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Allocating health resources.

Allocating Health Resources

I have spent many months now trying to answer a simply stated, reasonable question: How can the United States devise a health policy that provides adequate care at an affordable price? To ask such a question is not an indicatable offense. But it is also, I conclude, a question designed by a specialist in exotic forms of torture. The American health care system, and the public attitudes that support it, are a vast arena of confusion, contradictions, and conundrums. Imagine that some muddled cook once conflated the recipes for beef stew, bouillabaisse, and chocolate cake. Your task is now to take that concoction and make of it an edible dish. Imagine further that you have been assigned numerous subchefs not of your choosing, each of whom has different tastes, some of whom are allegedly on the payroll of the beef, or fish, or chocolate industries, and all of whom are strong-willed and prone to state their convictions in the language of high morality. If that analogy seems strained, a scanning of some recent headlines, an examination of some new public opinion surveys, and a tour through a number of recent books may give it more credibility.

The Failure of Cost Containment

These are the headlines, all from the New York Times and all in early 1988:

* "Prepaid Programs for Health Care Encounter Snags--H.M.O. Shakeout is Seen"

* "Outpatient Strategy Fails to Cut Health Costs"

* "Hospitals' Medicare Profits Drop; Decline May Curb Access to Care"

* "Insurance rates for Health Care Increase Sharply...Premiums Rise 10-70%, with Medicare up by 38.5%--Setback Seen on Costs" is

That last, wonderfully understand phrase "Setback Seen on Costs" is worth a closer look. Consider that beginning in 1970 with the Nixon administration and continuing into the Carter and Reagan eras, "cost containment" has been the health care crusade. In that context, these headlines tell us something of great importance about many of the most prominent strategies to control costs. They tell us, for instance, that the H.M.O. movement is having trouble controlling costs and is, as a consequence, not growing as originally hoped. They indicate that the rising hospital costs of Medicare patients are undermining efforts to keep hospitals solvent. They show us that the belief in lower outpatient costs has been confounded. And they tell us, most ominously, that general health care costs remain on the rise and uncontrolled.

Those headlines, moreover, are not isolated items. A strong consensus has emerged among health economists over the past couple of years that the cost-containment effort is in general a failure. Not one of the major cost-containment initiatives has yet succeeded--or shows any serious promise that it will eventually succeed. Not even the slightest downward dip of any significance has appeared on those economic charts that measure the ever-rising cost of health care. Relative to the pace of inflation in general, the rise in health care costs has actually increased in the past few years.

The failure of cost-containment efforts has some important implications. One is that further loose talk about the simple feasibility of "cutting the fat" in the health care system should cease. The logical possibility that waste can be controlled should not be confused with the pragmatic probability that it will be. Nor should it be assumed that a reduction of waste and inefficiency can proceed more rapidly than the cost-escalating power of constant technological innovation. What economists call an "intensification of services"--a greater use of technology with individual patients--accounts for 20 to 25 percent of annual cost inflation.

Another implication is that it would be utterly naive to continue invoking "efficiency" as a way of denying that we must openly discuss the coming need for rationing and limits. "Cutting the fat" was meant to be the economic magic bullet to save us from painful choices. Its failure must be acknowledged. A strategy of economic controls that relies on hope and a denial of reality cannot succeed.

There is another closely related implication. Cost containment is difficult because it must struggle against the combined force of technological progress, unlimited public expectations, and an aging population. But beyond the force of that powerful dynamic is a failure to recognize that any serious cost-containment efforts require the same kind of restraints as outright rationing. To have any chance of success, those efforts must force people to change their habits, their beliefs, their professional standards, and their desires. The line between "greater efficiency" and "rationing" is very fine indeed.

The last implication I will mention is that we cannot afford to await utterly desperate circumstances before considering the possibility of rationing. Yet that goes against the common grain. The most common way of denying the need for rationing in the United States is to invoke a severe standard, to hold that only grave triage-like circumstances can justify rationing. The reasoning here is that, since ours is an affluent country, and since more efficiency is theoretically possible, we are not yet in desperate enough straits to resort to rationing. At the least, it is said, we should ration only after less severe methods have failed. In response, I would argue that our less severe methods--the common cost-containment strategies--show every sign of failure (though one can of course endlessly hope for a change); and that we are already seeing growing shortages and inequities of a severe kind. It is not too early to discuss rationing seriously.

