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Review: Death Takes No Holiday By Daniel Sarewitz
A revised version of this review appears in the Journal of Health Politics, Policy, and Law, Volume 25, No. 5, October 2000, 988-991.
Amidst the rancor of Congressional debate over the federal budget, one government agency appears immune from political or fiscal attack: the National Institutes of Health (NIH). Even as Congress insisted on a small but symbolic across-the-board reduction in government spending for FY 2000, it bestowed, for the second straight year, a fourteen percent increase on NIH, bringing the agency's total budget to almost $18 billion -- about half of the government's entire civilian research expenditure. NIH's almost totemic status in Congress is of course wonderful news for biomedical researchers, for the biomedical industry which depends on federal research for continued innovation, and for those who hold stock in biotechnology corporations. But what does it mean, exactly, for the health of the Nation? The links between biomedical research and public health are of course complex. One might reasonably posit that the results of biomedical research are applied through the health care system to create a healthier, longer-lived population. Careful studies of the determinants of public health, however, fail to reveal such clear connections. (The best introductory discussions to these issues are found in Evans, Barer, and Marmor, 1994). Indeed, historical and individual country studies invariably demonstrate that the health of a population increases more or less in concert with socioeconomic development, and that within any given society the prime determinant of health is relative social status. These trends are more-or-less independent of the state of scientific knowledge. Members of Congress, biomedical researchers, and others may believe that an ever-increasing NIH budget will cause continual increases in the Nation's health, but the evidence to support such an argument is scant. On the other hand, there is no denying that modern, high-technology medicine often yields remarkable results at the level of the individual patient, especially at the margins of life -- saving premature or unhealthy babies, and prolonging the lives of the elderly. These successes, by-and-large, may not translate into statistically impressive changes at the population level, but they do create powerful political support. We're all going to die, we'd all like to postpone it as long as possible, and we're all inclined to support research aimed at the diseases from which affluent people tend to succumb. At the same time, advances in laboratory technology -- especially in the area of molecular genetics -- fuel an ever expanding frontier of scientific research that attracts some of our best minds, and promises, even if it has not yet delivered, astonishing breakthroughs in the treatment of cancer and other diseases of modernity. NIH's enviable position raises some troubling questions. Knowledge and technical innovation have advanced in parallel with increasing costs of health care, and with increasing disparities and inequities in our competitive, market-oriented delivery system. In False Hopes , Daniel Callahan, a medical ethicist and careful, long-time observer of the health care scene, argues that these trends are unsustainable. By borrowing the concept of sustainability from public discourse on environment protection, Callahan seeks to highlight the tension between today's choices and tomorrow's outcomes, a tension which demands that we "recognize the real biological, economic, and social limits of medical progress while meeting real, still-unmet health care needs." (p. 123) Central to this tension is the difference between individual- and population-based approaches to health care. In a democracy -- perhaps especially the American version -- the case for the individual approach is more easily sold, and more compatible with the zeitgeist of modern science as well. Callahan is resolute and absolutely fearless in highlighting the dilemmas that we would need to publicly confront were we to move towards a less individualistic health care system. For example, he suggests that a sustainable health care system will need to curtail "efforts to improve outcomes for low-birthweight babies," (p. 136) and that "it will feel no compulsion to rid the world of infertility [and] even less obligation to use genetic or other techniques to give couples the kind of children they want." (p. 254) Try telling that to aging baby-boomers! Of course, the real bugbear is the grim reaper herself. Extending lifespan is the ultimate motivator of both biomedical research and an individualistic health care system, and Callahan confronts this fact with disarming directness. "The present average life expectancy in the developed countries has proved perfectly adequate for most people to live a full life . . . I have heard no claims that an average life expectancy that moved from the low to the mid-eighties, much less higher, would lead to . . . a generally higher standard of collective happiness and sense of well-being. While a decently long life can no doubt contribute to those goods, more life beyond a certain point seems to offer no proportionate gains." (pp. 133-4) Callahan's overriding point is that a sustainable health care system will accept the idea of a natural lifespan and work to improve health within that lifespan, not to continually expand its limits. Much as I agree with it, this is a pretty tough argument upon which to base a reform movement -- especially if, as Robert Pollack argues in The Missing Moment , the human inability to understand and accept death acts as an overbearing but invisible stimulus on the biomedical research agenda. The structure of Pollack's argument seems absolutely original to me. Pollack is a molecular biologist, and his book starts out in the familiar style of a good scientific popularization. His putative subject is the biophysical basis for unconscious thought -- and his presentation is fresh and lucid -- but he has a particular fish to fry here. Scientists, as human beings, can never escape their own unconscious motives, and such motives are therefore and unavoidably prime determinants of the biomedical research agenda and health care delivery system. Science and medicine, Pollack suggests, "are too strongly motivated by an irrational, unconscious need to cure death to be fully motivated by the lesser task of preventing and curing disease simply to put off the inevitable end of their patients' lives and, by extension, their own." (p. 80) Both Pollack and Callahan are arguing that our approach to biomedical science and modern health aims at overcoming nature itself, since death, as the organic manifestation of the third law of thermodynamics, is perhaps the central reality of nature. This ultimately futile goal underlies both the strategies and tactics of modern biomedical research and health care. For example, Pollack lays the increasing failure of antibiotics squarely at the feet of our misbegotten, perhaps even tragic, desire to overcome nature. "Antibiotic resistance is not merely a flaw in the initial strategy of total war against the body's invaders. It reveals that this strategy is based on a willful misunderstanding -- a denial -- of the data . . . . the agenda for basic research on infectious diseases is still heavily invested in the dream of beating microbial enemies into total submission, as if they were small nations subject to our rules of military engagement." (p. 101) The consequences of this approach?: infectious diseases -- tuberculosis and malaria especially -- are on the upswing. Similarly, with cancer: "The unconscious fantasy that motivates much of today's cancer research is plainly visible in any country's budget for cancer research. Prevention is hardly mentioned. Instead, genes associated with higher risk are sought, on the premise that one day the information will provide better drugs to kill every last cell of the tumor that will inevitably arise." (p. 111) Whereas Callahan outlines an agenda for achieving a sustainable health care system, addressing such issues as rationing and the appropriate balance between market-oriented and government-managed delivery systems, Pollack focuses on the underlying science. In an appendix that must surely have been removed from the body of the text -- where it belongs -- by an editor who considered it too technical for the average reader, Pollack makes some concrete and sensible suggestions for redirecting the biomedical research agenda in light of the unavoidable realities of nature, and argues that such an agenda would go a long way toward addressing the goal that both he and Callahan promote: improving the quality, rather than the length, of our journey. While both books make a similar diagnosis, Pollack's treatment may have a better chance of working than Callahan's. It is hard to imagine today's society supporting the change from individualistic to population-based health care priorities that is central to Callahan's notion of sustainability. Pollack's program, on the other hand, requires only a change in the way that biomedical research dollars are allocated. If NIH's budget continues to rise, then there will be continuing opportunities to effect the appropriate evolution in research priorities. Both authors assume that the changes they advocate will lead to better and more direct linkages between biomedical research, health care delivery, and public health outcomes. We cannot know if they are correct, but it is critically important that we find out. References Evans, Robert G., Morris L. Barer, and Theodore R. Marmor, eds., 1994. Why are Some People Healthy and Others Not? The Determinants of Health of Populations. New York: Aldine De Gruyter.
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