6 World Health • 49th Year, No.5, September-October 1996
Achievable goals
Daniel Callahan
Scanner examination in Switzerland. The cost of high technology puts it beyond the range of most people in the world
Some people require only an aspirin over a lifetime to stay well. Others need expensive neonatal care at the beginning of life, and organ transplants at the end. A rights model implies that everyone s needs
should be met, regardless of the kind or expense of the care they need. The obvious difficulty with this model is that it overlooks the scarcity of resources.
I
t is not difficult in any society to persuade people that health has a high value, or that a healthy popu- lation is a social and economic necessity. What is more difficult isto find a way of making that case effectively in the face of scarce resources. No one will argue against good health as an aim, but not every- one is ready to give it the priority necessary to pay for it.
Part of the trouble is that modem scientific, high-technology medi- cine, while highly popular, is becom- ing more expensive with each passing year. This is particularly true as countries see the burden of illness shift from infectious to chronic diseases. The latter are less amenable to inexpensive and rapid cures.
There is also considerable confu- sion about the best way to make the case for good health care. One model, using the language of rights, argues that each person has a basic human right to health care, which it is the obligation of society to pro- vide. This model focuses on the welfare of the individual rather than that of society as a whole. The other model, using the language of soli- darity, holds that we ought mutually
to support each other in the face of illness and death through the provi- sion of decent health care. This model focuses on the welfare of the society as a whole. Where the rights model is individualistic in its orien- tation, the solidarity model is com- munitarian.
The struggle between these two models might be only of academic interest except for some serious implications. The premise of the rights model seems to be that an equitable distribution of resources requires that each individual (a) should have equal access to care, and (b) that equal outcomes of health care should be sought from that care.
And it seems to imply that the goal of medicine should be to reach and help everyone, regardless of the nature of the diseases and illnesses that afflict them. Some people require only an aspirin over a life- time to stay well. Others need ex- pensive neonatal care at the beginning of life, and organ trans- plants at the end. A rights model
World Health • 49th Yeor, No.5, September-October 1996
A young child with severe diarrhoea in Bangladesh arrives in the hospital for treatment.
Poverty brings inequity in both preventive and curative care.
implies that everyone's needs should be met, regardless of the kind or expense of the care they need.
The obvious difficulty with a rights approach is that it overlooks the scarcity of resources and pro- vides no clear way of balancing the good of some individuals against the overall good of the community.
There is no obvious way for the individualism of the rights approach to give way to the societal need to set limits on health care resources.
Characteristically, countries that emphasize an individual right to health care-such as the United States- have been weak in providing good public health programmes and community services. High technol- ogy and acute care medicine are accorded the power, prestige and economic glory.
Community orientation
The solidarity model, by contrast, has in practice had a population and community orientation. Historically the fruit of post -Second World War universal health care policies in Europe, solidarity approaches have stressed the need for primary care and public health services and the necessity of setting overall limits to care. Consequently, though rarely
written into explicit policy, there have usually been de facto limits on high-technology medicine, particu- larly for the elderly. The strength of this strategy is that it has guaranteed a decent base of care for everybody.
Its weakness is that it has sometimes, perhaps often, been forced to sacri- fice patients at the margins, where care is expensive and good outcomes less assured.
This is a broad-brush picture.
There are many exceptions to my generalizations about both a rights and a solidarity strategy, and they are often mixed together. But I believe that, on the whole, it is an accurat~
picture of two contrasting ideologies.
The question, then, is which ap- proach is likely to prove most helpful in the future?
Both approaches encounter prob- lems these days. Rights-based poli- cies run up against the hazards of new and expensive technologies, exceedingly valuable for a few but a terrible financial drain on the health care system as a whole. An effective combination of life-extending drugs for a person with AIDS can now cost from US $60 000 to $70 000 a year.
Solidarity-oriented approaches, with their guarantee of care for all, are
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encountering the increased resistance of a public unwilling to pay higher taxes to support a welfare state. The response in both cases has been to look for greater efficiency in the health systems in order to control costs, and to turn to the market to relieve pressures on government.
While both greater efficiency and the market may be of some help, there are some serious limitations to both. Much contemporary health care will remain inherently expen- sive, not amenable to efficiency solutions. A market policy runs the serious risk of increasing the dispari- ties between rich and poor in gaining access to health care; it is a direct threat to equality of care.
A third way?
Is there a third way to go? I want to suggest that the time has come for a fundamental international examina- tion of the goals of medicine and, along with that, a reconsideration of the place of medicine in health care systems. A market and efficiency strategy divorced from a reconsidera- tion of medical goals is not likely to work. Why look at goals? There are
A patient being token core of in Cuba. Guaranteeing a decent bose of core for everyone calls for a subtle balance between expensive and inexpensive technologies.
8
An immunization session in the Philippines. Access to preventive core is a right for the individual, and a necessity for society.
three reasons to do so.
The first is that the present goals of modern scientific medicine are no longer realistic or affordable. The most important of such goals is the dedication to unlimited progress and technological innovation. But it is clear that progress itself is often the problem, since it tends to generate unaffordable technologies with only marginal population benefits. A fresh analysis of the most helpful kind of progress for the future would be welcome.
A second reason is that more and more social problems are being transformed into health issues.
Substance abuse and the problems of urban living provide examples of that trend. A sober and careful examina- tion of the drift toward the medical- ization of life is in order. A third reason is that modern medicine has been unwilling to set any finite, achievable ultimate goals. It seems to want only more health, more
progress, more satisfaction of desire.
This proclivity plays into the hands of a profit -oriented medical market.
The moral need for equality is made all the more unattainable if priority is given to progress over fairness, more over enough, and infinite goals over limited, achievable goals.
World Health • 49th Yeor, No. 5, September-October 1996
In sum, the present goals of modem medicine have assumed the possibility of inexpensive endless progress and the capacity of biomed- ical research to overcome all biologi- cal boundaries. That assumption is proving false, but a more modest one has yet to appear. No doubt the future will see a mix of rights- oriented strategies, and a blend of public/government and private/
market strategies to control health care costs. But if those tactics are not accompanied by a fundamental reconsideration of what it is that medicine and health care ought realistically to seek, there is likely to be no way out of problems that will get worse before they get better. •
Daniel Callahan is the co-founder and President of the Hastings Center, 255 Elm Road, Briarcliff Manor, N. Y l 051 0, USA, he is
the author of The troubled dream of life:
in search of a peaceful death.
A TB patient being examined in Ghana. Is the lime ripe for a fresh analysis of the gaols of medicine, to ensure that they are both realistic and affordable?
