One Miracle, Many Doubts

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

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The British National Health Service practices triage by delay. For example, it provides heart transplants (110 this year) entirely at government expense, but there are waiting lists of up to a year for all such complex surgery. Though the principle of first come, first served is fair in its random way, rather like a London bus queue, the delay inevitably kills off a certain number of applicants.

And then there is the old tradition of triage by money.

A wealthy Briton who does not want to wait in the National Health Service queue can have a private transplant operation for a reported $13,000. In the U.S. too, and in most of the world, money may not buy health, but it certainly helps.

Ever since the coming of the welfare state two generations ago, there has been an increasing repugnance to the idea of the rich enjoying essential services that are denied to the poor. But that same period has seen a drastic change both in the meaning of essential services and in the way people die. At the turn of the century, most people died fairly quickly of infectious diseases, primarily influenza and pneumonia. Now that those diseases can be cured with drugs, the chief killers are slow degenerative diseases, notably heart ailments and cancer. At the turn of the century, most people died at home, cheaply. Today more than 70% die in expensively equipped hospitals, and it is estimated that half of an average person's lifetime medical expenses will occur during his last six months.

What quantity and quality of hospital care people have a right to expect lies at the center of the problem, particularly since 90% of the bills are paid by some type of organization. As Colorado's Governor Lamm tartly puts it, "We give food stamps, but we don't give people the right to go to Jack's [an expensive San Francisco restaurant] for dinner." Harry Schwartz, writer in residence at Columbia's College of Physicians and Surgeons, maintains that "people simply do not realize the costs of health care. In making medical care seem free, we've made people demand the best. Necessary care is what healthy people on the outside are willing to allocate to us. The best care is what we think we are entitled to. What we've done is build ourselves a system in which no one thinks of the cost of a particular form of care or whether the cost is justified." Schwartz's conclusion: "If you want to cut the costs of health care, you do it by denying people free care."

Financial triage of various sorts is already taking place even among fully insured patients in the best hospitals. In one New Jersey hospital, for example, there were two thoracic surgeons who did a number of bypass operations. One screened his patients carefully, rejecting smokers, overweight people and other risks; the second accepted sicker patients, including several whom the first had rejected. The second doctor's patients had to stay in the hospital an average of five days longer, and when that showed up on the hospital's computers, his privileges were withdrawn on the ground that his work cost the hospital more than insurance carriers were willing to pay.

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