Why Deny Health Care? R. Oldham

Recent medical advances have made avail able a variety of in-depth approaches to the treatment of serious disorders such as cancer, AIDS, and major organ failure that allow for correction, or a research-based attempt at cor rection, of the disorder. Transplantation brings forth a large number of potential recipients, a small number of donors, and huge costs for each kidney, heart, or liver transplant. These transplant stories are often in the news and may involve distressing reports of the need for a transplant in a child, a young mother, or a pro ductive, breadwinner father. The relative infrequency of the transplant di lemma has been a major saving grace. Our sym pathies go to each patient, and many of us have contributed to help a specific patient. No effec tive system-wide solution to the limited avail ability of this expensive technology has come forth. Robert K. Oldham, M.D. is Chairman and Scientific Di rector of Biotherapeutics Inc., based in Franklin, Tennes see, a firm which conducts cancer research for patients in the private sector.

Dr. Oldham is Director of the Biological Therapy Insti tute where he conducts clinical trials of new treatments for cancer patients. He was the first director of the National Cancer Institute's Biological Response Modifier Program. His articles have appeared in numerous publications, in cluding The New England Journal of Medicine and The Wall Street Journal. Individuals who can afford to pay for these transplants represent a major revenue stream for hospitals with transplant services. There is little discussion when the individual has the capabil ity to pay for a transplant. Is it not a wonder that the issue of restricting availability to those who can afford the transplant hasn't been raised by ethicists? There has been broad negative reac tion to the idea of "selling" organs, but trans plant programs go forward when organs are available for individuals who can pay for the procedure.

More difficult is the issue of a new cancer treatment or a new approach to the devastating problem of AIDS. In both of these situations, there has been much discussion about access and opportunity, the cost of research and med ical services, and the issue of availability. Gov ernment and university officials have often voiced the view that a certain number of re search-based approaches should be available through their hospitals. Individuals should line up and wait for the opportunity to avail them selves of these research services. Such a system resembles the National Health Service of Britain, except that in the United States, contacts, political pressure, and money often can abridge a system of equal opportunity for all. One is reminded of kidney dialysis in its early days-an expensive technology for which committees were created to judge the worthi ness of individuals in need. In spite of such committees, patients with resources were gen erally able to avail themselves of dialysis.

Once rejected from such a system or once on a too-long waiting list with too little time, why restrain an individual with resources from pur suing private options? It would seem obvious that an individual with resources should be able to use those resources as he or she sees fit, while alive and able to make rational decisions. Yet, there is an increasing call to restrain such individuals from pursuing private-sector oppor tunities to gain access to new medical technol ogies for the treatment of cancer or AIDS. The arguments go something like this: "If a medical service isn't available for everyone, should it be available for a few? Isn't it uneth ical or morally repugnant for someone with as sets to be able to pursue a new, research-based treatment approach when others, without these resources, cannot? Shouldn't there be restraints on the private sector in the delivery of medical services to those who wish to pay for them?"

This thought process would indeed be bizarre if it were applied to a vital product such as food. At the moment, no one is crying foul if some one with resources chooses to eat more than the minimum daily requirement. In a similar man ner, there has been no call to restrict the avail ability of air conditioners for those who wish to purchase them in spite of the obvious health advantages of air conditioning to the sick and elderly who can't afford them. There has been no call to remove private rooms or executive suites from hospitals where they are available to patients with resources. There has been no call to restrain travel by those who wish to fly to 95 Switzerland or Italy or to a distant clinical fa cility within the United States for specialized medical care. Different Standards of Ethics? As a physician, I often receive calls from individuals who ask if I have access to a spe cialized technology, a research-based approach, for the treatment of a relative. I am struck by the fact that the individual, often a practicing phy sician, has not called me about his patients. I am struck that such individuals often work in government or universities. Some have been openly critical of private-sector systems of can cer research that might provide opportunities for those with the resources to afford them until someone close needs access and opportu nity. What are the ethics of one standard for a relative and a different approach for a patient?

This curious schizophrenia between the idea that everyone should have equal access, but that if everyone can't have it, no one should, repre sents a dangerous thought process. To translate that to a system where no one can have access to more health care beyond a set standard would be a grievous error. Such thinking outside of the health field is clearly anomalous. Let's not apply a unique standard to healthcare services, but let's apply the same rules of logic to all basic services that individ uals might use, given their resources. 0 IDEAS ON LIBERTY Arguments Against Socialized Medicine I t is a mistake for the government to consider the problems of the sick . apart from those of society as a whole.... the broader problem is, in a moral sense, one of promoting respect for the individual and the furtherance of initiative and self-providence; in an economic sense, one of increasing production for the benefit of all citizens; and in a political sense, one of removing government as a battlefield for special favor and substi tuting cohesion and solidarity for division and disintegration.

-DARRYL W. JOHNSON, JR.