Making Medical Choices

...Callahan does not restrict himself to cancer research, or to the conflicting claims of cancer and AIDS investigators...

...Those who have lived a "natural life span"—defined by Callahan as somewhere between the early 70s and early 80s, dependi ng on the person—should be denied life-extending treatment if they are severely ill, Doctors should concentrate simply on relieving their suffering...

...Health care became concentrated in the medical profession and along with it, cancer research, funded primarily by the Federally supported National Cancer Institute (NCI...

...The upper-middle-class "alliance against cancer," with its optimistic faith that science can eradicate most or all medical ills, has waged its anti-cancer campaign since World War I. Centered in the American Cancer Society, it has educated the public to look out for the disease's warning signs and raised literally billions of dollars for research through government grants and private charitable contributions...

...The Dread Disease ends precisely at the moment when a new scourge, AIDS, has emerged to make its own case for a portion of the government's limited dollars—and with many more questions about America's war against cancer than answers...

...Twenty per cent of us will eventually be struck down by the illness...

...Hospitals and physicians are forever making choices about how to expend their time, energy and resources...

...He takes enormous pains to show that he is not being callous toward the elderly...

...There is, in any event, a better way to go about rationing than by setting rigid limits...

...Far from profiting from old age, many elderly people seem to have their lives preserved for too long, well beyond the point of continuing satisfaction and meaning...

...First, much of the risein the incidenceof cancer is due to our longer life expectancy...

...So long as the standing of physicians was unchallenged, the experts were free to decide how the research money should be spent...

...as many as one of three can expect to contract some form of it...

...Care should be rationed...

...Recognizing the potential for controversy, Callahan carefully hems in his proposal by calling for national health insurance, expanded research into chronic illnesses like Alzheimer's, and a broad discussion of medicine's current goals and the meaning of old age...

...It is hostile to science, suspicious of doctors and receptive to faith healers, fundamentalists and quacks...

...But muddling through has its virtues, especially when nobody can say how close we would be to a crisis if we assiduously cut costs or reallocated government spending...

...The "cancer counterculture" is more diverse, though essentially lower-class, poorly educated and traditionalist...

...Callahan's argument for a more coherent rationing mechanism is based on his sense of urgency, his belief that the nation must act quickly to avoid skyrocketing medical bills...

...The fastest growing age group in the country consists of the over-85s...

...It is the second leading killer in the United States, after heart ailments...

...More successful is the subplot of The Dread Disease, which traces the evolution of the national war against cancer to its present uncertain state...

...Yet rationing care should not seem shocking to us...

...Once the funding began to swell from a modest outlay in the 1930s to $1.3 billion in 1986, questions inevitably started to be raised, and today, with doctors under siege on several fronts, the policies of the NCI are being scrutinized as never before...

...Callahan would reply that such measures are merely stopgaps, and do not face up to the demographic inevitabilities...

...To support his contention that the conflict has been a "largely unchanging feature of America's experience with cancer between the 1880s and the 1980s," Patterson is obliged to bunch the 19th-century Bible-belters and charlatans with contemporary environmentalists and critics of the medical establishment, in effect joining premodernists and postmodernists in a jerrybuilt antiscience coalition...

...He is impatient with those who advocate the less radical course of cutting costs, even though an excellent case can be made for this strategy...

...More recently, evangelists like Oral Roberts have proclaimed cancer to be God's punishment for sin...

...Misinterpreted, Callahan can come across as a crank...

...Can anyone doubt which alternative the American people would elect if they were given the choice between regulating their inefficient and wasteful private health-care system or allowing over-80s to die because they had achieved their "natural life span...

...Those who can afford care, or the health insurance that buys the care, get it...

...But as disease after disease was conquered, new drugs and vaccines were developed, surgical techniques advanced, and life expectancy rose, the prestige of doctors climbed...

...Things are bad, Patterson indicates, but not as bad as the numbers may suggest...

...Indeed, voters might well opt for doing away with the space program or agricultural subsidies rather than sacrifice the additional years of life that modern technology might be able to give them...

