In a feature article in The New Republic, Daniel Callahan and Sherwin Nuland propose a radical reinvention of the American medical system requiring new ways of thinking about living, aging, and dying. They argue that a sustainable -- and more humane -- medical system in the U.S. will have to reprioritize to emphasize public health and prevention for the young, and care not cure for the elderly.
An interesting twist on their argument, which would aim to bring everyone's life expectancy up to an average age of 80 years but give highest priority for medical treatment to those under 80, is that Callahan and Nuland are themselves 80 years old. Daniel Callahan, Ph.D., is cofounder and president emeritus of The Hastings Center and author most recently of Taming the Beloved Beast: How Medical Technology Costs Are Destroying Our Health Care System. Sherwin Nuland, M.D., is a retired Clinical Professor of Surgery at the Yale School of Medicine and author of How We Die and the Art of Aging. He is also a Hastings Center Fellow and Board member.
"The real problem is that we have medicine excessively driven by progress, which aims to rid us of death and disease and treats them as the targets of unlimited medical warfare," said Callahan and Nuland. "That warfare, however, has come to look like the trench warfare of World War I: great human and economic cost for little progress. Neither infectious disease nor the chronic diseases of an aging society will soon be cured. Cancer, heart disease, stroke, and Alzheimer's disease are our fate for the foreseeable future. Medicine and the public must adapt it to that reality, one that has mainly brought us lives that end poorly and expensively in old age."
The article notes that the Affordable Care Act might ease the financial burden of this system, but not eliminate it. It reports, for example, that the cost of Alzheimer's disease is projected to rise from $91 billion in 2005 to $189 billion in 2015, and to $1 trillion in 2025 -- twice the cost of Medicare expenditures for all diseases now.
"We need to change our priorities for the elderly. Death is not the only bad thing that can happen to an elderly person," the authors write. "An old age marked by disability, economic insecurity, and social isolation are also great evils." They endorse a culture of care, not cure, for the elderly, with a stronger Social Security program and a Medicare program weighted toward primary care that supports preventative measures and independent living.
Callahan and Nuland point the way to a more sustainable path that reprioritizes the entire system. Among their recommendations:
- improve medicine at the level of public health and primary care, while reducing its use for expensive high-tech end-of-life care;
- shift resources for the elderly to greater economic and social security and away from more medical care;
- subsidize the education of physicians, particularly those who go into primary care, and decrease medical subspecialization;
- train physicians better to tell the truth to patients about the way excessively aggressive medicine can increase the likelihood of a poor death;
- shift the emphasis in chronic disease to care rather than cure;
- conduct a top-down, bottom-up, long-range study of the entire American system of health care, including the training of physicians, with a view toward reconstituting it along systematic lines that take science, humanistic concerns, economics, and social issues into account.
- Daniel Callahan, Sherwin B. Nuland. The Quagmire: How American medicine is destroying itself. The New Republic, May 19, 2011 [link]
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