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Daniel Callahan, PhD
The Hastings Center, Garrison, NY

JAMA. 1999;282:2077.

Health care faces 2 large problems that will in the future force consideration of some difficult questions about the nature of medicine and health care. The first concerns "marginal benefits," which affect the care of all patients. How shall we manage and allocate the growing number of expensive treatments and pharmaceuticals that provide only limited benefits? The second problem concerns health care for the elderly and the financial crisis the federal Medicare program is expected to undergo as the baby boom generation retires. These 2 issues are connected because health care for the elderly, particularly those over age 85, is marginal in the sense that life expectancy is relatively short thereafter, even if a particular intervention is successful by a particular standard.

A number of proposals in recent years have attempted to deal with this dual problem. One proposal argues for increasing and improving outcome assessment and evidence-based medicine to better determine what is and is not beneficial to patients.¹ This approach, however, does not resolve ethical dilemmas over health care allocation, such as whether to spend money on expensive treatments with a low probability of succeeding (eg, bone marrow transplants). Another proposal is to reduce the notoriously high costs of end-of-life care by a combination of outcome assessment studies and an expanded and improved use of hospice programs and advance directives.²

The key issue for the future is whether this society will continue its present course of using more marginally beneficial technologies to improve health care for the elderly—refusing, in effect, to accept the historical decline in health associated with aging—or whether society will take a population-based approach by putting more resources into improving health in younger years and thus increasing the likelihood of better health in later years. Examples of the latter might include working with health promotion and disease prevention programs to reduce illness and disability prior to death.

Only the latter course seems based in common sense. Trying to cope with the inevitably expanding health needs of the elderly by means of ever more expensive technologies with marginal health benefits to the population as a whole makes little economic sense. Conversely, to think that we can manage growing costs through cost reductions at the end of life and greater application of evidence-based medicine is far too optimistic.

My pessimism regarding the possibility of achieving a technical correction through outcome assessment studies runs counter to prevailing sentiments within US medicine. One reason for this pessimism is that the pharmaceutical and medical manufacturing industries are endlessly adept at developing new technologies, hardly any of them curative and most of them expensive. US physicians, with the eager support of their patients and sometimes the reluctant assent of HMOs, are ready to adopt these technologies. War has been declared against death and its historical ally, aging.

Are there any means to make a population health perspective more attractive to society? Three attitudinal changes would have to occur. First, there must be, at some point, a limit on the amount of money deemed worth spending on marginal medical improvements—a point where the price is too high for too little return. The second is to persuade the public that a population-based approach appears to produce not simply a less expensive way of dealing with health and illness, but overall improved health for most, though not all, individuals. The third change is the most radical, at least for this culture. We must accept old age and death as part of the course of human life and settle for the more modest goal of a decent average life expectancy of, say, 80 years³ and a good quality of life before that point.

In the search for a biological map, which many would call "reductionist," to better health in the future, current research emphasizes the genetic roots of disease. Although this may be a scientifically sound research strategy, it is not clear that it will result in more affordable medicine in the future. A population health strategy could, conceivably, produce comparable success at a more affordable price. Some marginal benefits might be lost, additional people might die, and others might have a lessened quality of life. But we could have a more realistic and economically sustainable kind of health care: in my view, a splendid trade-off.

REFERENCES
1. Larson EB. Evidence-based medicine: is translating evidence into practice a solution to the cost-quality challenges facing medicine? Jt Comm U Qual Improv. 1999;25:480-485. 2. Emanuel EJ. Cost savings at the end of life: what do the data show? JAMA. 1996;275:1907-1914. FREE FULL TEXT 3. Callahan D. Old age and new policy. JAMA. 1989;261:905-906. FREE FULL TEXT

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