Public Expectations for Health Care

Yet that will not be easy. The attitude of many health professionals--to resist any talk of rationing, and instead to invoke hopeful scenarios of efficiency as a way out--finds ample general support. Public opinion is confused and contradictory about the provision of health care. It indicates that we are in a deep psychological and ethical hole; and the solution is anything but clear. Two new and careful studies of public opinion--one by Louis Harris and Associates for the Loran Commission, and the other by the Public Agenda Foundation--help explain why there is so much confusion.

Let me first put on the rose-colored glasses. Like many others, I have long taken solace in the consistent finding over lmany years that the American public thinks highly of good health care for all and favors wider and better coverage. The Harris surveys confirm that such an attitude persists. Some 74 percent of the general public say they are willing to see more spent on health care, and an impressive 91 percent say that "everybody should have the right to get the best possible health care--as good as the treatment a millionaire gets." Not only does the public want splendid health care for all, by a significant majority (66% to 31%) it holds that "it's not fair that some people can afford to buy more and better health insurance than others." An even higher proportion (71% to 26%) believe that "health insurance should pay for any treatments that will save lives even if it costs one million dollars to save a life."

Yet those generous sentiments are a bit too good to be the whole truth. A large majority recognize (by an 80%-17% margin) that even if we radically increased what is now spent on health care, we could still not provide all the services people would like to have. They also recognize (by a 76%-22% margin) that the constant appearance of new and very expensive ways of treating the sick will soon force harsh choices. The public, in short, knows that we are not likely to achieve an ideal of universal access to all desired health care. Their idealism is tempered by realism; some limitations are understood to be necessary and acceptable. The public, moreover, also believes that we do not receive a good value for the money we now spend on health care, and thinks we could have a more efficient system.

The Harris survey ends on a positive note, stressing the power of public discussion to change attitudes and, especially, to make the public more realistic about what can be accomplished. "A public debate," the survey concludes, "would be likely to increase...the number of people who feel that it is not only inevitable, but reasonable, that health plans limit their coverage in order to stay within finite resources." That is an optimistic solution, grounded in changes noted in the survey respondents themselves as a result of participation in the study.

The findings of the Public Agenda Foundation at first seem to parallel those of the Harris survey. Asking a somewhat narrower set of questions--would the public favor a government program to cover catastrophic illness, even if the estimated cost ran to $10 billion a year?--the study found a strong majority in approval. There was widespread recognition that catastrophic illness could bankrupt a family, and that it was a danger for all families and not just poor ones. There was a corresponding belief that it is the duty of government, not families, to bear the cost of such illness. So far so good.

But the Public Agenda study pushed one step further, and the mood rapidly changed. It pressed its respondents--a sociologically solid and sophisticated population sample--to see if they would be willing to pay the taxes necessary to support the catastrophic illness program. The answer was "no": "...only about 1 in 10 of the respondents said they would agree to a tax increase of roughly $125/year--the proposal's estimated cost for the average taxpayer--for this purpose." This is a sobering outcome, removing what little hope for public reasonableness there was in the Harris survey. Worse still, the findings of the Public Agenda Foundation came after extended discussion and "time to ponder the problem"; the responses were not casual or unconsidered.

Their study concludes that, "As concerned as they were about their vulnerability to the high cost of catastrophic illness and long-term care...most of the participants...remained unwilling either to lower their own expectations about what the government should provide, or to pay what is necessary for even a modest level of government-provided coverage.... While there is strong support for more government involvement in this area, there is no corresponding inclination to pay for it...."

This ought to be a chilling piece of information for those who have long cherished the belief that the public is willing to pay more for good health care, and that only the timidity of politicians has stood in the way of more ample government programs.

What else might we make of that conclusion in the context of the continuing failure of cost-containment efforts? It suggests at the least that the correlation between high public expectations about health care and the failure of cost-containment efforts is not accidental. While the Harris survey notes some tempering realism about the possibility of unlimited health care, that realism does not seem strong enough to overcome the "wishful thinking" about health insurance that marked the deeper probing of the Public Agenda study. If the public shows little willingness to curb its desires for more and better health care, how can we reasonably expect that serious, demanding cost-containment efforts will be sustained?

