When Doctors Disagree

The American public has been warned that medical care may soon have to be rationed. In an article in Newsweek (November 12, 1984), Dr. William Schwartz writes that “either we will accept the continued rise of hospital costs that result from full exploitation of technological advances, or we will start to ration hospital care. And if it’s the latter, we will then have to say to some people, ‘Yes, a new liver would be good for you, but as a society we can’t afford it.’ ” The economist Henry Aaron, in collaboration with Dr. Schwartz, has elaborated on this theme in a recent, widely publicized book, The Painful Prescription: Rationing Hospital Care,1 as well as in articles in The New York Times and elsewhere.

The truth is that medical care is already rationed and it always has been. One of the disgraces of national policy is that the poor and unemployed who cannot afford to pay for medical care or have no medical insurance must often accept inferior treatment, if they can get it at all. What is new is that the costs of care, whether it is paid for directly or through insurance, are rapidly exceeding the ability or willingness of even the middle class to pay. The main reason for this is that medical scientists are inventing more new diagnostic and therapeutic “medical technologies”2 than the economy can pay for. The artificial heart is a famous example. If a workable model were developed and made available to the estimated fifty thousand terminally ill cardiac patients each year who could benefit from it, that would cost between three and five billion dollars. Since it is unlikely that the government will pay the bill—as it has for kidney transplants and hemodialysis for patients dying from kidney failure—we face the prospect that this enormously expensive medical technology, if it succeeds, will be made available primarily to those willing to pay for it.

The case of the artificial heart is by no means unusual. The potential costs of new medical technologies are enormous. They include the exchange of blood plasma (plasmapheresis) in the treatment of rheumatoid arthritis and related diseases, and diagnosis by means of nuclear magnetic resonance imaging, and liver transplants. We can assume that new medical technologies will continually appear, and we can also assume that major controversies will arise over who will benefit from them and who will pay for them.

A number of measures could be taken short of rationing. These include preventive medicine that would decrease the need for medical care, such as encouraging people to stop smoking, improving prenatal care, and increasing programs for immunization. In addition, the large US investment in basic research, primarily at the National Institutes of Health, will continue to produce health-improving technology and all of it may not increase costs. As Lewis Thomas has pointed out, truly effective medical technology, such as immunization and antibiotics for specific diseases, will be less expensive than the complex but inefficient “halfway…

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