 Thank you, Tim. I thought I was here to introduce somebody, not be so nicely introduced, but thank you nonetheless. When I was thinking about how to introduce our next speaker, my mind was actually drawn back to last year's Nobel conference. For those of you that were here, you might recall that the topic of last year's conference was Einstein's legacy. Einstein was a brilliant individual, certainly a man way ahead of his time in his thinking, but legend has it that when he was asked many years after his greatest accomplishments, if there was anything that he regretted that he hadn't done, if there was anything he thought was a personal weakness of his, he thought for a minute and he said, I wish I better knew the right questions to ask, if only I knew the right questions to ask. Well, our next speaker, Dr. Daniel Callahan, has gained a worldwide recognition for helping us recognize and face the right questions when it comes to medical care and its access throughout the world. He's asked questions such as, do our research efforts lead to better health care for all or only some? Are our current efforts achieving our societal responsibilities? Dr. Callahan has been recognized by many as almost single-handedly starting the bioethics movement in this country. He's also been recognized as one of our nation's most treasured rabble rosers in one article that I read. I asked Dr. Callahan how he got into the area of ethics and he stated that he was doing his PhD in philosophy, which he received in 1965, and he had an interest, of course, in ethics and things that were going on around the world at that time. And if you think back to what was happening in 1965 in the United States, it was an era of limited dialysis for patients, committees deciding who lived and who died. The first human transplants had just taken place. The idea of transplanting a tissue from one human to another was really kind of a foreign concept back then. Abortion was just beginning to become a national issue and, of course, birth control was a major issue at that time. And Dr. Callahan recognized those and said, somebody has to talk about those things. Somebody has to bring these things to the attention of the United States. Give people thinking about the important questions so we can move forward in the best possible manner. So Dr. Callahan founded the Hastings Center, which was a research and educational organization that was established in 1969, for which he was the president for the next 27 years until 1996. Since that time, he's been the director of international programs where he works with colleagues around the world, focusing much of his attention on the practice of health care systems and issues of equity and health care costs. In addition to his work at the Hastings Center, he is a senior fellow at Yale University as well as the Harvard Medical School. He's also an honorary faculty member of the Charles University Medical School in Prague, Czech Republic. He's an elected member of the Institute of Medicine of the National Academy of Sciences, which I know personally is a very, very prestigious organization. In 1996, he was awarded the Freedom and Scientific Responsibility Award of the American Association for the Advancement of Sciences. He's also received many other awards. He has authored 39 books, his most recent book, which is not listed in the program, has been published in 2006, and it's entitled Medicine and the Market, Equity versus Choice. He's also a contributor to many professional journals such as the New England Journal of Medicine, the Journal of the American Medical Association, and The Atlantic. Today, Dr. Callahan will be talking to us about affordable health care, reforming the idea of medical progress. Please join me in welcoming Dr. Daniel Callahan. Thank you very much. It's an extreme pleasure to be here. It's intimidating, however, to follow two fine speakers who graduated from Lutheran schools, a privilege I did not have, and it's intimidating indeed. I should apologize right off for the fact that I am a philosopher. We are the last of the talking heads, and I show no pictures, cartoons, graphs, numbers, only ideas. Thirdly, it's very difficult to follow Dr. Osterholm, who was obviously a very moving and dynamic speaker, and of course, a very speaker who sobered us and made us worry considerably. Happily, my subject is American health care, which is a much easier, more pleasant subject to deal with. So I at least have that in my favor. I will maybe mention a few problems in our health care system. Okay, I basically have four things I'd like to accomplish here. First of all, I want to argue that there's an inherent tension now between the ideals of equitable access to health care and the pursuit of unending medical progress. Second, I want to lay out and discuss the main attitudes and ways in which the control of cost has been pursued, because the problem of cost is one of our fundamental threats as well to equitable access. Thirdly, to analyze the problem of medical progress and technological innovation, an attempt to show that we need a fresh understanding of progress and of the control of aging and death. And I think in my final, most important name perhaps, is to ask the question, how can we achieve a medical culture, once I might say more broadly, a health care culture in this country, that is sustainable, affordable, and accessible? And I'll explain more toward the end what I mean by that. Let me begin just with a very rapid summary of where we are with health care in America. I will talk mainly about the problems, but let's recall that probably most people in this audience are well insured. They get adequate and decent health care, and certainly in Minnesota, you get very good health care. 85% of us are reasonably well insured, whether through our employer or through institutions of one kind or another. And in many ways, our technology, our institutions are among the very best in the world. So we have a lot to be proud of and thankful for. However, we do face some enormous problems. Very quickly, we have some 46 million people who are uninsured. 