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By Newsweek Editors
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I HAD BEEN A PHYSICIAN FOR 18 YEARS WHEN I FIRST held a beating human heart in my hands. The image of that pale, pulsing organ freshly amputated from its host will remain with me forever. True, it wasn't beating strongly and that's why it was removed and replaced with another. The replacement heart was taken from a newly deceased victim of massive, irreversible trauma. The first organ transplant at our hospital was the scene of high drama, and I was but a bit player. The heroes were the patient and the surgeons and the charitable family of the deceased donor. As a pathologist I was asked to take the diseased heart to the laboratory to determine why it had failed. This was a mundane task compared with the drama of surgery, but one that allowed me time to reflect on this miracle of modern medicine: we had the technology to successfully transplant diseased organs and give patients a new lease on life.
I find myself reflecting on this again as we enter the beginning of the congressional debate on health-care reform. We have the most technologically advanced health care in the world, but we seem unable to make it available to everyone. We are told there remain 39 million uninsured people in the United States and the number is rising. In the recent past the Clinton administration has demonized the insurance and the pharmaceutical industries for profiteering. I suspect that in the near future physicians will become the next target.
Like many others, I chose the profession of medicine for idealistic reasons, I wanted to be a hero. I have come to accept being considered a mercenary by the general public because I wish to be paid for my services and as a pathologist, I chose long ago not to be on the front line of patient care. But I will chafe if cast as a greedy villain by those in government who refuse to face the problem of health care today.
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The health-care system certainly does need reform. But all this technology will not become readily available to every patient even if we rein in all the supposed excess profit from the health-care industry and levy a payroll tax. Why not? Because high-technology health care is expensive and inefficient. Who would pay $1,000 for a test that has only a 1-in-100 chance of finding a tumor? No one, unless you are the patient. And would a judge and jury in a malpractice case lend a sympathetic ear to the doctor's defense after a missed diagnosis: "I didn't order the test, because it was too expensive and it usually isn't helpful"? Not likely.
We must cut through all the political rhetoric we are about to hear from politicians touting the entire spectrum of health-care plans and keep in mind one unalterable fact -- we now have more advanced medical technology than we can pay for. We cannot make all this highly advanced medical technology available to all those who need it without allocating an unreasonably large part of our national budget for payment. Look at other nations. Which of those without government control have good health care available for everyone? Which of those federally funded medical schemes is not in trouble? (Only recently I heard that the Canadian system is experiencing financial difficulties.)
Our politicians don't want to hear this. They want to be heroes and let others decide how to allocate resources. Allocation means value judgments: and votes are lost when politicians have to make value judgments. It involves who gets what treatment and who doesn't. In a country that cannot resolve issues about abortion, gays, gun control, drugs, how will we ever come to grips with this one?
Currently we have an informal multilevel health-care system. Those with the most resources get the best care. We can formalize this multilevel system so that some can obtain the best care (if they can pay) and make a lower level of care available and/or mandatory for all; or we can have one level of care for all, knowing that level must be significantly less than it is today. Whichever it is, we cannot have the highest level of care available for everyone without an unacceptable increase in cost. This is the single hard choice we face. We can't have it both ways. Beware of someone who insists we can, no matter how much data is made available. That person is either lost in a jungle of numbers or is simply lying -- probably, for personal aggrandizement and glory.
I have no inkling what kind of health-care plan may evolve in the future, but I know we all must get involved in shaping it. It is too important to ignore. One way we can help our elected officials attempt to come up with a reasonable plan is to insist that any health-care reform passed by Congress be accepted by them and by all government employees, totally and with no exceptions.
Sen. Bob Dole's prostate-cancer surgery of several years ago was and is a controversial procedure that most likely will be unavailable to a man of his age under a future managed health plan. Sen. Arlen Specter had to request an MRI scan for persistent headaches, which were caused by the brain tumor picked up by the scan. The MRI scanner is an expensive and sophisticated instrument, and its numbers and usage will surely be targeted for rationing. The doctors of Pennsylvania's Gov. Robert Casey miraculously found a donor with not just one but two organ transplants he needed (a heart and liver) just in the nick of time. The average citizen now often waits months for a transplant organ to be become available. In the future, selection of candidates for transplantation will be rigorous. How will these powerful figures fare in any future health-care system? When we come to understand the hard choice we face, we will insist that our elected officials be full and obligatory beneficiaries of any health-care plan they deem acceptable for the general public. Maybe then we could get meaningful reform. Maybe.
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