Proposals for Allocation of

Health Care

That question is worth keeping in mind when considering a number of recent books on health care and related issues. In different ways each of them takes on the question of how we might most justly and reasonably allocate health care. In Born to Pay Philip Longman sets the problem in the broadest possible context, examining the intergenerational impact of medical progress. "Since the beginning of modern medicine," he notes, "each succeeding generation has invested massively in research and developing new medical technology. But such investments are never matched with reserves designed to pay for the cost of applying whatever newmedical knowledge comes as a result. For this reason alone, the financing of health care becomes ever more problematic, with each new generation inheriting valuable new medical technologies but no dedicated capital to pay for their use." The consequence of this pattern is an accumulating burden of debt, one that can only be discharged by younger, coming generations. This pattern is exacerbated by efforts to extend our lives to advanced age--the beneficiaries of such a practice are not those who will have to pay for it.

Yet as some of us have discovered, to suggest that age itself be used as a standard for the rationing or limiting of care is an invitation to opprobrium. Thus it is hardly surprising that the papers collected in Timothy M. Smeeding's Should Medical Care Be Rationed by Age? go at their topic with the kind of anxious care that novice snake handlers must bring to their art. The result is that none of the papers gives an altogether straight answer to the question posed by the book's title.

The question is instead quietly transmuted by most of the authors into the different and more benign (if also vexing) issue of appropriate care for individual elderly patients and the efficiency of the health care system. As such it is a valuable book, one of the few that even comes near the issue of rationing health care for the elderly. In their summary of the issues raised in the volume, John M. Bunker and Bruce M. Landesman nicely catch the kind of tentativeness that marks the papers: "...all agree that we need much more data before we can be sure how great an effect reducing waste will have. In the meantime, we must be ready for the possibility that we cannot have everything we want, and that some form of health care rationing is inevitable."

But after many years of waiting for such data to appear, is it perhaps just more wishful thinking to hope that it will bring some revelatory clarity? And just how much more data do we need? The failure to date of the many and varied cost-containment ventures already tells us more than we may like to hear.

There is of course no direct way to prove that hopes for a benign solution to a difficult problem are nothing more than wishful thinking. That possibility might be confirmed only when a policy proves itself a failure but is pursued anyway. We can only look to specific policies being proposed or pursued to see whether they will fare well. Can they work? Two other recent books lay out some interesting agendas.

In America's Health in the Balance, Howard Hiatt deftly moves back and forth between the doctor-patient relationship and the health care system in general. Physicians, he says, must often ration the care they give. That is the result of the lack of adequate policies for a fair allocation of resources and a public failure to acknowledge the existence of a problem. By default, not policy design, physicians are left to cope as best they can. Constant technological developments and increasing numbers of the elderly work to raise costs in so far uncontrolled ways. Great Britain and Canada (particularly the latter) face the same kinds of pressures but, in contrast to this country, have policies that have kept their costs much lower yet with health outcomes as good as ours.

Canadian health economist Robert G. Evans has tirelessly argued a similar point, noting that an important difference between Canada and the United States is that the former has been willing to impose government controls in a way this country never has. Those controls restrain costs but they do not ruin good health care. That is important to bear in mind because the kinds of reforms that Dr. Hiatt calls for would all require a strong governmental hand: meeting basic needs through some form of national health insurance, and rigorous programs of preventive medicine, biomedical research, technology assessment, expanded use of pilot studies, and systematic evaluation of experimental programs.

The kind of programs Dr. Hiatt has in mind would require a toughness that has been conspicuously lacking in the American system, a point underscored by Joseph A. Califano, Jr., the former Secretary of Health, Education, and Welfare. The solution he proposes in America's Health Care Revolution attractively combines guaranteed health care coverage for the poor, the elderly, and the unemployed, with a requirement that most employers provide a minimum level of adequate health care. (Senator Edward F. Kennedy not long ago introduced a similar bill in the Senate.) That could of course be an expensive proposition, but Mr. Califano believes that the costs can be controlled. The key to that control lies in the buying power of corporate America: "Big business can put pressure on doctors and hospitals to reform without the political inhibitions that have made it so difficult for government to act effectively...the doctors, dentists, and hospitals need the paying customers of American medicine."

Mr. Califano's sensible book was published in 1986 and written, I would assume, in 1984 and 1985. Three years later, despite corporate efforts, costs continue to rise. The Health Insurance Association of America reports that commercial health insurers are raising the price of their premiums for companies about 20 percent in 1988, and much higher in some cases. Is it that the corporations have not tried hard enough? Or that they have tried and failed? I am not clear what the answers to those questions are, but I am sure that Mr. Califano is at least partly right when he says, at the very end of his book, that: "Our fate is in our hands. The uncertainties are not in knowing what to do, not in science, not in economics. The uncertainties lie in our ability to discipline ourselves and our individual and collective wills to act with courage and compassion in a host of forums."

