We have a culture addicted to the idea of unlimited progress and to the technological innovation that is its natural child.... this is an unsustainable value. There must be limits. American health care is radically American: individualistic, scientifically ambitious... I put changing those values within health care in the class of a cultural revolution dedicated to finding and implementing a new set of foundational values....
[It] is remarkable that global warming is now, finally, being taken seriously in the United States; and that there is, simultaneously, a fresh push for serious health reform. In both cases ... [we must have] fundamental alterations in our way of life. The drive for progress and constantly growing prosperity in the industrial order is behind the emergence of global warming; and an analogous drive has created the cost crisis in health care. In both cases, technology occupies a central place. In each instance, a basic question is whether we should be prepared to sacrifice some of the present and future benefits of science and technology, which have created the parallel dangers, or look to them for new initiatives to rescue us from the unwanted complications they have created.
... The immediate aim would be to reduce acute care at the highest levels, those of cost and technology, and aim as well to discourage the development and improvement of medical technologies at those levels. ...[T]echnological screening methods ... should decline along with many other technologies.... Successful prevention policies will do no economic good if we continue to find clever technological ways to keep people alive when they finally get sick which they inevitably will. Another aim of this emphasis will be to minimize the need for directly rationing care. That can best be done by not having technology readily available in the first place.
... The only fully useful technology assessment agency would be ... like the British National Institute for Clinical Excellence (NICE).... Technically, NICE only makes recommendations to the National Health Service, but it is understood that, in most cases, they will be followed; only sharp political outcries ... can derail them. That is the only kind of agency, I believe, worth fighting for.
... The traditional doctor-patient relationship, one of the core values of medicine, can be an obstacle to good health policy, invoked all too often by many physicians to justify practices at odds with the control of costs....
We must, I believe, stifle the notion of 'stifling technological innovation.' Unrestrained and cost-insensitive innovation needs to be stifled....
The idea that we might use age-based rationing to level the playing field [between the generations] was rejected out of hand from all quarters. I was beaten but not bowed for arguing that position."
In an era of highly charged ... politics, everything possible to keep ... poison out of the room would have to be done.... [The] talk goes much better ... if it begins in private.
If not handled properly, cost control is a topic that can bring out ... ad hominem attacks. Any mention of cutting back expensive care for the elderly will invite the charge of ageism; and any mention of reducing the use of expensive life-saving technologies for the elderly will add to that charge social euthanasia or murder.
Liberals ... are as reluctant to talk about rationing and limits as our market conservatives.... They are not comfortable with the language of tragic choices, foreign to Enlightenment optimism.
... Our whole health system is based on a witch's brew of sacrosanct doctor-patient autonomy ... and a belief that, because life is of infinite value, it is morally obnoxious to put a price tag on it.