One Miracle, Many Doubts

A feat of heart surgery sharpens the debate over benefits and costs

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In terms of the poor, the comparisons look even worse. "We are not giving basic medical care to people in the inner cities," says Tom Preston, chief of cardiology at the Pacific Medical Center in Seattle. A liver transplant of the kind that little Amie Garrison needs would finance a year's operation by a San Francisco inner-city clinic that provides 30,000 office visits in that time. Says Harmon Smith, a professor of moral theology at Duke: "I don't understand the fascination with these absurd, bizarre experiments when we have babies born every day in the U.S. who are brain-damaged because of malnutrition.

It is a serious indictment of our society." Barton Bernstein, a historian at Stanford, takes a similar but broader view: "Changing the conditions of poverty would improve health more than all the medical innovations we are going to get in the next decade."

Among those who criticize the financial inefficiency of spectacular surgical experiments, the most common prescription is a greater emphasis on preventive medicine—immunization, examination, nutrition—and not just medicine but a healthier way of living. "Control smoking, alcohol, handguns, overeating and seat belts," says Speer, "and that would be a new world." Sensible though such suggestions are, they are highly colored by wishful thinking.

What is far more likely, since overall demand exceeds overall ability to pay, is some form of rationing or restriction.

"There is no question that we face rationing," says Morris Abram, the New York attorney who served from 1979 to 1983 as chairman of the President's commission on medical ethics. But Gregory Pence, who teaches ethics at the University of Alabama Medical School, offers a warning: "Medical costs are uncontrollable because we lack moral 'agreement about how to deny medical services. Deciding how to say 'no,' and to say it with honesty and integrity, is perhaps the most profound, most difficult moral question our society will face in coming years. But face it we must, for the alternative is disastrous."

Triage is the French military term for the battlefront procedure by which overworked surgeons reject some casualties as too lightly wounded to require treatment, reject others as too badly wounded to be saved, and concentrate their limited resources on the remainder. No matter how it is done, triage is a cruel procedure, perhaps an immoral one, but generally recognized as necessary.

Nobody likes to admit that triage is already being employed in high-tech medicine. When a Long Island hospital was accused last summer of posting color-coded charts next to patients who could be allowed to die, its officials loudly denied the district attorney's accusations and the matter was allowed to drop.

But there are many ways of practicing triage. One of the simplest, quite possibly illegal, is by age. One reason both Barney Clark and William Schroeder wanted artificial hearts was that they were both over 50, the unofficial cutoff point for heart transplants. Schroeder had been rejected three times. A more ambiguous standard is the idea that doctors should decide on their own who is best suited for high-tech treatment. But who should get preference—the most sick or the least sick?

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