What Kind of Life: The Limits of Medical Progress
Setting Limits: Medical Goals in an Aging Society
Patrimony: A True Story
Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying
Must health care be rationed? Medical schools and research centers frequently hold conferences on such questions as “Is rationing inevitable?” and many new books address the question posed by the philosopher John Kilner in his book Who Lives? Who Dies? The inquiries are usually of three kinds. One addresses the narrow issue of which patient should get the last available bed in the intensive care unit, or the single available donated, heart, or the only remaining respirator. The dilemma arises over whether to choose the candidate who is first in line, the youngest, the most prominent, or the richest, to name only some of the criteria that are now used.
A second kind of inquiry addresses the broader problem of what percentage of national resources should be devoted to health care as against, say, education, defense, or highway construction. The total amount of money spent by the government, insurance companies, and private citizens on medical care now amounts to about $700 billion. What social choices may have to be made if American medicine is to live within this already enormous budget? It is not unusual for commentators to confuse this question with the first.
The third question is to what degree health care can be distributed more equitably—not, as now, largely according to income, but according to need. With 35 million people uninsured, and almost as many underinsured, those with low incomes must settle for second-rate medical care, or none at all. According to George Lundberg, editor of the Journal of the American Medical Association, national health insurance, which the Journal long opposed, has taken on “an aura of inevitability.” But should American politicians finally vote for it, we can expect they will try to impose tight controls on its cost, which in turn might require rationing. Lundberg, for example, believes there will never be sufficient money or services to provide everyone with the care they may want.
The use of the word “rationing” has helped, at least, to open up discussion of the social values implicit in any discussion of who will get effective treatment and who will not. In fact this may be why philosophers and other writers concerned with the moral implications of medical decisions—what is called bioethics—have become prominent in a debate that might otherwise have been monopolized by political scientists, economists, and health specialists. Two much-discussed cases suggest the central ethical issues that continue to be perplexing. The first occurred in the early 1960s in Seattle, Washington, when a committee of lay people was given the authority to decide which applicants should be able to use a kidney dialysis machine. The second is occurring right now in Oregon, where the state legislature is deciding the range of medical services that will be available to people who receive Medicaid.
In 1962, Dr. Belding Scribner of the University of Washington Medical School perfected an ingenious device to keep alive patients who would otherwise die from chronic kidney disease. They were connected to the …