50% of personal bankruptcies in this country are because of medical debts. We have rising co-payments and deductibles, and certainly those of you on Medicare have noticed that, as well as those of you who have company employment. Medicaid is a problem in just about every state with cuts in benefits in every direction. We spend more of our gross domestic product on health care and more per capita than any other country in the world, but we are by no means among the leaders in the quality of our health care. We see right now a cost increase that averages around between 7% and 8% a year, which is down a bit from the 10% or 12% it had been a few years ago, but still dangerously high. Europe, by contrast, has a health cost increase in the range of 3% to 4%. And of course, we are all facing the future of Medicare with the estimates that beginning in about 18 years that that program is going to be running into a significant deficit, and as the baby bloom retires, that deficit is going to get worse and worse. So, we clearly have problems. I don't think anyone can say the system is getting any better. Indeed, there are signs of deterioration in all directions. Now, why do we have these cost increases? That to me is a problem that I found fascinating from the beginning. There are lots of theories about it. One thing obvious is that we charge much higher price for medical goods and services than other countries, but beyond that, there are some other fundamental reasons as well. One reason is that we have an aging society, though interestingly enough, the impact of aging has not been that significant in our health care. Maybe somewhere between 3% and 4% a year of cost increase can be traced back to the aging, though as we move more deeply into the baby bloom retirement era, that figure of proportion is expected to increase quite radically. Secondly, our medical technology, which is what I'm going to heavily concentrate on, is a primary driver of health care costs. The estimate, pretty agreed upon by most health care economists, would be that somewhere between 40% to 50% of our cost increase each year can be traced to either new technology or intensified use of old technologies. Finally, and what's kind of fascinating phenomenon, I believe, is we really do have rising demands and expectations for health care. As our health has improved in this country, we keep raising the bar. Whatever we have is never quite good enough. People are constantly disappointed in their health and what they get from the health care system. And interestingly, a study about 15 years ago found that when asked a question similar to one asked 40 years ago whether people felt they were in better or worse health, by and large they tended to report they felt now in worse health than people 40 years ago did, though in fact objectively they were in better health. So you have the peculiar paradox of actually doing better but feeling worse a phrase some will remember from the 1970s in health care. But to be one of perhaps the greatest paradoxes is this. The healthier we've become, the more we spend on health care. We have increased longevity. We have a decrease of mortality rates from just about every major disease. People who are in older age now have a decreased disability rate compared with previous years. Nonetheless, as we get better we spend more. I sometimes think that maybe 150 years from now we'll have one final person suffering from some rare form of cancer. It will cost $3 billion. Everybody would say how it rages if we don't spend the money to save that person. That's a kind of future fantasy but the notion that as we do better we spend more. One has to ask, well where in the world is that kind of thing in? Now, let me say something about the idea of attention between medical progress and equitable care. I think it fair to say that we have in this country long at least admired the idea and usually pursued it of equitable access to good health care and indeed to an equitable society. Unfortunately, we have not achieved that. We have seen that over a half century of efforts have universal health care all of which have failed. But nonetheless people don't like the fact that they're uninsured in this country. Most people when polled on surveys for a long period of time have said that they would like universal health care by a very strong majority and we do see the scandal in the fact that there are so many people who have either no insurance or poor insurance. The problem is we have created a form of medicine I believe which is undermining the equity. If it's really the case that technological force is one of the driving forces cost to increase and at the same time our health care system is deteriorating in its coverage and one has to say why is that happening and I would want to say because we are so enamored with technology we pursue it, we want it, we spend lots of money on it, doctors love it, patients love it, the medical and drug technology industry really loves it and investors love it. And I suppose most fundamentally of all this country has from the beginning been a country that loves scientific progress, loves innovation, it's been one of the drivers of our economic power and growth over the centuries and it is certainly on display here. The problem however is that that very technology makes it harder and harder to run our health care system and the question is what do we do about that. Now over the years there have been a number of ways of trying to control costs and I want to distinguish two ways. At one level there's what I call the managerial or an organizational method. That is to say the faith that the belief that if we better organize our system, if we better find ways to manage the whole thing, to reorganize it if necessary, that we ought to be smart enough to deal with the rising cost problem and to control it. And again I think this as our level of technology is the basic kind of American belief that good management can