I was saddened to learn about the death of Daniel Callahan, one of the forefathers of the field of medical ethics, a thinker and a doer who influenced thousands of scholars all over the world. Callahan influenced my medical ethics scholarship more than any other scholar.
A prolific author, Callahan published 47 books and some 800 articles and blogs. Just 2 days shy of his 89th birthday, right up to the end of his life, he continued to publish 7–8 articles a year. Dan’s greatest satisfaction was to sit at his desk and to wrestle with ideas and articulate them in a way that is accessible to the public at large. When he took vacations, it was only for the purpose of increasing the pace of his writing. When one of his children was asked what his father does during vacations, the answer was “typing”.
Dan was not only a creative thinker who strove to identify challenges and suggest possible solutions but also a successful visionary doer. In 1969, together with his friend and neighbor Willard Gaylin he co-founded the Hastings Center, which became one of the world’s most important centers of medical ethics. Callahan served as the center’s director from 1969 to 1983, president from 1984 to 1996, and president emeritus. Dan was very proud of his creation. He thought that the shelf life of his extensive writing would be much shorter than the life of the center. Unlike many philosophers, he never wanted just to philosophize nor did he want to pursue a standard academic career. His audience was much larger. Dan wanted to influence societies. He wanted to change things in a way that would benefit the world. He strove to do this in various ways: advising, consulting, teaching, granting media interviews, facilitating, organizing, providing forums for deliberation, and helping other scientists, but his greatest love was writing. Dan was delighted to see the success of his books. Very few academics have sold the number of book copies that Dan sold.
In recognition of his many achievements, Callahan was an elected member of the American National Academy of Medicine and a member of the American National Academy of Social Science. His scholarship was practical and policy-oriented. The Hastings Center was the spearhead that facilitated scholarship and became a beacon of practical learning. Hastings provided a place for scholars to develop. The Hastings Center Report established itself as one of the world’s leading medical ethics journals. The Report served as a vehicle to disseminate many of Dan’s ideas. Dan was loyal to his home journal and was very happy and proud to watch its growing importance and stature through the years.
In March 2019, the Hastings Center celebrated its 50th anniversary and Dan wrote “Making Sense of A Life” to note the occasion. This is a very personal piece in which Dan reflected on his own life. In the draft he sent me, Dan wrote:
Taken as a whole, my life has been happy and successful. I had supportive and loving parents in Washington, DC, where I grew up. I had the advantage of education at Yale and Harvard. I served three safe years in the army as the Korean War wound down. I got married to a perfect wife, Sidney, and we had seven children, one of whom died. I am glad we had those children (in the famous baby boom era) even though we became active in support of contraception .
In his 40s, Dan had a very busy life. He was running the center as a full-time job, did research, wrote intensively, and fathered his children. At the top of his research concerns was end-of-life care. Callahan later explained that “complaints about care for the dying had mounted during the 1960s, fueled by technological progress in sustaining life, by too many patients abandoned by physicians as they lay dying, by a lack of patient choice on how their lives should end, and by woefully inadequate pain management” .
We first met in 1994 when I was a Visiting Fellow at Hastings. Dan and I discussed his ideas, articulated in his books The Troubled Dream of Life (1993), What Kind of Life (1990), and Setting Limits (1987) as well as the two books that I was writing at that time: The Right to Die with Dignity (2001) and Euthanasia in the Netherlands (2004). Dan firmly believed in setting limits on the use of medical technology, applying utilitarian philosophy in justification. We had lengthy conversations about utilitarianism, justice, and allocation of resources. He and I did not always agree about the essence of what is beneficial to society, but there was never a doubt about Dan’s intentions. Dan wanted to do good. He was not happy with my description of him as “utilitarian” for putting a crude age limit on allocation of resources; still, after some thought, he conceded that it was unavoidable to be utilitarian if you involve yourself in policy matters. Callahan described himself as a communitarian .
Elderly people during the last year of their lives consume close to $100,000. Callahan thought this is unreasonable. He was deeply troubled by the fact that 10% of the population—mainly the elderly—consumes about 65% of health care expenditures, primarily on expensive chronic illnesses and end-of-life costs. He thought this is unfair to the 90% of the population. At the same time, in a recent phone conversation he argued that the lines are fuzzy and if otherwise healthy elderly person requires resources, s/he should get these resources.
