One Miracle, Many Doubts

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

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Despite various criticisms of expensive novelties like the artificial heart, very few scientists see any possibility of retreating from high-tech medicine, which has the glamour that attracts talent, money and publicity. Very few think such a retreat desirable. Most argue that a number of now standard procedures were once regarded as extravagant: the cardiac pacemaker, for example, or the coronary-bypass operation. The artificial kidney, by now commonplace, was attacked 20 years ago in the Annals of Internal Medicine in words much like those now being applied to the artificial heart: "How much money should be diverted by society into an ex pensive procedure that can only deal with a very small fraction of the potentially suitable patients?"

Dr. Denton Cooley, the pioneering Houston heart surgeon, argues that even if the artificial heart ultimately fails, "spinoffs from that type of research would be invaluable. There would be development of new valves and so forth." Michael Hess, professor of internal medicine at the Medical College of Virginia, takes a similar view, though quite cognizant that it is the traditional scientific plea for funds. "This is a case of spending money on research that will be useful in the future," he says. "Only God knows when the future is in this profession, but you have to start somewhere."

Wherever science starts, the Government generally follows. "Let's face it," says Abram, "the Government will end up paying a major portion of the medical bill no matter what happens. That's the way Americans want it. We have never sold seats on a lifeboat, and I don't think we're willing to start now." Albert Jonsen, a professor of bioethics at the University of California, San Francisco, has been serving on a Government panel studying the costs of heart transplants and artificial hearts. Does he think the Government should pay? No. Does he think it will eventually have to pay? Yes.

"It's disgraceful that we are not dealing with more fundamental issues than these big-ticket items," says Jonsen, who estimates the prospective costs of heart replacements at $3 billion and the average increase in the lives of the patients at only three years. "There are lots of people dying, and they are dying because they are not getting adequate care. But once these expensive operations are available, is it fair to people who can't afford them that they should die while those who can afford them live?

You can't have that kind of "unfairness. That's why the Federal Government will be pulled in."

And as it does get pulled lin, many doctors hope that some form of public dialogue and debate will emerge on what should be done. Says Cardiologist Preston of Humana's venture into artificial-heart surgery: "A very small group of people are setting a policy, establishing a method of practice that is taking an inordinate amount of resources without gaining public approval. The public has a right and should be involved in these decisions.

There should be some process for deciding these things rather than following the whims of some research team."

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