get us out of any tight corner and that's very strong here. And the second level is what I call the ideological level and that's the long standing argument between whether our health care system should be heavily run or dominated by the government or heavily left to the private sector. Now let me say a little bit first about the managerial techniques. Anyone who pays any attention to health care knows that there are now a plethora of suggestions out there as to how to control our costs. First of all beginning some time ago we're really back to the Nixon era health maintenance organizations were thought to be one important panacea to have organized systems of care that could manage their budgets much more effectively than our present system. That worked for a while during the mid-1990s. Our health care cost in fact plateaued for a while. But it turns out the American people were unhappy with managed care in those days for a couple of reasons first of all that had interfered with their choice of health care very often. Sometimes their employers forced a particular company on them and they were simply forced to take it. But also that the standard technique was to have someone who your internist, your primary care physician who screens you before allowing you to go to a specialist. There was a lot of complaint about that. Physicians tended to complain very bitterly abetted as well that it was basically interfering with good health care that in fact bureaucrats and business types were indeed calling the shots on the health care and they thought that totally unacceptable. The net result that managed care gradually capitulated to these public pressures and a lot of the controls that actually work in controlling costs were taken away. More recently we've heard a great deal about evidence-based medicine. It's widely known that probably the majority of major medical treatments in this country have not been properly evaluated and there's been a call to do so and efforts have been underway for some time to do that. This obviously makes sense, finding out what really works and what does not work. And the problem is that has I think has been interesting and maybe found out some things but evidence-based medicine is a kind of double-sided coin in the sense it may tell us what's not working and what's wasteful but it may also tell us where we need to spend more money. It was evidence-based medicine that turned up the fact that probably only 50% of people who need hypertension medicine actually get it or cholesterol control medicine actually get it. We need to spend more money and in great part that's the result of trying to look at the evidence. Nonetheless we'll continue pursuing it and it's obviously a good idea but it may have some ironic outcomes. Secondly of course, one thing that happens with evidence-based medicine very often is you don't get just a you don't just find that something is terrific or lousy. What you get is something that's sort of good some of the time for some of the people, 20% of the time it works wonderfully, the other 80% of the time it doesn't work and then you have to make very difficult ethical and economic decisions about well just what is good enough? If you can save a life but the chance is 1 in 100 is that worth spending money on? So evidence-based medicine does not by any means solve the economic and ethical problems even if you have the evidence. Certainly there have been efforts recently to find what's called to inline, align physician behavior, physician activities and the quality of care to find ways financially or otherwise to resort to reward physicians who provide good care. There has been certainly an investment in quality improvement research and in improving the efficiency of healthcare systems. Information technology is a favorite for the past year or so. The idea that if we could all become properly wired, get ourselves computerized coast to coast we would be able to provide a better care. And finally of course, there's the use of copayments and deductibles which as I mentioned before have gone up and that's been a fairly effective means actually used around the world to control costs to some extent. The difficulty there though is if you make the copayments and deductibles too high you begin discouraging people from getting health care they should receive so it's a somewhat blunt instrument to use for controlling costs. Now I mention all of this because we have been trying to find more efficient ways of organizing a health care system since the Nixon years. It was really beginning with the Nixon administration that the question of cost began to arise in a very direct fashion and a lot of efforts were undertaken pursued by Jimmy Carter thereafter and every subsequent president. The problem is that despite all the efforts on the part of health policy experts, administrators, we have not succeeded. We have a decades of failure and we now have a 7% cost inflation rate a year and sometimes we used to hear the term the magic of compound interest. Well a 7% a year this is the horror of compound interest. Projects figures that are just out of sight. Excuse me, let me get a little water here. The second major argument in this regard has been the tension between a government dominated or controlled health care system versus one that is much more market oriented. Now let me try to summarize. The George Bush administration has been very strong on the private sector taking over but putting a lot of market things in the new drug plan and by and large the Republicans in this country would like to see less government, more private health care. Now let me, it's very difficult to kind of summarize all the arguments, but I think the essence of those who favor the market, who favor the private sector is really comes down to two rather simple propositions. First of all that people and patients should have expanded choice. Choice is their favorite value and it is the value they think should be the dominant value in the health care systems. And of course the medical