But why is there uncertainty about our collective discipline? My guess is that, as with an otherwise bright child unable to control himself, there is some basic lack of self-understanding, some failure to grasp why we act--or fail to act--as we do. Unless we can gain such understanding, our technical solutions will not work. Worse still, we may fall into the most common trap in discussions of health care reform, that of believing we have simply failed to come up with the right technical solutions (some new form of cost-sharing, or an adjustment of deductibles, for example). We need to dig deeper than that, however difficult in a society ever hopeful for clever technocratic, incrementalist solutions to problems that are fundamentally moral.

Conflicting Moral Values

Two other books help us to do that kind of digging. Robert Blank in Rationing Medicine shows how the contradictions of our health care system spring from some basic national character traits. Larry R. Churchill, in Rationing Health Care in America, exposes the inadequacy of moral individualism as the basis for a just--and in Califano's terms disciplined--system of health care. Together these two books help explain the seemingly willful blindness of those citizens in the Public Agenda Foundation study who are strongly committed to better health care but unwilling to pay for it.

For Blank, the question is not whether we must ration, but how. But is rationing even possible, at least in a sensible and fair way, in a nation with our political values? It is no accident, he argues, that we have a system that is both inequitable and too expensive. Ours is a pluralistic, individualistic nation, in love with technological progress, averse to limits of any kind, and resistant to government solutions to clearly societal problems. He nicely summarizes the fundamental obstacles to reform: "The belief that individuals have the right to unlimited medical care should they choose it; the traditional acceptance of the maximalist approach by the medical community; and the insulation of the individual from feeling the cost of treatment...."

Mr. Blank's steady perception of the underlying problems is so potent that he offers faint hope for the success of his own favored approach. He would have our policies focus on voluntary health risks, such as smoking, excessive drinking, and poor eating habits. That kind of emphasis, together with a much greater concern for health promotion and preventive medicine, would be highly valuable. But it would require a great governmental effort, and Blank's own analysis shows us that government is as much a part of the problem as its solution. The government is, after all, one of the great promoters and financial supporters of technological medicine; and it has strong public and congressional support for playing that role.

In many other ways, we also work at cross purposes with ourselves. Our commitment to individualism is always at war with our sentiments of justice and equality, even with efforts to promote voluntary changes in behavior. By what right, for instance, do we try to get others to make different personal health choices--it is their bodies and their lives, is it not? The moral conviction that physicians should do everything possible for the benefit of their individual patients clashes with the perception that, for society as a whole, no longer is everything affordable. Have physicians, who are part of a medical system heavily subsidized by public funds, no duties toward the public interest? And our pluralism--especially when combined with technological fantasies--guarantees that for every Cassandra who calls for rationing, there will be a Pollyanna to condemn his or her pessimism. In a standoff of that kind, Pollyanna wins.

Churchill takes a somewhat different and perhaps more promising tack. With Blank he agrees that our national values are ultimately the source of our problems in fairly allocating health care. He believes we must change some of those values. The need for rationing is evaded, he notes, because we persuade ourselves that "The hard choices of scarcity...can be avoided by efficiency, technological innovation, cutting the defense budget, or outproducing our needs." Yet even when rationing is seriously considered in the name of justice, we do not have good moral resources to pursue it as a policy: "The genius of the American self-image--individualism, self-reliance, progress, and prosperity--predisposes us to an ethical individualism and makes us forgetful of our interdependence and social connectedness."

Matters are scarcely helped by the fact that the most prominent theories of justice in medical ethics and elsewhere--particularly those of John Rawls and Robert Nozick--are themselves rooted in individual self-interest. "Liberal and libertarian traditions of ethical individualism," Churchill tellingly writes, "have ushered in a season of medical ethics in which justice is depleted of any social significance. They seek to pluck the fruit of freedom but see no obligation to nurture the communal vine from which it flowers." Churchill's alternative approach, though not fully developed, would have us return to traditions of civic virtue, emphasize common vulnerability and need, and seek the springs of justice in compassion and sympathy, not self-interest. As he notes, "A just health care system, whatever its final shape, requires a recognition of our sociability and mutual vulnerability to disease and death."

