My wife, a psychologist, once coined a useful phrase: “pathologies of hope.” The idea behind it is that, in desperate situations, people are often prone to invent improbable hopes, or to hang on to low odds, in order to cope with the likelihood of an intolerable outcome. A familiar clinical situation is when a physician is treating a clearly dying patient but provides hope to the family (and maybe himself) by saying, for instance, “I want you to know that your mother seems much improved today.” That statement may well be true but it has no bearing on the inevitable death. There can be good days and bad days in a downward trajectory.

The discussion on cost control has many elements of a pathology of hope. The aggregate evidence on rising health care costs shows that technology is one of the main drivers of cost increases. Yet it is also true that some new technologies, or better management of new ones, could reduce costs. The problem is that most of them will not succeed in doing so. As the Congressional Budget Office noted in a 2008 study, “examples of new treatments for which long-term savings have been clearly demonstrated are few…improvements in medical care that reduce mortality…paradoxically increase overall spending on health care because surviving patients live longer and therefore use health services for more years.”

That quotation suggests the need for a distinction. On the one hand, there are technologies whose direct impact might reduce costs. But on the other hand, if the patient lives longer and the possible treatments during the remaining life span are taken into account, the earlier savings will be nullified by the later down stream costs. That is one of the nastier features of medical progress, the one that is hardest to look straight in the face. I call that phenomenon the longitudinal factor.

But even if we put aside that factor (which some health care economists prefer to do), we are still left with the question of how to deal with the likelihood that some technologies may hold down costs but that most will not. To what extent do the minority of cost-saving technologies seduce us into the pathology of hope?

The seduction comes from the reality that, in the aggregate, costs can not be effectively controlled without taking draconian, politically unacceptable policy steps – and that is an intolerable thought. So, to comfort ourselves, we grab onto all kinds of hypothetical possibilities, plausible enough but with no track record.

Adding to the seduction is the deeply imbedded value in American medicine (with full cultural support from the citizenry) that technological innovation is a medical necessity. Henry J. Aaron, of the Brookings Institution, has over the years been one of the most prominent economists to show how important technology costs are in efforts to control those costs. Yet, in the end, he can’t quite stand the implication that our beloved technological innovation is the ultimate culprit. He has written that any efforts to curtail research or to place barriers in the way of “the fruits of such research…is sheer madness.”

The oft-repeated “threat to innovation” has been raised again and again against ideas for serious control of technology costs. And it is the possibility that some technological innovations may reduce costs that invites the pathologies of hope: gosh, maybe it is not so bad after all.

There is an analogy in the debate on comparative effectiveness research. Many industries and some groups of physicians lobbied successfully to make certain that the research cannot be used to set practice guidelines or to ration care. The main technical argument was that the studies would be population studies, not in the end suitable for the individual care of patients; that is, in judging the value of drugs or medical devices for them. Some technologies may be economically valuable, even if most are not, just as some drugs and medical treatments judged to be wanting in population studies will be efficacious with individual patients. Sometimes that may well be true but sometimes as well the pathologies of hope are at work, and it may not be easy to tell the difference.

For me at least the historical record shows that, for at least 40 years, efforts to control costs in general, and technological costs in particular, have not been successful. With some small rises and falls costs have always risen each year (flattening only for a time in the mid-1990s). The weakest argument, regularly used in the Congress, is that more money spent on medical research will eventually rein in cost growth. But there is considerable agreement among economists that research drives up costs.

It is that wide-lens perspective that should guide us in thinking about costs, not the fact that some cost control strategies may improve the situation. They may well do so, but my bet is that there is no good reason, without politically tough steps – for example, price controls; cost-effectiveness research; and sharp cuts in patient benefits and in payments to physicians and hospitals – that they can do the necessary work. To constantly invoke wondrous possibilities is more often than not to indulge in pathologies of hope, just putting off the day of reckoning.

Daniel Callahan is editor of the Health Care Cost Monitor. His most recent book is Taming the Beloved Beast: How Medical Technology Costs are Destroying Our Health Care System.