One Miracle, Many Doubts

By Otto Friedrich

The dying heart was an I ugly yellowish color when Dr. William DeVries finally cut it loose, tore it out of the Mercurochrome-stained chest cavity, and put it to one side. For the next three hours, while a nearby heart-lung bypass machine kept the unconscious patient alive--and while a tape in the background eerily played Mendelssohn and Vivaldi--DeVries' sure hands carefully stitched into place a grapefruit-size gadget made of aluminum and polyurethane. At 12:50 p.m. last Monday, the Jarvik-7 artificial heart newly sewn inside William J. Schroeder began beating steadily, 70 beats to the minute. When Schroeder opened his eyes 3 1/2 hours later in the intensive-care unit, DeVries bent over his patient and whispered assurances, "The operation is all through. You did really well. Everything is perfect."

So, for only the second time in history, a human heart had been permanently replaced by a machine. Like a landing on the moon or a close-up photograph of Saturn's rings, it was an event that seized the world's imagination, arousing once again a sense of shuddering awe at the incredible powers of technology, a sense that almost anything is possible, almost anything that can be imagined can be done.

Though nobody could predict how long the aging and diabetic Schroeder would survive--his only predecessor, Dr. Barney Clark, died after a courageous 112-day struggle last year--he was reported at week's end to be doing "beautifully" (see following story). But even if Schroeder dies soon, there will be more such operations, and even more complicated ones, in the near future.

The Humana Hospital Audubon in Louisville, where the operation took place, has received permission from the Food and Drug Administration to perform another five artificial-heart implants. One candidate is now in the hospital for evaluation, but will most likely be turned down. At the same time, two Southern girls are scheduled for complex variations of organ replacements this month. Cynthia Bratcher, 6, of Scottsville, Ky., will be taken to Birmingham for an operation that will install a second heart inside her. Meanwhile, Mary Cheatham, 17, of Fort Worth, will go to Pittsburgh for simultaneous transplanting of heart and liver. (The first recipient of such a double transplant, Stormie Jones, 7, of Cumby, Texas, is still doing well after ten months.)

In what should be a time for congratulations and rejoicing, it may seem carping to raise questions about the value of such spectacular operations, yet that is exactly what a number of medical experts were doing last week. They did so because they feel serious doubts about the whole course of high-technology medicine doubts about cost, ethics, efficiency and simple justice.

On a narrow technical level, this is partly a continuing debate about the comparative merits of transplanted human hearts vs. mechanical hearts (not to mention animal hearts like the one that kept Baby Fae alive for three dramatic weeks). When Dr. Christiaan Barnard began performing some of the world's first heart transplants in 1967, such efforts usually ended in failure and death because the patient's immune system rejected the implanted heart. But the development in 1980 of the antirejection drug cyclosporin has brought a drastic change. More than 200 heart transplants a year are now being performed in the U.S. alone, and the survival rate is about 80% for one year, 50% for five years. "I love life," says Dr. Barnard, now 62, retired, and contemplating a third marriage (to a 21-year-old Cape Town model), "but I certainly wouldn't go for an artificial heart. A transplant, yes, but I don't fancy being attached to a machine for whatever life I have left." On a more philosophical level, some experts challenge the very idea of artificial and transplanted organs. Dr. Lewis Thomas, president emeritus of the Memorial Sloan-Kettering Cancer Center and the thoughtful author of The Lives of a Cell, warns that such procedures represent an "insupportably expensive, ethically puzzling, halfway technology." Says Kenneth Vaux, professor of ethics in medicine at the University of Illinois: "We are going to have to decide as a society what we want from our bio-medical projects. What kind of a person are we seeking to create? A collection of interchangeable parts you can continually change when those parts fail? An artificial person? We are going to have to temper our ambitions and learn to accept the inevitability of disease, the inevitability of death itself."

Colorado Democratic Governor Richard Lamm, 49, who created a furor last spring by declaring that "we've got a duty to die and get out of the way with all of our machines and artificial hearts, so that our kids can build a reasonable life," reasserted" that view last week. Said he: "High-tech medicine is really the Faustian bargain, where for a few extra days of life, we have to pay the price that could bankrupt the country."

Pay the price--the argument keeps coming back to that. When people are sick, they and their families hardly question the price; somebody will have to pay--the insurance company, the Government, the hospital. Humana, for one, is waiving all heart implant fees for Schroeder and other pioneering patients, though this may serve primarily to give the institution a commanding leadership in the field of artificial hearts. But somebody does eventually have to pay.