...By the 1950s their status was higher than that of ministers or atomic scientists...

...ALLOCATION of resources, the most pressing issue confronting the alliance against cancer, is precisely the subject of Daniel Callahan's Setting Limits: Medical Goals in an Aging Society (Simon & Schuster, 256 pp., $18.95...

...Cancer's peculiarly invasive nature, he argues, terrifies the public out of proportion to its prevalence or impact, and thus he considers it a useful touchstone for examining certain social and cultural patterns in our history...

...In place of the Institute's narrowly focused cancer investigations, critics are calling for broader biological studies, for more attention to environmental causes, for a larger emphasis on prevention, and for additional cancer clinics for the poor...

...When Canada introduced its health plan in the early 1970s, it was spending the same proportion as the U.S...

...When the statistics are adjusted for age, they show only a small increase over half a century...

...Despite the current influence of fundamentalism, science and its technological offspring have surely come to dominate popular thought, almost totally displacing superstition and folk wisdom...

...He is concerned about the rapidly mounting costs of health care in general, and he locates the difficulty in the kind of treatment we provide to the elderly...

...Now that the consensus of the 1950s has been shattered, it is not even clear who the experts are anymore...

...Another form of rationing results from the decisions of individual doctors in individual situations...

...These matters will not be easily resolved...

...Money has always been an effective if utterly inequitable means of rationing...

...Patterson's construction is useful, yet too schematic, too pat, for the opposing camps he describes can hardly be said to be battling on equal terms...

...A decade later, it had fallen closer to the British level...

...In the 19th century, when medicine was primitive and hospitals positively dangerous, cancer victims were compelled to choose from a chaos of remedies, and there was little more reason to select an accredited physician than the man with the live frogs...

...The primary objection to be made against Setting Limits is not to rationing per se, but to Callahan's attempt to formalize something that is best kept loose, decentralized, discretionary, and discreet...

...What is more, even that increase can be explained by the second important fact, the effect of smoking on cancer rates...

...The United States, the only major industrial country without a national health insurance system, spends an outlandish percentage of its GNP on health care, more than one-third again as much as Great Britain...

...A considerable virtue of James T. Patterson's The Dread Disease: Cancer and Modern American Culture (Harvard, 380 pp., $25.95) is the cool-headed perspective the book lends to these disturbing figures...

...We have, after all, been doing it since the birth of modern medicine...

...As Callahan observes, the evidence suggests that "in the case of about one in every six elderly patients on renal dialysis, treatment is deliberately stopped and death ensues...

...In 1985, about 125,000 Americans died from tobacco-related malignancies...

...A few experts predict it will become number one by the turn of the century...

...Others pursue lives that are potentially nasty, brutish and short...

...But Setting Limits is a serious work that tries to face some ugly problems hard-headedly...

...There is a great deal for the counterculture to be receptive to, because quacks have been peddling their nostrums to the desperate and the ignorant probably since the day Hippocrates noticed a growth's resemblance to a crab and gave the disease its name...

...After age and tobacco use are taken into account, mortality rates from cancer show an actual drop since the 1930s...

...He notes that those over 65, representing 11 per cent of the population, account for 31 per cent of total medical expenditures, and that those percentages will climb higher as life expectancy continues to be extended...

...Not so long ago, sufferers were advised to apply live frogs to their tumors, to inject vinegar into their bodies, to avoid toilet seats because they produced "autointoxication" of the bowels...

...Patterson perceives a long-standing struggle between two groups...

...If the malady is today the most dreaded in the country, Patterson remarks, the reasons for that fear are not wholly rational...

...Restricting what doctors and hospitals can charge for their services could produce a degree of rationing based on need, not age, an extension of the in formal arrangement that already exists...

...Although ploddingly written, it deserves a wide audience...

...We are confronted, Callahan says, with a "demographic, economic and medical avalanche," and he advises changing our medical system to establish limits based on age...

...Not everyone, however, who has doubts about the efficacy of technology and what is commonly called "progress" is a prospective faith healer...

...Two facts significantly alter the grim picture...