Restraining the Unsustainable

Medical care the world over stands on the brink of a huge expansion of investment in health care in two possible directions: either need-driven coordinated expansion of labor-intensive continuing care and health maintenance for whole populations… or profit-driven independent expansion of capital-intensive technical repair, as an ultimately false alternative to continuing care, directed at profitable sub-groups in the population. —Julian Tudor Hart1 Several years ago, Daniel Callahan (Director of the Hastings Center, founded in 1969 for the study of value and the sciences) examined the implications of a frequently noted observation: “No matter how much money is spent, and no matter what the health gains, they never seem enough.”2 This worrisome image of insatiable demands led him to ask some fundamental questions about the “appropriate goals of medicine.” Callahan2 was interested to see similar issues in debates about the environment, and he concluded there is a “need for a view of medicine that would be at once equitable and sustainable.” Despite all of its excitement, he opined, modern medicine has become “increasingly and painfully unaffordable.” “Just as we need a sustainable environment, we need a sustainable medicine.” Conservationists have argued that nature must be protected to serve human needs. With wise management of natural resources, according to this line of reasoning, there is no reason to expect that these assets will …