Questioning America's obsession with open-ended medical progress that neglects other necessities of health and life, the author examines the relation between proper medical goals and reasonable health care.

In Setting Limits, Daniel Callahan advances the provocative thesis that age be a limiting factor in decisions to allocate certain kinds of health services to the elderly. However, when one looks at available data, one discovers that there are many more elderly women than there are elderly men, and these older women are poorer, more apt to live alone, and less likely to have informal social and personal supports than their male counterparts. Older women, therefore, will make the heaviest demand (...) on health care resources. If age were to become a limiting factor, as Dr. Callahan suggests it should, the limits that will be set are limits that will affect women more drastically than they affect men. This review essay examines the implications of Callahan's thesis for elderly women. (shrink)

Resistance to rationing health care to the elderly is enormous. This article lays out the need for rationing, based on projections of Medicare expenditure in the near future, and the judgment of policy experts that there will be no technological breakthrough that might lower costs. Various forms of rationing possibilities are discussed as well as cultural and political obstacles to needed reform. Some general principles for thinking about health care for the elderly are presented.

Debates over health care have focused for so long on economics that the proper goals for medicine seem to be taken for granted; yet problems in health care stem as much from a lack of agreement about the goals and priorities of medicine as from the way systems function. This book asks basic questions about the purposes and ends of medicine and shows that the answers have practical implications for future health care delivery, medical research, and the education of medical (...) students. The Hastings Center coordinated teams of physicians, nurses, public health experts, philosophers, theologians, politicians, health care administrators, social workers, and lawyers in fourteen countries to explore these issues. In this volume, they articulate four basic goals of medicine — prevention of disease, relief of suffering, care of the ill, and avoidance of premature death — and examine them in light of the cultural, political, and economic pressures under which medicine functions. In reporting these findings, the contributors touch on a wide range of diverse issues such as genetic technology, Chinese medicine, care of the elderly, and prevention and public health. The Goals of Medicine clearly demonstrates the importance of clarifying the purposes of medicine before attempting to change the economic and organizational systems. It warns that without such examination, any reform efforts may be fruitless. (shrink)

Much has been written about medicine and the market in recent years. This book is the first to include an assessment of market influence in both developed and developing countries, and among the very few that have tried to evaluate the actual health and economic impact of market theory and practices in a wide range of national settings. Tracing the path that market practices have taken from Adam Smith in the eighteenth century into twenty-first-century health care, Daniel Callahan and Angela (...) A. Wasunna add a fresh dimension: they compare the different approaches taken in the market debate by health care economists, conservative market advocates, and liberal supporters of single-payer or government-regulated systems. In addition to laying out the market-versus-government struggle around the world -- from Canada and the United States to Western Europe, Latin America, and many African and Asian countries -- they assess the leading market practices, such as competition, physician incentives, and co-payments, for their economic and health efficacy to determine whether they work as advertised. This timely and necessary book engages new dimensions of a development that has urgent consequences for the delivery of health care worldwide. (shrink)

American bioethics began in the late 1960s, stimulated by a plethora of new medical technologies and biological knowledge and by a scandal-induced interest in human subject research. Although it was understood that there would be ethical debate , no one thought the disputes would be ideological in character, as if part of one's voting pattern as liberal or conservative, Democrat or Republican. There were arguments, often sharp, but no culture wars.

For well over 20 years I have been arguing that someday we will have to ration health care for the elderly. I got started in the mid-1980s when I served on an Office of Technology Assessment panel to assess the likely impact on elderly health care costs of emergent, increasingly expensive medical technologies. They would, the panel concluded, raise some serious problems for the future of Medicare. The panel did not take up what might be done about those costs, but (...) I decided to think about that question and wrote a book called, Setting Limits: Medical Goals in an Aging Society. (shrink)

The social sciences playa variety of multifaceted roles in the policymaking process. So varied are these roles, indeed, that it is futile to talk in the singular about the use of social science in policymaking, as if there were one constant relationship between two fixed and stable entities. Instead, to address this issue sensibly one must talk in the plural about uses of dif ferent modes of social scientific inquiry for different kinds of policies under various circumstances. In some cases, (...) the influence of social scientific research is direct and tangible, and the connection between the find ings and the policy is easy to see. In other cases, perhaps most, its influence is indirect-one small piece in a larger mosaic of politics, bargaining, and compromise. Occasionally the findings of social scientific studies are explicitly drawn upon by policymakers in the formation, implementation, or evaluation of particular policies. More often, the categories and theoretical models of social science provide a general background orientation within which policymakers concep tualize problems and frame policy options. At times, the in fluence of social scientific work is cognitive and informational in nature; in other instances, policymakers use social science primarily for symbolic and political purposes in order to le gitimate preestablished goals and strategies. Nonetheless, amid this diversity and variety, troubling general questions persistently arise. (shrink)

