Date?

To The Editor:

The rapidlyescalating costs of medical care have stimulated studies to containor control these costs, and one of the methods proposed is that ofutilizing cost benefit and decision analysis.

This approachis well defined in the book entitled, "Costs, Risks, and Benefits ofSurgery" by Dr. J.P. bunker, professor of anesthesiology, StanfordUniversity School of Medicine; Dr. B.A. Barnes, professor of Surgery,Tufts University School of Medicine; and Dr. F. Mosteller, professorof mathematical statistics, Harvard University.

The authorsjustly point out that the resources to provide medical care arefinite and, in fact, scarce, and that society cannot undertake eachand every medical program that is proposed, however seeminglyworthwhile. Choices will soon have to be made among health programsand other social programs.

Today we arecapable of developing life-saving methods that are well beyond ourcapacity to pay for, and society no longer has the ability to pay forall the medical care that can technically be provided by our welltrained physicians in our modern equipped hospitals. We will soonhave to decide which medical care programs can be afforded and whichare simply too costly to undertake.

Unfortunately,each new medical triumph creates new moral and economic issues. Forexample, society must soon determine how much and what types of lifeprolonging intensive care will be made available for critically illpatients, especially those with end-stage heart, lung, kidney, andliver disease, and government economists are also asking how oftencan society afford to readmit to expensive intensive care unitspatients with acute exacerbations of essentially chronically andirreversible diseases.

The recentdevelopment of the CAT Scan (Computerized Axial Tomography) hasproved society with a non-invasive diagnostic technique which farsurpasses the brilliant and intuitive physician's ability to diagnosediseases of the brain; but, it is costly and cost control commissionsare denying its use to many hospitals and physician's officescontending society cannot afford it or that it will be abused.

The CAT Scan,however, is merely the first generation of its type and the MayoClinic is developing a diagnostic unit that incorporates 27 CAT Scanguns and that can render a picture with such fine resolution that onecan actually see the valves within the heart! The picture is almostas good as peering within the heart itself! As a diagnostic unit, itis almost the ultimate but unfortunately it is costly!

During arecent visit to a medical convention, I was exposed to the latest inthe utilization of electronic sophistication in the diagnosis ofbladder dysfunction, and the implication was that everyone shouldhave such diagnostic devices in one's own office. Urodynmics is "in"today and carbon dioxide cystometry, urethral pressure urinary flowdeterminations are, as it is claimed, an absolute must in one'soffice practice.

A modestexpenditure of 10 to 15 thousand dollars will purchase the equipment,and a technician can do the study in one hour at a cost ofapproximately $100 per examination. May I ask if every wellintentioned and serious urologist can afford such an outlay, orbetter still, can society afford to pay for the sophistication?

As the dollarsign becomes more a determinant in the delivery of medical care, adoctor may soon have to discard some old notions like, "all life ispriceless and that no cost can or should be spared to save adeserving life." He may soon find himself trying to answer questionslike, "Is saving one year of life the same for a young man as an oldman, or for the rich as the poor? Is an extra year of life for one 35years of age worth more than one 75 years of age, and is a year offull relief of pain worth more than a year of partial relief of painor intermittent pain?"

How can onereduce to a dollar figure inherently non quantifiable entities suchas death, time lost from work or leisure, pain, or suffering? Ourcost benefit analysis may determine for us that it is inefficient tobe compassionate and humanitarian, and that to be efficient one mustbe inhumane!

Noknowledgeable person would question that the medical care availabletoday is vastly superior to that available to his parents orgrandparents, and that the quality if medical practice has improvedeach year as science has added to our understanding of the diseaseprocess and the process of healing.

Thisexplosive increase in knowledge, however, has come at a tremendouscost, and society, especially HEW, is beginning to question this costand is, in fact, engaging in a trade-off of lives for dollars. Infact, the government has put a dollar value on virtually everythingthat medicine has to offer and seems more interested today in savingdollars than lives. Deficit financing by our government has broughtthem to this low position.

Triage is aconcept developed in the war for the care of the battered casualtiesand, in brief, consists of assigning the injured to one of threeareas of disposition. The severely or critically injured in whom theprospects of recovery or salvage are minimal and in whom a maximum oftime, talent, and equipment would be required, are assigned to anarea for which little or no care is contemplated. They are simply toofar gone for recovery. ( In war all is expendable, even lives!)

The minorcasualties are assigned to another area based upon the assumptionthat they will get well on their own or with minimal expenditure oftime, personnel, and medication. The intermediate group are treatedfirst as the recovery potential is the greatest in this group interms of man power hours expended and the actual costs ofhospitalization and treatment.

In war timethis program is practiced and may be practical or reasonable, but tohave to abide by it in peace time is distressing and repugnant. Yetwe are being brought to this program by cost benefit analysis andmandatory cost containment legislation.

Virtually allof the socialist countries which have national health insuranceprograms have a ready solution for the problems of medical care.First, a limited number of hospitals are available and, second, alimited number of physician's posts, personnel, and supplies areinvolved in the program. (On a per capita basis these numbers are farless than those available in the United States.)

As aconsequence, only the critically ill are usually cared for, and longwaiting lists for surgery and other forms of therapy are the rule. Insocialist Romania, palm tipping of under-the-table bribes go a longway in assuring that your mother and father are really seen as oftenas necessary and that adequate care is really rendered.

Human natureis the same the world over, and government-employed physicians wouldnot be immune to temptation or would refuse extra income for specialfavors extended to special patients. National health insuranceprograms all over the world leave much to be desired, at least whencompared to the quality and availability of medical care in theUnited States.

Thefrightening prospect of practicing medicine tomorrow- and my son mayhave to face it- is that the day may come when one can no longerpractice medicine to the best of one's ability and may have to abideby government guidelines which dictate who may or may not be admittedto the hospital, what operations may or may not be performed, and howmany days are permitted for the treatment involved. A bureaucrat willmake these decisions for the medical profession, and what is probablyfar worse a lay clerk may supervise the government's "cook book"directions for medical care.

All of thismay come to pass because the government controlling the purse stringswill be in a position to call the tune.

If medicalcosts continue to escalate, the day may come when every physicianwill have to decide for himself, if he is capable, which of hispatients have the greatest "recovery potential" and then devote histime and talents to their behalf; as a consequence, he mustnecessarily ignore the care of those with lesser potentials forsalvage.

Life and itsmany diseases is being assigned a price tag today in the same fashionthat a merchant places a price tag on his merchandise on the shelf,and the medical care provider will have to decide which medicaldiseases he will treat or purchase with his limited funds.

As onecompassionate physician said, "I find this quite distressing andunethical. Unethical because I took the oath to do all I can for mypatients."

Cost benefitand decision analysis is indeed a frightening prospect.

Charles E. Jacobson Jr., M.D.

45 Wyllys St.

Manchester, CT