Dr. Thomas Starzl, a noted transplant surgeon at the University Health Center in Pittsburgh, argues that "the cost of transplants is no higher than the cost of dying from severe diseases of vital organs." A patient can run up expenses of $250,000 before getting a liver transplant, Starzl points out. Nevertheless, the prices of organ transplants remain staggering: heart transplants cost somewhere between $100,000 and $200,000 (Clark's hospital bill was $200,000, not counting $9,000 for the artificial heart, $7,400 for its pump, and the $3,000 or so per year that it would have cost him to run the system if he had survived). The prices for other organs are comparable. A liver transplant costs $135,000, and a year of rehabilitation treatment can double that. Bone-marrow transplants run to $60,000.

Organ transplants are by no means the only miracle cures provided by high-tech medicine. A hemophiliac's Autoplex injections, which stimulate blood coagulation, can cost up to $100,000 to keep him alive for three months. Dialysis machines for kidney patients, which pump the blood through an artificial cleansing device, cost nearly $20,000 per year.

If there were only a few desperately ill patients to be saved, extraordinary measures could be organized to save them. At one of the Humana press conferences last week, a young woman named Theresa Garrison sat wearing a T shirt that said HELP US HELP AMIE LIVE. Amie Garrison, 5, of Clarksville, Ind., was born without bile ducts, which drain bile out of the liver, and she will die unless she gets a liver transplant. A country-and-western band has so far helped raise $20,000, but the Garrisons also need publicity to find a liver donor. Both Indiana Senators are assisting. To further promote Amie's cause, the Garrisons hope she can join President Reagan in lighting the national Christmas tree next week.

But there are at least 150 other Amies around the country who are hoping for liver transplants, and the need for other organs runs into many thousands. Medical insurance firms generally decline payment for such operations on the ground that they are still experimental, though Blue Cross of California has paid between $95,000 and $100,000 for each of two heart transplants this year. The prospect of the Federal Government taking over the financing is none too cheering either, since the Social Security system is already staggering under a burden of an estimated $85 billion in annual medical costs.

The only real precedent for a federal intervention is Congress's decision in 1972 to pay 80% of the ruinous cost of kidney transplants and dialysis for anyone whose kidneys fail. Congress expected to pay nearly $140 million for 5,000 to 7,000 dialysis patients. The first year's bill came to $241 million for 10,300 patients. In a decade, the number of patients has soared to 82,000--including dying cancer victims and nursing-home octogenarians--at a cost of $2 billion, which accounts for 10% of all Medicare payments for physicians.

Heart replacements could run considerably higher than that (some guesses go as high as $40 billion).

The number who could benefit from artificial or transplanted hearts is usually estimated at 50,000 per year, possibly 75,000. Multiplying 50,000 cases by an average cost of, say, $150,000 per operation comes to a breathtaking total of $7.5 billion annually.

In theory, even such a cost is quite feasible in a trillion-dollar economy. For the Federal Government, the gigantic bill would represent only about 3% of the budget deficit, the price of three Trident submarines, or about half of what is spent annually on bridge and highway repair. And until fairly recently, the ideal of good medical care for every citizen was proclaimed to be a top national priority. "The fulfillment of our national purpose," Congress rather grandly declared in 1966, "depends on promoting and assuring the highest level of health attainable for every person."

Realistically, however, the question is not how much the U.S. could theoretically afford to spend but how it should apportion the resources available for medicine. Those resources, though not unlimited, are enormous. After a generation of rising costs, the U.S. now spends more than $1 billion every day on health care, 10.8% of the gross national product. Once a country spends more than 10% of G.N.P on health, says Robert Rushmer, a professor of bioengineering at the University of Washington who has studied medical costs in Europe, it begins imposing restrictions on who gets what. "We have to come to grips with the fact that our technical abilities have outstripped our social, economic and political policies," says Rushmer.

"But where has all the money gone?" asks one of Rushmer's colleagues, James Speer, a professor of biomedical history at Washington. "We are not living all that much longer. These expenditures can't be understood in the health of people, but in the creation of a very large industry." Harvey Fineberg, dean of Harvard's School of Public Health, attributes fully one-third of the past decade's increase in Medicare costs to the increased use of high-tech medicine, particularly surgical and diagnostic procedures. "I don't mean to downplay the bravery of this individual," Fineberg says of last week's artificial-heart recipient, "but someone has to speak up for the thousands of people whose names are not on everybody's lips, who are dying just as surely as Mr. Schroeder, and whose deaths are preventable."

