INTRODUCTION
Diagnosing Twenty- First- Century Health Care
Medicine today comprises an unthinkably broad array of
knowledge and skills, professions, co ali tions, and interest
groups, fears and promises, fantasies and soon- to- be- realities,
concrete and virtual institutions, folklores and sciences.
Arthur Frank, The Renewal of Generosity
Medicine has changed radically over the past fifteen years. Some of those
changes are obvious and dramatic and have provided welcome benefits.
Who doesn’t welcome the availability of cholesterol- lowering drugs, joint
replacements and arthroscopic surgery, the anti- retrovirals that have
made aiDs a chronic, manageable illness, and so much more?
Other equally obvious and dramatic changes, however, have become
the subject of widespread lament: too much life- sustaining but death-
prolonging technology is being used at the end of life; drug companies
are paying physicians to promote their products; expensive tests, devices,
and procedures are overused; drug costs, especially for cancer treatment,
have skyrocketed, yet the new drugs don’t necessarily offer better results
than existing treatments. Most everyone who has had intimate dealings
with the U.S. health care system of late can add to this list of obvious and
well- publicized problems.
However, many equally dramatic and relatively recent changes within
the U.S. health care delivery system are far less visible— indeed I contend
that they are very well hidden. But although they function well below the
radar of scrutiny, these changes have not just complicated medical prac-
tice and health care delivery but actually have altered their very nature.
They have also altered how and what we think about health per se and
about the options we have for controlling our life span and that of our
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