savings accounts which have been pushed by the Bush administration are meant to implement that belief in choice. Secondly expanded provider competition. That is to say if you want to meaningfully give patients a choice you have to give them something to actually choose among. So therefore you would like to have a wide number of health care providers offering services in a competitive way so that we are free to choose which one we would like because either of the price or the quality of their services or both together. There's also a strong view that choice will make consumers more conscious of costs and not in one way it frees them to make more choices they want to make but it also forces them to be more conscious of choice that therefore that will help to control costs. And finally as part of that view is a very general long-standing antipathy to government intervention in our lives and certainly a earlier at least in the history of American medicine there was a long-standing antipathy to government and which is one reason we didn't earlier have a universal health care and one reason why perhaps it's still we still don't have it. In any case the idea that government per se is something to be avoided that maybe at best you need a safety net but by and large the emphasis with the market orientation is on choice not on equitable access. You can read for instance the editorial pages of the Wall Street Journal which loves the market you will not find much worry about the uninsured or in fact you won't find even much mention of it. And then so that's a very fundamental value. Now on the other hand I think those in favor of a strong government role do stress the notion of equity or sometimes use the language of justice or right to health care and their view is that generally speaking the market for some economic reasons is not well equipped really to function well in providing health care. Individuals as consumers will not be very good consumers very difficult to get knowledge and medicine medical outcomes are very uncertain. It's not to buy health care is not like buying a computer or an automobile. There aren't any guides and even if we had some guides it would still be exceedingly difficult to do and I think the art feeling very generally is therefore you do need a strong role of government in order to help people make proper choices those they do make but in some cases it will be the government that will determine what the choices are. There's a widespread belief among market proponents that government management makes possible lower bureaucratic costs and certainly they can use the Medicare program as an example because it's overhead costs are lower than those in the private sector. And they would say I think there are no government proponents that would not want to say that choice is important and choice of position as much choice as possible but in the end choice is less important than equitable access to care. Now what is the evidence to support these two ideologies they are very they're strong ideologies they run through our culture and they are increasing part of our health care system. Well my own belief and evidence at least from the recent book I wrote and the research I put into it suggests to me that the government managed government control government run systems are by far superior to anything the market has to offer. When one looks at Canada or the Western European countries one sees on the holes generally very successful health care systems. There are two kinds really one is tactical tax base which would be the United Kingdom and Canada for instance in Sweden where his direct health care system is paid for directly by taxation. The other is called social health insurance system which basically is private insurance companies providing care but the government requiring all employers with an employee contribution to be part of the health care system so that one way or the other everybody is covered. By almost any standard those countries do better than we do they do better in life expectancy and mortality rates quality of care access patient satisfaction you name it they do better. We are always on most of the list down the number 14 or 15. Despite the fact that we spend much more money per capita as percentage of our gross domestic product. It is true in some of the countries there are waiting list and this is particularly notable in Canada where one hears much about that among American market proponents and in the United Kingdom. But I've come to think maybe Dr. Aaron will say a little bit more about this that Canada and the UK are among the weakest of the universal health care systems. Market proponents rarely mention of France or Sweden countries that do do much better. Canada does have a waiting list problem they know they have a waiting list problem but by and large patient satisfaction there is somewhat higher than in the U.S. Now why is it that the European countries do better control in their costs well I'd have to say it's the heavy hand of government that's what many conservatives don't like but if you want to control us it works very well. First of all nurses and physician fees are typically set by negotiations between the government and professional associations. There are price controls on drugs so the drugs are simply much cheaper over there than here. There are much stricter standards for the introduction of new introduction and distribution of new technologies. There is control over the number of students who can enter into medical schools and a great deal of control over the construction and placement of hospitals and clinics. The net result is that costs are much better controlled in this country. Now I would say at the same time I got interested in the problem of European health care not only because of an interest in universal health care but after a number of visits there I began finding that they were anxious and worried about the future of their health care system. In this country we were have been figuring how to sort of climb our way up to