Rina Spence, president of Emerson Hospital in Concord, Mass., estimates that the bill for Schroeder's operation represents 790 days of hospital care at her hospital, or full treatment for 113 patients for an average stay of a week. "That's what is in the balance," she says sternly.

In terms of the poor, the comparisons look even worse. "We are not giving basic medical care to people in the inner cities," says Tom Preston, chief of cardiology at the Pacific Medical Center in Seattle. A liver transplant of the kind that little Amie Garrison needs would finance a year's operation by a San Francisco inner-city clinic that provides 30,000 office visits in that time. Says Harmon Smith, a professor of moral theology at Duke: "I don't understand the fascination with these absurd, bizarre experiments when we have babies born every day in the U.S. who are brain-damaged because of malnutrition.

It is a serious indictment of our society." Barton Bernstein, a historian at Stanford, takes a similar but broader view: "Changing the conditions of poverty would improve health more than all the medical innovations we are going to get in the next decade."

Among those who criticize the financial inefficiency of spectacular surgical experiments, the most common prescription is a greater emphasis on preventive medicine--immunization, examination, nutrition--and not just medicine but a healthier way of living. "Control smoking, alcohol, handguns, overeating and seat belts," says Speer, "and that would be a new world." Sensible though such suggestions are, they are highly colored by wishful thinking.

What is far more likely, since overall demand exceeds overall ability to pay, is some form of rationing or restriction.

"There is no question that we face rationing," says Morris Abram, the New York attorney who served from 1979 to 1983 as chairman of the President's commission on medical ethics. But Gregory Pence, who teaches ethics at the University of Alabama Medical School, offers a warning: "Medical costs are uncontrollable because we lack moral 'agreement about how to deny medical services. Deciding how to say 'no,' and to say it with honesty and integrity, is perhaps the most profound, most difficult moral question our society will face in coming years. But face it we must, for the alternative is disastrous."

Triage is the French military term for the battlefront procedure by which overworked surgeons reject some casualties as too lightly wounded to require treatment, reject others as too badly wounded to be saved, and concentrate their limited resources on the remainder. No matter how it is done, triage is a cruel procedure, perhaps an immoral one, but generally recognized as necessary.

Nobody likes to admit that triage is already being employed in high-tech medicine. When a Long Island hospital was accused last summer of posting color-coded charts next to patients who could be allowed to die, its officials loudly denied the district attorney's accusations and the matter was allowed to drop.

But there are many ways of practicing triage. One of the simplest, quite possibly illegal, is by age. One reason both Barney Clark and William Schroeder wanted artificial hearts was that they were both over 50, the unofficial cutoff point for heart transplants. Schroeder had been rejected three times. A more ambiguous standard is the idea that doctors should decide on their own who is best suited for high-tech treatment. But who should get preference--the most sick or the least sick?

The British National Health Service practices triage by delay. For example, it provides heart transplants (110 this year) entirely at government expense, but there are waiting lists of up to a year for all such complex surgery. Though the principle of first come, first served is fair in its random way, rather like a London bus queue, the delay inevitably kills off a certain number of applicants.

And then there is the old tradition of triage by money.

A wealthy Briton who does not want to wait in the National Health Service queue can have a private transplant operation for a reported $13,000. In the U.S. too, and in most of the world, money may not buy health, but it certainly helps.

Ever since the coming of the welfare state two generations ago, there has been an increasing repugnance to the idea of the rich enjoying essential services that are denied to the poor. But that same period has seen a drastic change both in the meaning of essential services and in the way people die. At the turn of the century, most people died fairly quickly of infectious diseases, primarily influenza and pneumonia. Now that those diseases can be cured with drugs, the chief killers are slow degenerative diseases, notably heart ailments and cancer. At the turn of the century, most people died at home, cheaply. Today more than 70% die in expensively equipped hospitals, and it is estimated that half of an average person's lifetime medical expenses will occur during his last six months.

