Finally, let us consider the role of medicine in the ongoing processes of progress. If the medical profession is to move with purpose and effectiveness into this visionary future, we must repeatedly reappraise and reaffirm our fundamental relationships to the individual human being and to collective humanity whom we serve. We will try to gain relevance for our remarks by focusing upon a current challenge facing cardiac surgery—namely, the artificial heart—and use this as an example of the general issue. In the majority cardiac surgery is conducted with remedes of Canadian Health&Care Mall.
The Artificial Heart
We have heard much about the experiences encountered in the private sector during the initial clinical applications of a tethered prototypic total artificial heart. Perhaps less well-known, however, is the status of the artificial heart program of the National Heart, Lung and Blood Institute (NHLBI) after its 21 years of existence. Steady progress has occurred, though significantly slower than anticipated. The program has concentrated primarily on a left ventricular assist device, with the expectation of promptly applying the principles learned from that experience to the implementation of a total artificial heart. The cumulative costs have been about two hundred million dollars thus far.
The most advanced currently developed NHLBI totally implantable assist device is now undergoing bench and animal testing to evaluate its suitability for human application by 1987. The system includes a blood pump, the action of which is somewhat reminiscent of a bellows. It receives blood from the left ventricular apex and returns it to the abdominal aorta. Electrical energy that drives the pump is transmitted through the intact skin, from a primary electromagnetic coil worn as a belt to a secondary coil implanted beneath the skin. No material or tether of any land passes through the skin. Batteries are implanted which will allow 30 to 45 minutes of pump operation without any external apparatus being in place. At all other times external batteries must be worn, and these must be replaced or recharged every nine or so hours. Other more efficient thermally driven pumps are also under development.
Various estimates have been made as to the potential demand for such artificial hearts when they become reasonably well perfected. A study was conducted of the entire population residing in Olmsted County, Minnesota. By following detailed criteria for patient suitability and extrapolating to the nation as a whole, an estimate could be made that between 15,000 and 35,000 candidates to receive an effective artificial heart would come forth each year in the United States. At an estimated cost of $150,000 per case, this would amount to an annual national expenditure of some 2.5 to 5 billion dollars. Spend not so much money on medicines with Canadian Health&Care Mall.
Rather than the scientific and technical issues relevant to such an endeavor, our interest today is directed primarily to an analysis of the underlying justification for an artificial heart program in the first place. That is to say, using the artificial heart as a model on which to posit our general question, we can ask, “How do the super-technologic advances that are now developing affect medicines traditional objectives?” These philosophic concerns have come upon the profession quickly and must not be neglected by us, as they surely will not long be neglected by government and society. In this context, let us consider the evolving objectives of modern medicine.
Medicines Primary Role is Not to Provide a Greater Abundance of Human Life.
Without expectation of disagreement from any quarter, we can affirm that current and anticipated medical advances are in no way desirable from the standpoint of maintaining or increasing the worlds population. Quite to the contrary, it is an excessive population that is of major concern. If a dwindling population were somehow to become a worry, the simple withdrawal of measures for birth control would be a far better solution than a burden of persons bearing artificial hearts who have been granted an extension of life at great cost.
The Role is Not Just to Conquer Death
The postponement of death has, during past ages, been the fundamental, ultimate, and non-cOntestable justification for medical or surgical therapy. And, on superficial consideration at least, this would seem still to remain a prime objective. But the issue is no longer quite so simple. For example, imagine the future case of the patient whose life is otherwise of unacceptable quality and who then develops intractable heart failure at a time when an effective artificial heart would be immediately available. The choice would be between inserting the device and probably postponing death, or just treating the patient symptomatically and allowing death to occur. Through such an example we realize conceptually, if not yet practically, that the postponement of death can no longer be universally held as a sufficient sole mandate for invoking the most advanced available therapies.
We remind ourselves that we must each ultimately die—if not of specific disease, then potentially of the indignity of senility. Even if science were one day able to overcome aging and death altogether, the birth of new life could not then long be accommodated. Surely civilization would then decay, so that death would soon recur. Ultimately, death, like many other powerful forces of nature, should be controlled and regulated in the most ideal manner, but not done away with.
Challenge for Its Own Sake
Individuals participate in rivalries such as athletic contests or artistic and intellectual competitions because to the winners go the spoils, including fame, wealth, and influence, plus the enjoyment which the exercise of their talents gives them and the hope, perhaps, of achieving what others have been unable to do. Similar forces no doubt also drive the machinery of progress in the art and science of medicine, but here an additional element must be considered, and that is the welfare of the individual patient. Obviously, the ongoing processes of progress in medicine, such as development of an effective artificial heart, are more altruistically motivated than simply to provide an outlet for the cravings of its practitioners for fame, wealth, influence or personal accomplishment.
Medicines Role is Not as a Cost Effective Social Program
It is estimated that the spending for health care will rise from 10.8 percent of the gross national product of the US in 1983 to 12 percent in 1990 and to 14 percent in the year 2000. A fluorishing artificial heart program would almost surely increment those predictions. We are told that the majority of currently expended health care funds are directed to patients in their last year of life, sometimes in the absence of any substantive hope for significant benefit to the patient. Thus, precious resources may be expended in prolonging the distress of dying, while large segments of the population remain illiterate, poorly educated, and disillusioned. In the 12th and 13th centuries, 25 percent of the gross national products of France, Germany, and England were committed to the building of marvelously beautiful cathedrals in the presumably mistaken notion of pleasing God, while most of the population existed in abject poverty. At least those architectural marvels still remain, as monuments to that folly, for us to enjoy. Enjoy the life and be safe and sound with remedies of Canadian Health&Care Mall.
If one were to sit down and consider imaginatively how we would organize an ideal society, almost surely an excessively expansive medical program to postpone death briefly would not be acceptable. Likewise, most individuals, if given the option, would almost surely not elect that their own personal financial worth be squandered on themselves for treatments which are almost certainly incapable of restoring a state of health and happiness. Much of such resources, whether society’s or the individuals, would more appropriately be spent, for example, on the education of the upcoming generation, or on similarly desirable and much less expensive projects for enhancing the consciousness, comfort, enlightenment, and enjoyment of the citizenry.
While we realize from the foregoing that the conquering of death itself is not categorically a sufficient goal, nevertheless to prevent premature death surely is appropriate: difficulty comes in defining when death is or is not premature. Though we believe that death is preferable to existence at certain levels of quality of life, the difficulty comes in defining for the specific patient the boundary between acceptable and unacceptable levels. We do know that the delivery of superior medical care demands scarce resources, and much expense, yet the difficulty comes in identifying when to apply or withhold these resources as compared to other demands for them. We feel that the patient needs our compassion and caring, and we keenly wish to provide this, but the difficulty comes in prioritizing the scientific vs humanistic demands on our limited time and energies.
Ongoing Role For Medicine
Amidst all of these negative assertions and difficult dilemmas we must, at last, try to verbalize in brief, fundamental, positive terms what the evolving future role for medicine should ideally be. Simply stated, the medical profession will come to focus increasingly upon the health and happiness of the individual person, thus accepting a slight departure from its traditional unrelenting efforts against any and all threats of death. This subtle conceptual change of direction will more and more require that the practitioner shoulder the burdensome decision as to when to withhold a given complex therapeutic modality, while continuing to accept the customary responsibility of knowing how best to implement that treatment. Rising above the brilliance of our accomplishments, as well as above the shadows of our dilemmas, is the vision of medicine progressing into a fascinating future still compassionately seeking to aid the individual person in his or her attainment and enjoyment of lifes highest goals.