The very best’ medicine is at stake worldwide
Panel recommends drastic shift in priorities
Twentieth century medicine is simply the best the world has ever experienced or is it? An international panel of world health experts brought together by the Hastings Center recently concluded not only that medicine is in a state of crisis worldwide, but that hospital administrators, physicians, and public officials must shift the current priorities in today’s medicine in a drastic fashion.
Although some infectious diseases have been eradicated, genetic anomalies have been detected in utero, and people with disabilities have been rehabilitated, "the primary values of medicine itself are at stake," says Daniel Callahan, Hastings Center founder and now director of the new international programs at the bioethics think tank in Briarcliff Manor, NY.
Callahan says he convened the international panel of experts representing four continents "after realizing that every country in this world is having a health care crisis, regardless of the country’s finances." Fiscal and organizational reforms are not the answer to health care system problem, he contends.
"The emphasis is on the means, not the ends," Callahan laments. From a bioethics perspective, "The dilemmas always revolve around achieving goals that the medical establishment have created."
Callahan contends that hospital ethics committees spend a great deal of time discussing end-of-life problems and conflicts that arise between the medical professional(s) and the patient or family. What they should focus on more intently, he says, is answering the more empirical questions: "What is good for human beings?" and "What should be the purpose and direction of medicine?"
The international panel says priorities in medicine must shift "away from highly technical solutions aimed at curing disease to public health strategies intended to prevent disease and to focus on caring for people’s physical and emotional well-being when cure is not possible."
People in the 20th and 21st centuries have lived and will live longer than their ancestors, but Callahan and others insist that the quality of these lives is often not better at all. "People are living longer lives but are they healthier?" Callahan asks. "More and more people are not dead but they are disabled and have three and four chronic conditions and are forced to live in nursing homes," he says.
Too much at risk?
Will the Hastings Center work have an impact on American medicine? "Not until we hit rock-bottom and realize what a mess we are in," says Philip Boyle, PhD, senior vice president and editor in chief at the Park Ridge Center, a Chicago-based bioethics group.
As a former Hastings Center fellow, Boyle worked with several health care groups on setting priorities for health care and says it was nearly impossible to do. The best hope for change, he maintains, is among religious hospitals that do strategic planning around their mission goals. "The closest we come otherwise is in technology assessment committees that review purchases of major technology. But even these committees work from a finance and market-driven perspective," he laments.
The panel’s report states, "The language of reform is ordinarily dominated by discussions of the role of the market, privatization, incentives and disincentives, cost control and cost-benefit analysis. . . ." Boyle contends this is the pervasive problem. "Goals that attend to real health needs of people don’t fit in well with a society that treats health care in a market capacity," he says.
Instead of focusing on financial and market objectives, the panel urges health care professionals to champion these four goals:
1. Prevention of disease and injury and promotion and maintenance of health. Physicians should help their patients remain healthy and address the dangers posed by tobacco, alcohol, drugs, and other lifestyle hazards. Community needs should take priority over the needs of comparatively few individuals.
2. Relief of pain and suffering caused by maladies. Contemporary medicine has an inadequate understanding of pain relief and little understanding of how to address the psychological and spiritual suffering that can accompany illness. The field of medicine has the responsibility to educate its practitioners in the relief of pain, and in "the limits to which medicine can go in providing relief of suffering that requires a philosophical or spiritual response."
3. Care and cure of those with a malady and care of those who cannot be cured. The effort required to seek cures for all diseases is often at the expense of improvement in the quality of life and reduces the general health of the public. Chronic illness is an increasingly common phenomenon, caused in part by technological advances that keep people alive in very poor health.
4. Avoidance of premature death and pursuit of a peaceful death for all. Care of the dying should be seen as having the same importance as care of those who will go on living.
Callahan hopes that bioethicists and other health care professionals will place a strong emphasis on palliative medicine, relieving patient pain and suffering, disease prevention, and maintaining healthy behavior in the future. "If we could get people on ethics committees talking about these kinds of priorities it would be a triumph," he says.
Instead of having your next committee discussion about how to increase Medicare reimbursements or ethical allocation of resources, talk about what is appropriate care for your elderly patients, he says. Instead of talking about whether a patient should be enrolled in a clinical research trial, discuss the value of the goals of the research itself. "This is where the discussion must begin," he explains.
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