What quantity and quality of hospital care people have a right to expect lies at the center of the problem, particularly since 90% of the bills are paid by some type of organization. As Colorado's Governor Lamm tartly puts it, "We give food stamps, but we don't give people the right to go to Jack's [an expensive San Francisco restaurant] for dinner." Harry Schwartz, writer in residence at Columbia's College of Physicians and Surgeons, maintains that "people simply do not realize the costs of health care. In making medical care seem free, we've made people demand the best. Necessary care is what healthy people on the outside are willing to allocate to us. The best care is what we think we are entitled to. What we've done is build ourselves a system in which no one thinks of the cost of a particular form of care or whether the cost is justified." Schwartz's conclusion: "If you want to cut the costs of health care, you do it by denying people free care."

Financial triage of various sorts is already taking place even among fully insured patients in the best hospitals. In one New Jersey hospital, for example, there were two thoracic surgeons who did a number of bypass operations. One screened his patients carefully, rejecting smokers, overweight people and other risks; the second accepted sicker patients, including several whom the first had rejected. The second doctor's patients had to stay in the hospital an average of five days longer, and when that showed up on the hospital's computers, his privileges were withdrawn on the ground that his work cost the hospital more than insurance carriers were willing to pay.

Despite various criticisms of expensive novelties like the artificial heart, very few scientists see any possibility of retreating from high-tech medicine, which has the glamour that attracts talent, money and publicity. Very few think such a retreat desirable. Most argue that a number of now standard procedures were once regarded as extravagant: the cardiac pacemaker, for example, or the coronary-bypass operation. The artificial kidney, by now commonplace, was attacked 20 years ago in the Annals of Internal Medicine in words much like those now being applied to the artificial heart: "How much money should be diverted by society into an ex pensive procedure that can only deal with a very small fraction of the potentially suitable patients?"

Dr. Denton Cooley, the pioneering Houston heart surgeon, argues that even if the artificial heart ultimately fails, "spinoffs from that type of research would be invaluable. There would be development of new valves and so forth." Michael Hess, professor of internal medicine at the Medical College of Virginia, takes a similar view, though quite cognizant that it is the traditional scientific plea for funds. "This is a case of spending money on research that will be useful in the future," he says. "Only God knows when the future is in this profession, but you have to start somewhere."

Wherever science starts, the Government generally follows. "Let's face it," says Abram, "the Government will end up paying a major portion of the medical bill no matter what happens. That's the way Americans want it. We have never sold seats on a lifeboat, and I don't think we're willing to start now." Albert Jonsen, a professor of bioethics at the University of California, San Francisco, has been serving on a Government panel studying the costs of heart transplants and artificial hearts. Does he think the Government should pay? No. Does he think it will eventually have to pay? Yes.

"It's disgraceful that we are not dealing with more fundamental issues than these big-ticket items," says Jonsen, who estimates the prospective costs of heart replacements at $3 billion and the average increase in the lives of the patients at only three years. "There are lots of people dying, and they are dying because they are not getting adequate care. But once these expensive operations are available, is it fair to people who can't afford them that they should die while those who can afford them live?

You can't have that kind of "unfairness. That's why the Federal Government will be pulled in."

And as it does get pulled lin, many doctors hope that some form of public dialogue and debate will emerge on what should be done. Says Cardiologist Preston of Humana's venture into artificial-heart surgery: "A very small group of people are setting a policy, establishing a method of practice that is taking an inordinate amount of resources without gaining public approval. The public has a right and should be involved in these decisions.

There should be some process for deciding these things rather than following the whims of some research team."

Among all the scientific anxieties, however, Prince|ton Economics Professor Uwe Reinhardt takes a determinedly cheerful view of the prospects. "Where is the crisis?" he says. "I have yet to see any real signs of it." Reinhardt predicts that healthcare costs could grow from the present 10.8% of G.N.P. to 12% or 13% before public opposition became serious.

"Americans will get disillusioned with defense spending long before they are disillusioned about spending money for health care."

If any such disillusionment does come, he believes, the solution is to cut back not on advanced research but on overused routines: hysterectomies, annual X rays, marginally useful laboratory tests.

The Government is already following a similar line of attack for Medicare patients by reimbursing hospitals at fixed rates for many medical procedures.

How high a price for modern medicine is too high a price? There is, as usual, no clear answer. The problem itself reflects a paradox best stated by French Novelist Andre Malraux: "A human life is worth nothing, but nothing is worth a human life."

--By Otto Friedrich.

Reported by Barbara B. Dolan/Louisville and Dick Thompson/San Francisco

With reporting by Barbara B. Dolan, Dick Thompson