inserting themselves clumsily into treatment decisions between patients and providers has created ground for outrage. Anecdotes of needed care denied or delayed as a result of managed-care companies have driven public perception and public policy. Often lost in the debate are the facts that managed care has reduced health-care cost increases and can improve health indicators, that wide and unexplained variations in clinical practice do exist, and that no alternatives to private financing and delivery of health care are being considered in the United States.

False Hopes is Daniel Callahan's canary-in-a-coal mine message about the plight of Western health-care systems. In a series of books over the last ten years, Callahan has poked at the foundation of Western medicine like a moral engineer, documenting its fragility as he examined attitudes toward death, our inability to set funding priorities, and our addiction to the notion of endless medical progress. False Hopes builds on his past work and extends his reach across all national systems of health-care delivery and financing to consider what attitudinal changes are necessary for modern medicine to survive.

Callahan begins with a fundamental observation: all systems of health-care delivery and financing are under duress. Demands exceed resources in every case, not just in the United States. His thesis: modern medicine has aspirations and practices which guarantee stress and collapse. The themes of medicine's current era - domination of nature, unlimited capacity for improvement and social expansionism - ensure its demise. If the Viagras and new Alzheimer drugs don't bankrupt it, invasive surgeries on eighty-five-year-olds will.

Callahan's proposal is suitably grand - a new concept of a "sustainable medicine" for a new era. A sustainable medicine, he maintains, is "a medicine that, in both research and health-care delivery, aims for a steady-state plateau, at a level that is economically affordable and equitably available, and also at a level that is no less psychologically sustainable, satisfying most - but, of necessity, not all - reasonable health needs and expectations."

Callahan draws the concept of a sustainable medicine from the environmental movement. As an awareness of the earth's ecosystems has reshaped our view of economic growth toward the idea of sustainable development, so might a reacknowledgment of human limits change our expectations of medicine. "I am after a change in the hopes and ideals of medicine," he proclaims, "not simply in the way we organize and deploy the provision of care to sick people."

The bulk of False Hopes is a series of independent but connected essays in which the concept of a "sustainable medicine" is applied to themes important to medical philosophy. While this is familiar ground for Callahan readers, he attempts to use the sustainable medicine concept to integrate and further his previous work. For example, when he looks at how a notion of sustainability would influence the concept of progress, which occasionally supplants the patient's own well-being as a goal of contemporary medicine, he comes to a not surprising conclusion: "sustainable medicine requires the acceptance of an idea of progress that sets finite goals, that is willing to accept adequacy rather than perfection." In the end, this type of medicine must be one which is comfortable in saying - in its research and its patient care "enough already."

Callahan spends much time assessing humanity's attitudes toward nature. Mainstream environmental thinking has slowly moved from a conservationist view, seeing nature as something to be managed and exploited for our use and enjoyment, to more of a preservationist stance, which views humanity as part of an ecosystem, rather than sitting at the controls. Medicine, he maintains, has much to learn from this more modest, less instrumental view of how humanity interacts with nature. This bias toward the conservationist stance is reflected, he maintains, in the historical hegemony in Western medicine of aesculapius - the belief that only medical intervention can cure a body's ills - over hygeia - the notion that a well-tended body can cure itself.

Hygeia does not deny the pain nature inflicts upon us, nor our need to conquer or mitigate that suffering. Still, there is a balance to be achieved. Sustainable medicine, Callahan writes, must live within boundaries of nature, recognize human need to struggle against aspects of nature that cause suffering and premature death, and manage that struggle in some affordable way. This structure is characteristic of much of Callahan's writing in the book - to work from principles and fundamental experiences, to think analogically and syncretically, and to hew a middle path when the going gets tough, explicitly acknowledging the limits of individual and community resources.

The fundamental scandal of the U.S. health system is its inability to guarantee universal access. Callahan is at his strongest toward the end of False Hopes when he considers these equity issues. Here he maintains that, given the technological, market, and ethos-of-progress imperatives dominant in contemporary medicine, an equitable health system is only possible if informed by a notion of a sustainable medicine. This chapter, where he applies the concept of equity to themes previously discussed, is an elegant overview of his work and should be required reading for any would-be reformer.

While False Hopes is an important extension of Callahan's previous work, it has some conceptual weaknesses. The environmental analogy at the basis of the notion of sustainable medicine is informative but fundamentally limited by the very personal nature of health care. Limits and interconnectedness are much easier to accept when recycling than when rationing treatment decisions for myself and my family.

Callahan is also gentle in his treatment of the market economy, which exacerbates or even causes many of the woes he cites. Absent regulatory restraints, the profit motive continues to fuel a ravenous pharmaceutical industry, which takes wants, turns them into needs, and then enshrines them as health-care rights. Similarly, many technological advances in diagnosis and treatment are driven not by patient care but by investor-owned companies. More generally, in a market-driven culture individual want trumps collective need, and all bow to the altar of autonomy and choice, growth and expansion. Public health priorities lose out to individual medical treatment and research.

One also wonders if Callahan paints with too broad a brush and fails to acknowledge differing cultural attitudes that might make a sustainable medicine more likely. Certainly there are elements of non-Western and alternative medicine traditions which are sympathetic to a more limited medicine. Although he spends considerable time differentiating between rights-based health systems such as that of the United States and solidarity-based health systems such as those found in Europe, Callahan concludes that all are in equal trouble. In fact, the traditions of communal solidarity which made global health budgets and universal access realizable in those countries would appear to make them more amenable to the concepts of limits and sustainability that Callahan promotes.

The self-professedly broad arc of Callahan's aspirations make for a good balance against the puffery that passes for reform these days in Washington. It does, however, also leave one wondering what interim steps can be taken toward his promised land. For Hugh and Pat Armstrong, both of Carleton University in Ottawa, who co-authored Universal Health Care, the answer is crystal clear: Head North! This brief collection of essays summarizes the implementation of universal health insurance in Canada and then catalogues the Canadian system's virtues.

As a tract, Universal Health Care has the cheerleader tones and one-sided nature one would expect. However, its underlying story - that broad-reaching activist public policy for the public good can be achieved - bears repeating. Universal hospital insurance was established in Canada in 1957 and physician insurance came nine years later. Since then the national government and the provinces have continued to tweak the program, but its five underlying principles of portability, comprehensiveness, access, universality, and public administration have remained untouched. Delivery systems consist largely of private providers, and financing and administration is a combination of federal and provincial responsibility. The Armstrongs do their best responsibly to debunk the traditional criticisms of the system - long queues, government bureaucracy, heavy taxes, and dissatisfied providers. They also admit a few faults: cost inflation, and lack of drug coverage primarily. In the end, Canadians can boast of lower per capita costs than the United States, higher satisfaction ratings, equal or superior public-health outcomes, and, of course, universal coverage.

Will we all be done in by a plethora of Viagras and gene therapies, the burdens of an aging society, and our own furious needs? Absent the sort of attitude change for which False Hopes calls - one that will allow us to change our expectations and name our priorities - it is a distinct possibility.

Christopher F. Koller is the chief executive officer of Neighborhood Health Plan of Rhode Island, an HMO focusing on publicly insured populations, in Providence.