Imagine a world where the deadly effects of chronic diseases like Alzheimer’s and cancer were eliminated. In this medical utopia, a baby’s genetic profile is determined at birth and then medical interventions are performed that abolish his or her genetic mutations, meaning the child will grow up without chronic or life-threatening disease. Instead of dying in their 70’s, 80’s or 90’s, most adults would be living to 130.
Such a world is not that far away, predicts William B. Schwartz, professor of medicine and a renowned medical economist, in his upcoming book Life Without Disease: The Pursuit of Medical Utopia. “We are on the verge of a revolution in molecular biology and molecular medicine which brings the hope of control and even prevention of some of the medical plagues we now face,” he said.
Schwartz, who was formerly Chair of the Department of Medicine at Tufts University, expects such a vision of the future will take many people by surprise. “Many physicians over 40 who have been out of medical school for a number of years aren’t aware of the enormous accomplishments in genetic medicine in recent decades,” he said. “The only reason I feel comfortable speaking cautiously about it is that I spent over a year studying the new research and talking with experts about it.”
Schwartz calls Life Without Disease the “culmination of a lifetime of work.” In his clinical and laboratory research and in his economic research over many decades, he found that one of the driving forces of recent medical progress has been advances in bioengineering.
“I think what we look forward to now is a completely new paradigm, a completely new way of thinking about medicine,” he said. “Instead of dealing with the consequences of disease by replacing a hip or doing an angioplasty, we will be thinking instead about avoiding disease, about preventing human suffering, about making certain we intervene early enough so that these diseases of all sorts will be treated without the expensive interventions that we now are engaged in.”
This utopia, Schwartz cautions, is still decades away. Getting there, he predicts, will be very expensive and will require difficult decisions and resource allocation as health care rationing becomes a certainty.
“Without question, in the next ten to 20 years, as we develop these new methods of clinical intervention – gene therapy or ways of neutralizing the effects of the abnormal proteins which mutant genes induce -we’re going to have a long period in which therapy is quite costly,” he said. “Partly this is because these therapies will not be fully effective at first and we’ll spend a lot of money trying them out. Partly it is due to the fact that, initially, we’re going to convert a number of diseases which are now fatal into long-standing, chronic diseases. Many instances of cancer that kill quickly will be converted into chronic diseases that are very expensive. “
That means, he said, that society will have to learn to accept rationing of medical care, particularly of that care which yields small benefit but is nevertheless very costly.
For example, he noted, Magnetic Resonance Imaging (MRI) can be very helpful or even life-saving for someone with a head injury.
But there is only a one in 2,000 chance that if someone has had recurrent headaches and the physician orders an MRI that it will find a treatable tumor or aneurysm.
“We’re just not going to be able to do a $1,000 MRI on every patient who has an occasional headache, because the cost per case discovery will be $2 million,” he said.
Schwartz, who is also a fellow at USC’s Pacific Center for Health Policy and Ethics, is quick to note that most people in the U.S. do not readily accept the idea of rationing. “If it’s me or my family, I want the test even if the chances are only one in 2,000,” he said. “What this means is we’ve got to confront the issue publicly. We’ve got to help the public understand that there is a wide range of benefits from these expensive technologies and ask the question, ‘Are you willing to pay the bill for the one in 2,000 chance that you’ll be helped?’ If so, we’ve got to let health care costs go up sharply. If the answer is that we’re not willing to pay that bill, then we’ve got to limit the availability of this care and the public has to recognize and accept that reality.”
The rise in health care costs of the past several decades is largely attributable to advances in health care, he notes.
“As a physician, I remember very clearly how 25 years ago people were totally disabled by the pain of hip disease, totally bedridden or going around with a walker before hip replacement surgery became commonplace. I remember when lens implants were not feasible and people were struggling with their vision in a major way, and where retinal detachments regularly caused blindness, when prior to angioplasty, coronary artery disease created intractable pain.”
Although the advances are expensive, he said, “I do feel we have improved the quality of life enormously.”
Despite experience in recent years with HMO and federal Medicaid attempts at rationing care, says Schwartz, most of the public has not come to terms with the fact that “we can’t do everything for everybody.”
In his book, Schwartz predicts public protest will be carried out mainly in the court system, which will be forced to determine acceptable levels of physician care.
“We act with our HMOs and the government as if we can have it both ways – cost containment and improvements in quality of care,” he said. “It just isn’t possible,” he said.
Eventually, in about 40 or 50 years, well within the life expectancy of today’s young adults, the cost of medicine should go down, not up, he maintains. “The deeper our insight into the molecular character of medicine, the easier it’ll be to devise therapies which are absolutely responsible and inexpensive.”
Schwartz acknowledges that achieving a medical utopia will bring new and different problems.
“Even if we are successful in eliminating most illnesses and maintaining quality of life until 120 or 130 years of age, which I think is very likely, there’s a black and dark side: if people are living healthfully and happily to 120, they’re not going to want to die. There will be pressure to prolong life even further, to prevent aging. It will have enormous social and political consequences,” he said.
Still, Schwartz looks forward to what he sees as the enormous progress that will happen in the future. “I’ve been in medicine for a good many decades,” he said with a smile. “I’ve been very excited about the medical advances of the last decades, as a laboratory scientist and as a clinical consultant. What I really regret is I won’t be around for the next 30 or 40 or 50 years to see a period of change in medicine which will make previous changes pale.”