the top of the mountain and get universal health care but in some European countries there's a fair amount of anxiety and a kind of sense they're hanging on to it and very strikingly most of the European countries do use some market techniques but they use the market techniques not to compete with universal health care but to make universal health a to make it work more effectively and also to provide to respond to the idea of greater choice. But the point is the European health care systems themselves have many of the same problems they control those problems better but they are facing costs that are rising faster than they should be and they are worried and they are particularly worried as we are about a much larger generation of elderly people coming along. Now I think the main problem as I've suggested at the beginning is the introduction and development and dissemination of new technologies and this comes from the idea of medical progress and I think there's probably no value more deeply embedded in American and indeed Western health care than the idea of progress and the idea of progress it's child so to speak, it's technological innovation drugs, machines, various therapies of one kind or another. Now I believe our view of progress is what I call utterly open-ended that is to say it is an unlimited view of progress if one asks anyone in medical research or health care when would you say you had enough health when would you say people have lived long enough when would you say you've relieved enough suffering I don't think anyone would have an answer to that and indeed it's a question that doesn't get asked as far as I can make out no one is interested in I think it's very much like a lot of technology in general we just should have more of it it should always get better there are always new frontiers a famous person after the end of the second world war talked of science it's the endless frontier health care is the endless frontier indeed in the 19th century the labor leader Samuel Gompers was asked what is health what do the workers want his answer was more and if one asks what is the medical research and health care establishment want the answer is more now it seems to me that if it turns out that that desire for unlimited progress begins to create severe economic problems then we have a very difficult dilemma particularly if it seems to begin interfering with the actual provision of the care that's developed from that very progress and my own view is I particularly look at the research enterprise of medicine is to see first of all that de facto I say de facto no one will quite admit this there is a war against death of any and all kinds our national institutes of health does not have a sign over the door say we're after immortality but there is nothing that kills you they don't like they're going to go after every known disease and of course if it turns out that you suffer from maladies other than that won't lead to death that they don't like those either and they will pursue those as well and of course these days we have some very interesting what I call efforts at utopian aging that is to say to carry out research to find ways to keep people alive longer and longer with better and better quality life and again no one ever will say just where that might end so what we've done is we have this very deep seated values that there has to be forward movement and it's forward movement with that end now it seems to me that that is simply a recipe for long term destruction of the healthcare system and we might not get destruction in the most gross form but we'll get destruction but by simply a creep people will pay more and more out of pocket and insured will grow everybody will ring their hands we are very good at this country and ring their hands and doing nothing at all so I think many of us for many years have thought my gosh it's sort of all suddenly going to fall apart and everybody will take action well it turns out we are very clever we're much more clever about not doing anything than we are about doing things and our history is long and solid and deep there as well so it's very possible we won't we will have a crisis but nobody won't be admitted or we'll deal with it by lots of cutting away in a way we hope people don't notice too much now my own view is that this notion of progress is based on a very false wrongful view of what medicine should be all about I don't think that medicine should have as its ultimate aim as de facto it seems to be mainly the conquest of death nor for that matter more recently somehow the conquest of aging I believe that aging and death are permanent parts of the human condition to be accepted one way or the other we are going to die of something or other we'll cure cancer and that will nicely set us up for Alzheimer's or some successor disease and it seems to me that if we're going to really seriously reform medicine we have to move away from thinking this is just a managerial organizational problem to ask debate the basic premises and I think that the common premise of endless progress war against death fight against aging together make for an impossible combination in the long run to control cost the problem of course is that here one finds that there are great differences between the right and the left in this country but both the right and the left love technological innovation the left loves it because of a tradition from the Enlightenment of using science to have the endless frontier to pursue to improve our lives indefinitely the right likes technology because it gives people more choice it's a good source of profit and money and here the left and the right hold hands and say that the fundamental values we differ on how to organize the system but we don't differ about the fundamental values and I want to say it's those fundamental values we have to rethink if we are serious about this and let me try to make that a little clearer by giving you my vision of what we or ask the question I think we need to ask it this way at this