Much has been written about medicine and the market in recent years. This book is the first to include an assessment of market influence in both developed and developing countries, and among the very few that have tried to evaluate the actual health and economic impact of market theory and practices in a wide range of national settings. Tracing the path that market practices have taken from Adam Smith in the eighteenth century into twenty-first-century health care, Daniel Callahan and Angela (...) A. Wasunna add a fresh dimension: they compare the different approaches taken in the market debate by health care economists, conservative market advocates, and liberal supporters of single-payer or government-regulated systems. In addition to laying out the market-versus-government struggle around the world -- from Canada and the United States to Western Europe, Latin America, and many African and Asian countries -- they assess the leading market practices, such as competition, physician incentives, and co-payments, for their economic and health efficacy to determine whether they work as advertised. This timely and necessary book engages new dimensions of a development that has urgent consequences for the delivery of health care worldwide. (shrink)

Humans have long been troubled by the prospect of old age and its culmination in death. Whether to rebel against or accept this fate have been wrestled with down through the centuries. But new medical technologies and the growing science of aging have sided with rebellion. We know that aging can be pushed back and improved in its quality. That progress is well under way, but now intensified by many scientists and Silicon Valley entrepreneurs. In 2016, Mark Zuckerberg and Priscilla (...) Chan pledged three billion dollars toward eventually “preventing, curing or managing all diseases.” And some visionaries have made the elimination of death or its indefinite postponement a goal. To put those aspirations in a broader context, it is helpful to keep in mind where population growth and aging trends stand. Apart from any success in the explicit efforts to increase longevity, there will be a steady increase in the number of elderly worldwide—and a much higher percentage of the elderly as part of the overall population. Most of the largest changes will be in developing countries. They will be overburdened by the death of the elderly from expensive chronic diseases—already a vexing problem for affluent countries. (shrink)

The field of medical rehabilitation is relatively new.... Until recently, the ethical problems of this new field were neglected. There seemed to be more pressing concerns as rehabilitation medicine struggled to establish itself, sometimes in the face of considerable skepticism or hostility. There also seemed no pressing moral questions of the kind and intensity to be encountered, say, in high-technology acute care medicine or genetic engineering.... Those in biomedical ethics could and did easily overlook the quiet, less obtrusive issues of (...) rehabilitation.... The Hastings Center set out in 1985 to rectify that situation.... To explore the issues, the Center assembled a group of practitioners in the field, Hastings Center staff members, and individuals experienced in other areas of medical ethics.... The report that follows was written by Arthur Caplan and Daniel Callahan, assisted by Dr. Janet Haas of the Moss Rehabilitation Hospital in Philadelphia... (shrink)

A confession is in order. As did almost everyone else of a certain persuasion, I recoiled when Sarah Palin invoked the notion of a "death panel" to characterize reform efforts to improve end-of-life counseling. That was wrong and unfair. But I was left uneasy by her phrase. Had I not been one of a handful of bioethicists over the years who had pushed to bring the need for rationing of health care to public attention and proposed ways to carry it (...) out? And was not a common thread running through the latter efforts the likely necessity of some kind of committee or other public mechanism to make the hard decisions? Were we not in other words talking about a "death panel," even if none of us has been so imprudent to .. (shrink)

The Hastings Center was founded in 1969 to study ethical problems in medicine and biology. The Center arose from a confluence of three social currents: the increased public scrutiny of medicine and its practices, the concern about the moral problems being generated by technological developments, and the desire of one of its founders (Callahan) to make use of his philosophical training in a more applied way. The early years of the Center were devoted to raising money, developing an early agenda (...) of issues, and identifying a cadre of people around the country interested in the issues. Various stresses and strains in the Center and the field are identified, and some final reflections are offered on the nature and value of the contributions made by bioethics as an academic field. (shrink)

The possibility of human cloning first surfaced in the 1960s, stimulated by the report that a salamander had been cloned. James D. Watson and Joshua Lederberg, distinguished Nobel laureates, speculated that the cloning of human beings might one day be within reach; it was only a matter of time. Bioethics was still at that point in its infancybioethicsand cloning immediately caught the eye of a number of those beginning to write in the field. They included Paul Ramsey, Hans Jonas, and (...) Leon Kass. Cloning became one of the symbolic issues of what was, at that time, called a biology that would be dominated by molecular genetics. Over a period of five years or so in the early 1970s a number of articles and book chapters on the ethical issues appeared, discussing cloning in its own right and cloning as a token of the radical genetic possibilities. (shrink)

This paper looks at the future from the perspective of the way in which present thinking can influence what the future might be. It assumes that history shapes the future and that the present generation is in a position to shape it. It looks at the future of medicine as a science and a professional discipline, of health care as policy and politics, of culture and ideology as forces shaping medicine and health care, and of biomedical ethics as an influential (...) source of wisdom and perspective. The paper argues that a strong future for bioethics requires a broad rather than a reductionistic vision of its proper work. (shrink)