Life Without Disease: The Pursuit of Medical Utopia

William B Schwartz

University of California Press

California

£17.95

pp 159

ISBN 0 520 21467 6

Rating:

Schwartz provides a framework for understanding how the increasing potential of a disease-free existence can be reconciled with the pressure for containing costs in a US context. To understand where we are and where we may be headed, the book is divided into separate sections focused on the last half of the 20th century, the next 20 years, and the period leading up to 2050. Each section begins with a discussion of actual or prospective developments in what medicine can do, followed by consideration of the challenges these developments have presented or will present for the organisation of health care in the United States. The underlying theme is that cost control requires rationing in one form or another.

The strength of the book lies in the “potted” descriptions of medical advances past, present, and future. The mind boggles at what we can now do and what we might be able to do. The “boggling” is intensified when one recognises that only a small proportion of the US population has access to many of these advances—a rationing mechanism given little attention within the volume.

Rationing in the United Kingdom, France, Germany, and Canada is described. However, the seven pages devoted to this international perspective fail to do justice to an important and well researched topic. Rationing in the United States in the form of “managed care” is dealt with somewhat superficially in 14 pages, though this is sufficient to illustrate that the “programmes” in question have nothing to do with either patient care or population health and much to do with corporate profits. The author's own “proposal” is “Oregon-esque” in the underlying principle of seeking the biggest (health) bang for the healthcare buck. However, the Oregon approach is enhanced by recognition that the outcomes of pairings of treatment and disease will vary according to the severity of the condition. Under Schwartz's approach less severe cases would be less likely to be served (something closely resembling the NHS approach that Schwartz has previously condemned). Emerging evidence shows that healthcare outcomes may be systematically related to other determinants of health, such as the social, cultural, economic, or environmental conditions to which individuals are exposed. The proposed approach would then produce widening disparities in health within societies. Moreover, the approach assumes that the opportunity cost of better health is the same for all—yet the trade-offs underlying “choices for health” may be very different between social groups.

Schwartz considers that “exploding knowledge” begins to make possible the once impossible dream of a disease-free existence and an average life expectancy at birth of 130 years. Whether that knowledge can be turned into wisdom to provide improvements in health expectancy for all our fellow citizens remains to be seen.