Our Misplaced Faith in High-Tech Medicine

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The following essay appeared on the website of the Hastings Center, which is running a colloquium on the values behind health care reform.

“One could make a good case that improvements in education and job creation could be a better use of limited funds than better medical care.” – Daniel Callahan, “Medical Progress: Unintended Consequences”

The president emeritus of the Hastings Center opens his insightful essay with the observation that the American people’s faith in medical progress is boundless. In this short comment, I want to expand on his thoughts by reexamining the cardinal tenets of that faith, since they embody a set of values that distract us from building a society that promotes good health, an infinitely more difficult task than building a better sick care system.

What are the core values driving our belief in high-tech medicine?

At their root, they are the values of good old-fashioned American individualism. This is the land of opportunity, where everyone has the God-given right to thrive and prosper. It’s also the land of the second chance, a place for the self-made and remade man – like President Ronald Reagan or Don Draper of the award-winning new drama “Mad Men.”

Death in this value system is not the end of a journey, but a rotten break. It’s the end of our chance to make a mark in the world, thus a fate to be avoided at all cost. Ray Kurzweil, the nonpareil Baby Boomer inventor, is the faith’s high priest, gobbling dozens of pills and supplements daily in his quest to remain on his “Fantastic Voyage: Live Long Enough to Live Forever,” to use the title of his 2005 book.

These values have been written into the laws that govern the delivery of health care, especially Medicare. That universal, single-payer system was designed to provide health care for our oldest and therefore most vulnerable citizens. But in setting up that system, Congress said the government (i.e., all of us) would pay for any medical intervention deemed “reasonable and necessary” to return a person to health, and it could never consider cost when making those determinations. How deeply ingrained are those values? So deeply ingrained that it was child’s play this past summer for right wing demagogues to stir up passionate outrage over nonexistent efforts to “pull the plug on grandma.”

The public religiously believes there will be a technological fix for the hundreds of diseases that may hit us as our bodies degenerate, and tithes accordingly. Any effort to limit prices for what must be paid for new technologies is met with cries from industry that it will stifle innovation. The taxpayers provide the seed corn for new technology by investing nearly $30 billion a year in basic research through the National Institutes of Health and other government health-related programs (this year supplemented with $10 billion in stimulus act funds).

But that’s just the start of the process. Those researchers are encouraged to patent their findings and start companies to bring their inventions to market, a reflection of another core American value – entrepreneurialism. The government refuses to limit prices so these companies will have “incentives” to leap the regulatory barriers to entry. And even when it invests in comparative effectiveness research to determine if these new inventions are any better than older interventions, the government will insist that those findings cannot be used to determine payment policy.

Where has this lead us? We have new anti-cancer drugs that cost $50,000 to $100,000 a year despite extending life a matter of weeks or months. We are helping pay to develop cameras-in-a-pill that can scope out our innards, the latest twist in imaging technology. We will collectively pay additional billions for a pill that can be taken once a day instead of twice a day. As I write, a hospital in suburban Chicago is building a $130 million cyclotron to deliver proton beam therapy to prostate cancer patients in the name of sparing them the life-altering side effects of incontinence and impotence that affects some patients given traditional interventions like surgery or radiation. Does it work any better? No one knows. Did these men need these interventions in the first place? For many, the answer is no. Will anyone tell them the alternatives, or challenge the erection of this new altar to high-tech medicine? Alas, the answer is no.

The results are as described by Callahan and others: half of the annual increase in the cost of our increasingly unaffordable health care system can be attributed to the proliferation of newer and always more expensive forms of care. What gets lost in that lament is that the return on this investment is on a downward spiral. Our life expectancy not only lags behind other advanced industrial countries, but every year it grows a little more slowly.

Why has our technological faith failed us? The answer is simple. Increased longevity has nothing to do with extending the natural human lifespan. Societies increase longevity by eliminating premature mortality. Technology is one means to that end, but it is probably the least efficient method. It’s definitely the most expensive.

The dramatic increases in longevity we saw in the early 20th century was largely the result of better sanitation that reduced infectious disease deaths. The gains of the postwar era were largely the result of better housing, better heating, less burdensome work, and more leisure – each a product of an increasingly wealthier society. In more recent years, cleaner air, less smoking, and better diets have played a bigger role than medical interventions in extending life.