Callahan was a staunch opponent of euthanasia and of physician-assisted suicide (PAS). He said time and again that these practices are outside the role of medicine, that they would corrupt medicine, and would lead to abuse. More people will die prematurely. In March 1999, I visited the Hastings Center in New York for the second time. I was startled when Dan told me that “there is a culture of death in the Netherlands.” Culture of death, no less. This was an unequivocal condemnation of the Dutch policy and practice of euthanasia. During our conversations, Callahan voiced repeated concerns about the situation in the Netherlands that results in premature death of many patients. Dan told me that he met with the Dutch Minister of Health who expressed a wish that the Dutch legislators enact a law that would enable terminating life without patients’ consent. Dan also vehemently opposed the Dutch proposal of instituting an off-the-counter death pill. Dan thought, quite rightly, that people who suffer from transient depression, e.g., due to a nasty divorce, or loss of a job, might opt to take the pill. Later, per our conversations, I titled one of my articles “’Culture of Death’ in the Netherlands: Dutch Perspectives” . Dan was not surprised to hear that a similar culture is prevailing in Belgium, and that there as well patients’ lives are shortened prematurely. He provided constructive comments on an article I wrote in this regard .
During my 1999 visit to the Hastings Center I was still writing my book The Right to Die with Dignity,  focusing on the issue of allocation of healthcare resources as well as working on a paper that criticized Callahan’s utilitarian approach. Once I completed the first draft, I asked Dan whether he would be willing to comment on the draft paper. He agreed, and the following day, at 08:30 am, I received a phone call. “Would you like to come to my office to discuss?,” he asked. I came to his office, where he returned the paper to me, full with comments in bright red. We had a long conversation that was stopped only because he had to go to the airport.
Dan was a true intellectual who was willing to engage in debates and listen to counter ideas. Much of our debate related to Dan’s proposal to set age limits to allocation of resources. In his books, Setting Limits and The Troubled Dream of Life, he proposed criteria for what he termed “acceptable death,” thinking that age 80 was an important dividing line. Thus, for instance, bypass operations for patients aged 80 and over poses an ethical and financial problem. Callahan asked: even if we agree that each person should have access to a decent level of health care, does this mean that the government must provide at the tax payer’s expense every technological development that science may bring, at any cost? Callahan’s answered this question, which to him seemed purely rhetorical, in the negative [7, 8].
In February 2019, I wrote to Dan, reminding him of this paper and expressed an interest to know whether his views had changed since then. He asked me to send him the paper, published in 2002 , and a few days later Dan wrote to me:
Rafi: I have had a chance to read your paper. It has been about 25 years since I began writing my book on aging. One reason I did so, though not mentioned directly in the book, was that the US government was then projecting intolerable future costs in treating and caring for the old. One response was simply to keep raising taxes to pay for it. The other was to find a way to control those costs apart from explicit rationing. The policy ultimately chosen was that of copayments and deductibles often called out-of-pocket costs. That is, government support for some level of care accompanied by forcing people pay for the rest. I am old enough to qualify for the government care (Medicare), but I also pay $250 a month for expenses not supported by Medicare. For millions of people, their out-of-care costs are much higher, particularly if they need expensive drugs.
As for my paper, I would not write it that way now. I now favor reduction of out-of-pocket costs for the old as well as more government control over elder costs.
Dan sent me a draft paper titled “Trumping Drug Costs”  in which he wrote about the damaging feature of out-of-pocket costs for the elderly. Most distressingly, so he noted, two sets of figures cast a shadow over the future. Retirement savings, which should be rising, have remained stagnant since 2000. Most families, including those close to retirement, have little savings, some $17,000 in 2013, down from $36,000 in 2007. Dan, who always tried to discern future patterns and find solutions, concluded that with many families already suffering bankruptcies from out-of-pocket costs–their numbers and health care cost rising—a real disaster could emerge in a few decades.
