After listening to economists, physicians and politicians, among others, Oregonians have concluded that they can no longer afford unlimited medical care. The only way they see to control the rising costs of such care is to ration it. They have legislated a rationing system that has attracted national interest. It may turn out to be a trial run that could eventually affect all of us.
On the surface, the arguments for rationing seem reasonable. Each year, health care costs rise much faster than inflation. New procedures and technologies appear at a breakneck pace and jack up medical expenses. Large segments of the population, such as older people, increase in number and need more complex care. Yet as a nation, we have only a limited amount of money to spend on treating the sick.
By not recognizing this dilemma, by not realizing that we are, in fact, already rationing care and by not institutionalizing a fair and logical system for rationing, we fly in the face of common sense. We spend huge sums of money on individuals whose chances of benefiting are painfully small, such as elderly patients with only days or weeks to live, while depriving others, such as children and pregnant women, of care that could make a big difference at only a modest cost.
Despite the compelling power of the reasoning, I'm not ready to go ahead, and I don't believe that those who are ready fully understand what rationing implies. We have not given enough consideration to other alternatives. The financial problem is serious, but by accepting the concept of rationing we cross a moral divide from which there may be no return. It is no small step to decide that we will require physicians, nurses and their colleagues to adhere to a formula that spells out who is worth saving and who is not. We should move cautiously and try to avoid mistakes.
We've made some big mistakes in the past, especially in medical matters. In the early '70s, experts persuaded us to release the bulk of the mentally ill from the back wards of institutions. Lacking adequate community facilities, the patients ended up fending for themselves in a hostile environment, and as a result the mentally ill now make up a major segment of the street people, many of them suffering worse fates than they did in the institutions. We cannot reverse this mistake easily or quickly.
Let us not make another. We should learn much more about the implications of rationing before adopting it. Under rationing, we would undoubtedly decide not to fund expensive procedures, such as kidney dialysis or transplantation, for patients classified as too old. The British set the age limit for treatment of kidney failure at 55. In the abstract, such a decision may seem regrettable but unavoidable. Still, when the guidelines affect a real person -- such as yourself or a close relative -- views change briskly.
A friend of mine who taught English literature developed kidney failure at age 57. Because chronic dialysis was available to him, he was spared a sentence of early death and remained active for 10 more years, teaching and mentoring his grateful students. Was the money spent on giving this man 10 more years of productive life a waste? Did we really deprive some children of immunization against measles and polio because we spent the money prolonging the life of this teacher? Would rationing have been the more intelligent course?
Under rationing, major new ideas for medical treatment would be discouraged as too expensive and unnecessary. The problem is, what seems far-out and frivolous today could become commonplace and essential tomorrow. In the early '50s, one of my surgery professors developed a new technique for operating inside the human heart to repair defective or damaged valves. Early on, the procedure was very expensive and seemed to be just a futile technical exercise, but we paid for the development and evaluation costs, and today valvular surgery constitutes a routine treatment providing a long and useful life to heart patients of all ages.
Had rationing been in effect when the procedure was first proposed, in all likelihood it would have gone unfunded and left at the idea stage. By and large, rationing would narrow our horizons, inhibit creative imagination and vision, slow the progress of medicine and trap us within the limitations of today's knowledge and today's technology -- a high price to pay.
Do we really have only a limited amount of money for medical care, and must we start rationing now? Obviously, we cannot allocate the bulk of our gross national product to medical care, and we must continue to improve the efficiency and effectiveness of the myriad activities we group under the phrase "health care system." But isn't it odd that even though we are resolved to spend $500 billion for the S&L bailout, when it comes to dealing with the far lesser costs of medical care, we grow mightily exercised, dig in our heels and turn to rationing?
Could it be that our preoccupation with the bottom-line has reached the point of gross insensitivity to values that cannot be quantified or incorporated into a balance sheet? What kind of people will we become after we agree to toss sick human beings onto the trash heap because they aren't worth paying for? Are we really so impoverished financially and intellectually that we see no other way out? Possibly, but we ought to slow down some and get ourselves a second opinion.
The writer is chancellor of the University of Massachusetts Medical School.