I think some sobriety about the practical possibilities of a communitarian approach is in order here, however. The promises of such a perspective for addressing problems of scarcity and allocation are many, but its actual contributions to real problems have so far been scant. They have been more rhetorical gestures than practical contributions to developing feasible and politically attractive policies. Churchill's book has the great advantage of offering a new direction. To hope that we will all find it in our personal self-interest to support, say, some form of guaranteed minimal health care, makes more psychological sense in times of growing affluence than in an era of cutbacks and cost-containment. A different kind of argument, one that shows how our common good is at stake in these unpleasant choices, is needed. Churchill's book is an important contribution to that intellectual agenda.

Denial and Rationing

We are left, however, with several national tasks that are extremely intimidating. We must, first, cope with a massive problem of denial. The evidence suggests that the general public is not yet willing to accept the reality of growing scarcity. In a country of close to 250 million people, even some thirty-five to forty million not covered by any medical insurance can be overlooked. If the Public Agenda Foundation's results are valid, the evidence of "realism" shown by the Harris survey may only be skin deep. The simple and I believe true proposition--that we cannot have everything we want in health care--has not, it seems, taken root. Those experts who radiate optimism, or still hold out hope for some massive turning of the corner on cost containment, do us no service. They help to rationalize the public denial, already too strong.

Our national denial is in part attributable to how we envision the problem. The common view of rationing is that it is only necessary when there is an absolute shortage of some good and that nothing can be done to improve the situation; a crowded lifeboat with finite supplies is the popular image. Yet a better image of rationing is that of the wealthy individual or corporation on the verge of bankruptcy, their liabilities beginning to exceed their assets. In many cases, one reason is inefficiency and sheer wastefulness. Addressing these problems is where most efforts to avoid bankruptcy begin. But a second reason is usually much more difficult to deal with: a whole way of life, one knowing no bounds, that must be changed.

That can be far more traumatic than efforts to cut costs here and there, requiring a transformation of goals, methods, and behaviors. The apparent inefficiency, it turns out, is no accident, but so inextricably tied in with the way of life that the former cannot be changed apart from the latter. Thus the Diagnostic Related Group (DRG) system, designed to reduce hospital costs under Medicare, does bring about greater efficiencies and has reduced the number of hospital beds. But the ultimate result is still a failure. Why? Because the DRG system seems to drive the sick out of hospitals faster--and into more outpatient care or extended stays in critical care nursing homes. The overall health care costs continue to rise.

The point, I suggest, is that our nation's affluence (especially when harnessed to technology) unleashes open-ended desires and aspirations. Eventually those aspirations, and the technological possibilities that give them credibility, begin to outrun the ability to pay for them. Perhaps in some theoretical sense they could be paid for, but at such a high cost to any sensible pattern of allocation among the different needs of society, or any real--politically plausible or feasible--capacity to pay for them, that the actual result is the same as bankruptcy. The system then begins to fail at critical points: basic needs go unmet, shortages grow, services deteriorate, tempers fray, and the control of high costs becomes an angry, frustrating obsession. That is what we are now beginning to witness.

To continue thinking that the real problem is simply inefficiency promotes self-deception. A more fundamental change is needed. To think that such change should await the outcome of a campaign against waste simply compounds the problem. That campaign will never adequately work. The ultimate problem is not waste or inefficiency; these are only symptoms of a deeper problem, which is that we want more than we can reasonably afford. One would think that eighteen years of failed cost-containment programs would have made that much evident.

The only certain, if difficult, solution to the threat of bankruptcy is to change our goals, scale down our desires, and set firm, even inflexible, limits. I am prepared to call that rationing, and it is what is needed. That will not be easy. Those accustomed to wealth and unrestrained possibility always have a harder time curbing themselves than do the poor, who have had more practice.

Prudent Pessimism

Our second task, then, is to understand that the many reformist solutions constantly offered to get us out of the economic snares we have devised cannot work in the absence of basic changes in attitudes and thinking. The striking failure of so many cost-containment efforts should suggest that the fault does not lie in mistakes about technical details. The more obvious insight is that there is no strong will, much less Joseph Califano's desired discipline, to make any potent plan work. The unpleasant secret is that we just may like things the way they are. The wishful thinking noted by the Public Agenda Foundation seems more acceptable than the less comforting alternatives. It usually is.

In puzzling over the disturbing finding of the Public Agenda Foundation--that the public may be willing neither to give up their aspiration for ever better health care nor to pay for it--I am reminded of another odd phenomenon that I increasingly encounter. That is the enormous internal pressure many seem under to remain optimistic in the face of disturbing evidence about health care trends. That optimism is usually combined by its most dedicated adherents with anger or indignation as a way of persuading themselves that reform is perfectly feasible if some bad actors would just change their behavior. Since there is bound to be at least some possibility of truth in such a view, it nicely obviates the need to examine the optimism itself.