That’s not to say that medical technology hasn’t helped. It can and does save lives. It can even perform miracles in some cases. But the truth is that investment in technology will never bring the U.S. up to the longevity standards of other advanced industrial countries. Why? Because our misplaced faith has distracted us from tackling the real and enduring determinants of ill-health in our society- poverty, income inequality, social insecurity, and status anxiety, the hallmarks of our increasingly dysfunctional social order. There’s a vast literature on the social determinants of health. Alas, it has gone unnoticed and unremarked in the current health care reform debate.

Rebuild our health care delivery and health insurance systems? It’s a necessary, even laudable goal. But it’s not sufficient if we want to improve our population’s health. Until our values allow us to put that goal to front and center, we’ll be forever doomed to disappointment by the poor returns from our massive investment in high-tech medicine.

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6 replies »

  1. I was once told in a lecture that it costs the same to ‘get from’ 90% to 100% as it would to ‘get from’ 0% to 90%. Of anything? Accuracy. Productivity. Quality. Paperlessness. Diagnosis? Cure? Improvement of Quality of Life until The End?
    Most entities dispense with that last 10%, out of necessity, and call it ‘good’. With health care it really is a bit more difficult. But. Just because we can, doesn’t mean we should. We’re none of us here forever.
    At least morphine’s cheap.

  2. Truer words were never written. There is too much technology in medicine. This has taken the place of actual healing and doctoring. Patients demand it and a compliant medical profession acquiesces. As a physician, I understand our reliance and infatuation with tech medicine. Why do we do it? Techno-medicine is easy. It obviates the need for lengthy office visits. It is an escape hatch away from thought and reflection. It offers litigation protection. And patients love it. How do I know all this? Because I have done it. Technology should be a tool used judiciously, not reflexively. See http://www.MDWhistleblower.blogspot.com

  3. rbar, there is something else, I think, that affects your graph. If you add a time dimension along a Z axis, then up to a point, the increasing comforts of civilization (sanitation, housing, leisure, etc. as Merrill lists above) are pushing the curve up.
    However, at least in the US, it is possible that we have reached the point where these comforts are excessive (too much food, too much processed food, too much leisure, too much automation, lack of physical activity…) and detrimental to both health and longevity, so the curve is now starting to head down.
    The extreme and expensive new measures are probably tempering the descent somewhat.
    I know “personal responsibility” is the standard answer to this, but I’m not quite sure that things are really as simple as that.

  4. I agree. I used to think, like most people, that the correlation between health care spending per person and benefit from HC is a steadily rising graph (with the x axis being money spent and the y axis “benefit of care”; the hypothetical “ideal health care at present” would be parallel to the x axis). And I thought that with rising investment, one comes closer to “ideal care” in an asymptotic fashion (getting closer and closer, but never reaching it).
    Well, initially, that is true: at the left part of the cost/benefit curve, we have some antibiotics for infectious diseases, basic surgery (appendectomies, wound care), insulin (like basic supply in 3rd world countries), and moving more to the right on the x axis, we have basic chemotherapy, subspecialty surgery, ICU care, and the benefit is still rising solidly (although not as much). But at some point – and here comes the difference, with higher costs, close to the max. benefit, the curve dissolves and becomes a punctuated spectrum of cost/benefit ratios, depending on where you get your care, and that’s exactly what one can observe in the US: if you have evidence based, considerate and conservative physicians (including, but not limited to, pretty much everyone at Mayo and probably other elite MSGs), you get some modest benefit from plasmapheresis, MR spectroscopy, gamma knife, top of the line chemo which pushes you closer to “ideal care”… but if you are with typical aggressive, inconsiderate docs who have lots of ressources, you will end up with unnecessary prodedures and prematurely die in the hospital from c. diff colitis, or from a fall at home because you are elderly and overmedicated (of course I am simplifying here).
    Rick, your link doesn’t work for me, but I’ll get the full text article of your great tip
    from my library tomorrow.

  5. Only when we bear a part of the cost for our feckless care will this come to an end.
    If the choice were bewtween comatose grandma on the ventilator for two months and no inheritance and hospice care with a modest inheritance, the dynamics of end of life care would be very different. Death panels would not be needed.

  6. Dr.Elliot Fisher from Dartmouth published a landmark article in 1999 in JAMA to which we should have paid much more attention. see http://vaoutcomes.org/papers/JAMA_1999.pdf.
    He was among the very first to dare to ask the basic question about “more possibly being worse” in US bio-medicine.
    We sure could use a large dose of hubris
    Dr. Rick Lippin

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