Sick Transit

People who are elderly, disabled, prematurely born, or seriously ill have much to fear from the medical intelligentsia — those bioethicists and moral philosophers who have in recent years transformed medical ethics.

It was bioethicists and moral philosophers, after all, who made it acceptable to dehydrate to death people diagnosed as permanently unconscious — a practice that has already spread to brain-damaged people who are unquestionably conscious.

It was bioethicists and moral philosophers who made a distinction between “human beings” and “persons,” with only persons enjoying the right to life — a theory intended to pave the way for the legal killing of babies born with birth defects and involuntary euthanasia of legally incompetent patients. (Both forms of medicalized killing already occur in the Netherlands, a country some look to as a model for the United States.)

It was bioethicists and moral philosophers as well who promulgated “Futile Care Theory,” which allows doctors and health-insurance executives to deny not merely high-tech interventions but also such treatments as CPR and antibiotics to the profoundly disabled and people at the end of life. Even if the patient or the patient’s family wants the care, what matters is the medical professional’s assessment of the quality and worth of the patient’s life. Little noticed by the mainstream media, Futile Care Theory is already being implemented in hospitals and nursing homes, both informally in clinical settings and formally through hospital protocols.

In short, with the exception of helping to create laws that permit people to refuse unwanted medical treatment, the attitudes and policies of most mainstream bioethicists and moral philosophers are very bad news for the medically defenseless and vulnerable among us.

It is in this context that two new books, False Hopes by the noted bioethicist Daniel Callahan and Life Without Disease by physician William B. Schwartz, cause so much concern. Both authors urge the laudable reform of our currently dysfunctional health-care system in order to make it more widely accessible and cost efficient. Unfortunately, both authors choose methods that are unethical and immoral.

At first blush, Callahan and Schwartz seem mirror opposites: Callahan is nihilistic; Schwartz is utopian. Callahan is convinced that medical progress has advanced just about as far as it reasonably can. Schwartz sees a medically miraculous future where life expectancy will reach 130 years. Callahan would put more money into public-health education, while Schwartz would increase investment in medical research. Callahan writes too long. Schwartz writes too short.

Despite these differences, however, the authors have much in common. Both write in the passive prose so favored by the medical intelligentsia. Both attempt to appear rational and balanced as they grapple with health-care policy. And both surrender abjectly to medical utilitarianism.

Each enthusiastically espouses a rigid system of health-care rationing that would sacrifice the life and health of some people for the sake of health-care “equity” — which for both the authors represents a higher good than the fate of individual patients. And therein lies an acute and fast-approaching danger to the future of America as a moral nation.

Callahan disbelieves in medical utopia, and everywhere he looks, he sees only limits. People expect too much from their doctors. Medicine is too expensive and getting more so. Health care consumes 14 percent of the gross domestic product and takes resources away from other important community interests.

And what have we gotten for our huge investment in medicine? Not as much, according to Callahan, as might be supposed. It’s true that life expectancy has increased by approximately thirty years during the twentieth century, but that has mostly to do with improved infant-mortality rates. And our increased lifespan is actually a bit of a curse. We used to die quickly from infectious disease. Now we die slowly from such chronic and debilitating conditions as Alzheimer’s disease and cancer.

To our false hopes of a health utopia, Callahan’s alternative is an intentional turning away from medical progress and a radical reshaping of America’s health-care system. In a parallel to the environmentalist movement, the key word in False Hopes is “sustainability.” A sustainable health-care system, Callahan asserts, is both affordable and equitable. It is a system that intentionally turns away from medical progress and accepts as it already is the current level of medical science — a “steady state,” as Callahan labels it.

Callahan’s prescription for maintaining this steady state is worse than the disease he seeks to cure. The traditional ethics that has served medicine so well in the past must mutate into collectivism rather than individualism. Private medical decisions between patient and doctor will be severely curtailed. The “community” (which turns out to mean the professional bioethicists and moral philosophers) will decide what can and can’t be prescribed in specific circumstances. Nothing will be done to increase average life expectancy or find new ways to help premature babies survive. Research into the causes and cures of cancer, AIDS, heart disease, and other afflictions will be reduced by negative financial incentives that will dissuade private businesses from investing in medical research. Funding to pay for acute medical care will be drastically cut in order to restrict the options for sick people. And if, despite the heavy hand of government, new technologies are discovered, only those demonstrating in advance that they will benefit 50 percent of patients will be allowed to be put into clinical use.