point in history that is to say can we envision and it may only be a vision can we envision a kind of medicine and healthcare system that is at once sustainable equitable and affordable sustainable equitable one understands what I mean by what do I mean by sustainable that to me is the key I mean by sustainable a healthcare system where the cost by and large do not increase significantly over the years they begin to plateau and we don't spend much more on healthcare than we do any cost increases come from a cost general increase in cost of living not because we have constantly embedded new and more expensive ways to save life because it seems to me we've got to begin entertaining the notion of us have a sustainable model in our hand because you can't keep having the cost rise at the present rate that is going to create great chaos in the years ahead and it's going to really get bad when the baby boom generation is in full retirement now it seems to me that if one wants to think if one tries to think it was a sustainable medicine then it's pretty clear you have to rethink the idea of progress if that's one of the reasons it's things that drives up God that we I don't think I'm not saying we reject the idea of progress I'm saying we have to we have to think about it in a different way we need to ask at this point what kind of progress do we really need should the war against death which has been de facto the main driver should that war continue or should we perhaps be willing to consider accepting death and then ask what is that exactly mean I've always thought American medicine has at its very heart a kind of deep deep schism those of you who know about contemporary medicine know the importance of say the palliative care movement and hospice the notion that what people need at the end of life is very good care but very fundamental part of that movement has been the notion that death is a part of life to be accepted at some point you stop fighting it and that's been a very important development but the research side of medicine is by no means buying into that at all the research side keeps death as the main target of its most fundamental efforts and it is not in any case willing to tolerate the fact that people die so far as I can make it willing to tolerate it if absolutely nothing can be done but the researchers already say well yes this year she dies of cancer but ten years from now people like her won't die and that's the way we keep going I'm saying that we have to try to go one of the wonderful things about the palliative care movement is it wants to go back to the older traditions of medicine which was comfort and care not simply an aggressive effort to save life I think we have to find a way to build that back into the healthcare system and not just in so-called end of life decision making now when I have said this in other occasions that people say well you know see that sounds very good and maybe you're absolutely right maybe we won't be able to fundamentally deal with the cost problem unless we have a kind of cultural change and I guess my answer is yes we need a cultural change and then the response is well how do you get that I guess cultural change is impossible to get particularly when we are so wedded personally professionally economically wedded to the present system that loves these wars against death and suffering because they not only make us feel better and save our lives but also because they generate a lot of money well it seems to me that during my lifetime I have seen three important cultural revolutions of a kind that would have seemed implausible a hundred years before feminism, environmentalism and the civil rights movement each of those movements began often decades ago but by the 1950s and 60s really started moving into high gear environmentalism stimulated by a book by Rachel Carson Betty Friedan of course was a key figure in feminism and of course Martin Luther King for civil rights all of them brought about a huge change in the way we think about something that for years had always been thought of very differently it was an effort to restore bring rights to people or to restore rights to give people a different vision of how we should live with blacks on the one hand with women on the other and with their environment as well I think that's what we have to do now with medicine we can't keep throwing expensive technologies at our diseases that way is obviously the route to disaster we will have to ration health care and I'm sure Dr. Aaron will say more about that tomorrow but I think at the same time as we're doing some of the managerial things that we need evidence based medicine alike we have got to be having a parallel effort to rethink the very foundations of the entire enterprise that'll be hard work but I think that is important as a revolution that will be just as important as the other three I've already mentioned and with that I will stop and let me end on one hopeful note one thing that always needs to be said when one looks at the problem of American health care is to keep in mind that we are the healthiest Americans in the history of the country that most of the improvement in health care longevity in life does not come from medical care as such it comes from an improvement in our socioeconomic condition improvement in jobs, education, a lot of environmental things those are the estimate is around 60% of the improvement in health care comes from those social causes not from the provision of medical care so even if we absolutely stop all progress which of course we won't we would still be getting healthier for quite a while to come if in fact we live much healthier lives so part of the key of rethinking progress is obviously making seriously the notion of prevention taking seriously the importance of education other background conditions that make for good health but in ways looking for other ways of having progress other than simply inventing new expensive fancy technologies to throw at them that's the dead end we have to avoid thank you