In his 2016 book, The Five Horsemen of the Modern World: Climate, Food, Water, Disease, and Obesity, Callahan explored the social, ethical, economic, and political aspects of these critical global challenges. In this wide-ranging book, Callahan noted that obesity, anthropogenic climate change, degenerative diseases, ecological degradation, and global famine are often the unintended consequences of unchecked industrial growth, insatiable eating habits, and technologically extended life spans. Only through well-crafted political, regulatory, industrial, and cultural counterstrategies can we change enough minds to check these threats .
The combination of increasingly longer lives and technological advances have all of us in their grip. It certainly caught up with Dan. Callahan reflected a lot on the questions of age, medical progress, and cost. Medical progress kept him alive beyond the age 80. He candidly wrote that he found himself “in an odd position, personally up to my neck with the mixed benefits of medical progress. From a social perspective, I can see little benefit from longer lives, including my own, and much harm looking down the demographic road” . Dan seemed to be troubled by the question of why he willingly accepted all the “medical wizardry” which kept him alive beyond his age limit. The best answer he could give was “a basic biological instinct for life. One part of this instinct is to stay alive when possible, even if that life has many miseries” .
Until his last day, Callahan continued to be deeply troubled by the technology that enables longevity at a high cost that, for him, was unreasonable. Setting Limits is the title of his 1987 book, and the issue is repeated throughout his writings. Much of his work relates to the meaning and impact of medical progress. Callahan wrote: “It is medical progress that has brought us great benefits, some harms, and plentiful knotty dilemmas with each new development” . His thought always far-reaching and expansive, in a piece titled “Aging: Drawing a Map for the Future,” Callahan voiced concerns that in 2100 there will be 11.2 billion people on the planet of whom 3.1 billion would be 60 years and older . In his 2017 book, Taming the Beloved Beast, Callahan weighed the ethical arguments for and against limiting the use of medical technologies, arguing that reining in health care costs requires us to change entrenched values about progress and technological innovation, that the cost crisis is as great as that of the uninsured, and that only a government-regulated universal health care system can offer the hope of managing technology and making it affordable for all . Callahan called for comprehensive planning to deal with the enormous challenges that lie ahead, including populated planet, global warming, dementia, and growing healthcare costs. He wrote unequivocally that all research efforts to radically extend life expectancy should be abandoned. Adding long-living elderly will help no one .
In a draft paper, “The Health Care Show Down,”  Callahan argued that it is not prudent to think that it will be possible in the years ahead to devise an ideal or perfect health care system. The number of elderly people will rapidly continue to grow, and the technological ways to keep them alive longer will grow as well. Even with great public support for affordable universal care, as is the case in Europe, countries are “stumbling and gasping.” Economically sustainable health care and solving all needs, is certain to remain an elusive goal but, Dan ends on an optimistic note, progress is possible.
Throughout the years, Dan and I had extensive correspondence. Dan was a member of my unofficial peer-review panel that I use before sending articles for publication. Dan kindly read and commented on many of my draft publications. I benefited greatly from his astute and sharp comments. I could not have asked for a better, more knowledgeable, and wiser referee.
During the past year, when Dan told me that he had spent most of his time at home and was suffering from arthritis in his hands which inhibited typing letters and therefore he would welcome phone conversations with me, I used to call him every few weeks to have a chat on recent events as well as about his and my own publications. We discussed his health, medical ethics, developments in the field, politics, media events, family, and anything else that came to our minds. A few weeks before his death, in May 2019, he sent me his last communication, writing in his usual style:
Rafi: … You might be interested in a project I have started at the Hastings Center. It is to stimulate their work on global warming and bioethics. On June 3–4, we will bring together global warming efforts and people in various universities who teach courses on the two subjects. I am attaching here the agenda for the meeting and the list of participants.
His wife, Sidney, confirmed that Dan took part in what was the last event he organized.
My dear Dan, relentless doer and most thoughtful scholar: May you rest in peace. You will continue to do good wherever you are.
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Cohen-Almagor, R. In Memoriam: Daniel Callahan (1930–2019). Pain Ther 8, 289–293 (2019). https://doi.org/10.1007/s40122-019-00137-4