The resources that once went into research and treatment will be diverted to fund a massive bureaucracy charged with public-health education, which may include coercive measures to force people to live healthier lives. Rationing will be strictly enforced, with doctors required to deny individual patients beneficial treatment in order to serve a higher obligation to the “community.” Treatment will be based on such characteristics as the patient’s age, disability, and even lifestyle choices.

Not a pretty picture, Callahan admits. Indeed, he acknowledges that these policies will “lead to harm or death to some portion of the population at risk.” But what does that matter, when the misery inflicted on individuals is in pursuit of collectivist notions of equity and affordability? According to the bioethicist, “a sustainable medicine can do no other than accept this unpleasant reality.”

The most frightening thing about all this is the stature of the author. Daniel Callahan is not a wild-eyed character on the futuristic fringe. He is a pillar of the bioethics establishment, a co-founder of The Hastings Center, one of the world’s most famous bioethics think tanks. When Callahan speaks and writes, policymakers listen; when he espouses something, his lesser known colleagues in universities, medical associations, and hospital committees are thinking it and sometimes acting upon it.

Callahan’s antipathy toward medical progress — and his firm belief that some of us must be pushed out of the lifeboat to benefit others — can be said to reflect fairly the predominant view in the bioethical community. We ignore the threat of False Hopes at our peril.

It is an interesting experience to read William B. Schwartz’s Life Without Disease along with False Hopes. Where Callahan sees medical progress as coming to a standstill, Schwartz believes that we can and probably will reach near-perfection through genetic research and molecular medicine. The result for those lucky enough to be alive in the middle of the twenty-first century will be long lives generally free from the chronic afflictions of old age that so depress Callahan.

Schwartz had an intriguing notion for his book — though with only 204 pages of text, the core of it concerned with health-care rationing, he doesn’t develop it well. Life Without Disease takes the reader on a hundred-year journey through medical history — a real history from 1950 to the present and an imagined history from the present to 2050.

Great strides are being made in cancer research, medical science can already stimulate the body to regenerate bone tissue, and there is hope that damaged nerves can be regenerated. The future holds even greater promise, according to Schwartz. We can expect accelerated progress against heart disease, auto-immune disease, and other afflictions. Even old age, Schwartz predicts, will become a treatable condition. Indeed, he writes, “the medical successes of recent decades provide ample reason for us to plan for the possibility of a world in which disease and death are pushed ever farther into the second century of life.”

Unfortunately, in the course of this trot through fifty real and fifty imagined years of medical history, Schwartz falls into the same unethical pit as Callahan does, promoting health-care rationing as a way to finance the great medical strides he sees coming in the future. Rationing as described by Schwartz requires a massive bureaucracy in order to undertake the project of ranking medical outcomes — with those of the highest value financed and those of the lowest value cut off.

The construction of such a ranking, as Schwartz sees it, is a community responsibility. In other words, medical care would devolve further into politics than it already has. The obvious result would be a gigantic struggle over rationing: AIDS activists fighting breast-cancer activists, fighting prostate-cancer activists, fighting multiple-sclerosis activists, each seeking to ensure that one particular disease has adequate funding. The redefinition of medicine as the politics of interest groups is no way to run an ethical and compassionate health-care system.

The authors of both False Hopes and Life Without Disease have little or no regard for the equality of human life. This is their most fundamental error, for if we are to resolve our problems in health care, we must hold tightly to Jefferson’s self-evident truth that all of us are created equal, with an inalienable right to life.

America is not a nation that should accept — in the name of the greater good of the “community” — a health-care system that is the moral equivalent of exposing disabled infants on hills or leaving our elderly and wounded to die by the side of the trail. All of us, the healthy and the unhealthy, the able bodied and the disabled, the young and the elderly, those just born and those on their death beds, have equal moral worth. None of us is expendable. No one can be discarded.