CONCLUSION
Toward a New Social Contract?
Hope and reality have fused. Medical miracles are expected by
those who will be patients, predicted by those seeking research
funds, and profitably marketed by those who manufacture
them. . . . What the biologist Rene Dubos some de cades [ago]
spoke of as “the mirage of health”— a perfection that never
comes—is no longer taken to be a mirage, but solidly out
there on the horizon.
Daniel Callahan, What Price Better Health?
Our practices in medicine define the kind of society we have. Ordinary
medicine is emblematic of other trends in American society, and how
we shape the values and directions of the health care delivery enter-
prise will determine— and reveal— the kind of society we create in the
coming years. Because the trends that have brought us to this point are
ongoing— especially the dominance of private industry in health care
ser vices, the priority given technology use regardless of cost, and the lack
of equity in the distribution of medical care— they continue to derail the
practice of medicine, indeed the entire health care delivery enterprise
as a social good. So our current state of affairs raises a critical question:
What values do we want to govern that enterprise?1
Observers of medical practice and health care delivery— from health
economists, policy analysts, and ethicists to journalists, doctors, patients,
and families— note that the necessity of cost control sits in tension with
the value we place on open- ended choice, individual rights, and always
escalating need.2 To date the need for cost control and the tension be-
tween cost control and rationing have dominated the po liti cal debates;
some, however, have begun to argue that those debates should not be
centered on cost control at all. They point out that the cost issue deflects
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