There is every incentive not to look at the optimism. It is the most powerful engine behind medicine's quest to conquer illness and disease and to forestall death. It is no less a powerful engine of an economy that would see itself growing indefinitely and infinitely without any natural restraints. It is also part of a psychology, familiar enough among devoted adherents to the power of positive thinking, that the upbeat thinking itself changes reality and generates its own good outcomes. If enough stock brokers convince their clients that the market outlook is good, and they then invest their money, there is a fine chance the market will in fact do well. Social reformers have long known that their most important first step must be to persuade people that things can change; their pessimism must be vanquished.

Yet there comes a point with some matters at which the malleability of reality in the face of relentless optimism will fail. It is now the nature of medical progress, I believe, systematically to outrun our ability to pay for all that we might want or that is theoretically feasible, and we have reached that point. There is no reason to believe that some further improvement in medicine and the health care system is impossible; obviously improvements are possible. But there is no reason to cultivate any longer the kind of optimism that refuses even to discuss, much less admit, the need for rationing in the face of endless technological possibilities on the grounds that the discussion itself will do harm.

A continued angry search, moreover, for an as-yet-undiscovered bogey-man who has thwarted efficiency and cost containment merits a similar skepticism. Even if we find him, our deeper problem will remain: we cannot afford everything we want. We would do better to pursue the possibility that in prudent pessimism lies the course of reason and moderation. It is also our best hope to get the public to give up its contradictory impulses. If we scale down our hopes and demands, we have a far better chance of gaining a reasonable outcome than is now the case.

Individual and Community

The most important future task is that of transforming public opinion and the values that lie behind it. The combination of a belief in unlimited medical progress and the right of everyone to share fully and equally in that progress will be hard to dislodge. Public opinion is powerfully prone to think (as the Harris survey underscores) that everyone should have equal access to the best possible care and that, through research, "best" should constantly be improved.

Equally difficult to counter will be the belief that fine-tuning the system of financial incentives, disincentives, and entitlements will avert the need for serious and organized rationing. The chances that there will ever be some minimal level of guaranteed care for all--an important idea surfacing once again--are just about nonexistent for the foreseeable future in the absence of some fresh ways of thinking about health and human community. Politicians are certain otherwise to be profoundly wary, fearful of the potential cost of trying to meet even minimal individual needs.

The greatest puzzle in determining how to allocate health care fairly is that individual needs are highly varied, perhaps more so than any other common human need. Some people need continuing care from the day they are born, and others not until the end of life. That variation is further complicated by technological developments, which lead us to redefine constantly, and ordinarily to escalate, individual needs.

That any attempt to set limits must logically mean that some individual needs will not be as well met as others, and that not everyone will be able to have the best care, can only insult some deeply held values. A view of reality that has optimistically declared limits to be unnecessary and even to think about them as dangerous, and that has self-righteously declared any denial of a capacity to meet some needs in an affluent society to be morally wrong, is one at war with any realistic notion of human community. That notion should encompass mutual help, mutual sacrifice, and mutual limits. The present system of focusing on individual needs leaves no room for the broader needs of the community as a whole, no room for anything less than crude trade-off thinking in moments of pressure, and no room for placing health needs within some broader perspective of the full scope of many other human needs.

A Painful But Necessary Balance

The victims of alcoholism or drug addiction, it is said, often have to hit bottom before they are likely to gain the insight and motivation necessary to transform their lives. While the same may be necessary to reform our health care system, it would be good to avoid that purgative method. But we may be required to do something almost as painful: to begin thinking about the problem in ways that will be troubling, working against the national grain.

Since the end of World War II we have tried in this country to create a health system that will be all things to all people: to meet the needs of all individuals, including the right to redefine need when they choose to do so; the need for scientific and medical research, which is always to push on to the next frontier; and the logic of the economic market, which must stimulate a sense of need to create the wealth it seeks. Those happy day strategies are no longer working. Accepting the need for rationing, a strong dose of prudent pessimism, and a revitalized sense of community would restore the necessary balance.

Daniel Callahan is director of The Hastings Center and author of the recent book, Setting Limits: Medical Goals in an Aging Society (Simon & Schuster). He is now writing a book on the allocation of health care resources.
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Title Annotation:review article
Author:Callahan, Daniel
Publication:The Hastings Center Report
Article Type:Bibliography
Date:Apr 1, 1988
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