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surgeons, or gastroenterologists, what was good for academic medical centers or rural family practices, but not about what they all had in common.
Which is why, by the 1990s, the once-powerful American Medical Association could speak only in vague platitudes. Proposals for reform come from subspecialty groups, and usually reflect rather transparent attempts to benefit those subspecialties. Though unsuccessful in its attempt at health-care reform, the Clinton administration did learn that it could effortlessly play off primary-care doctors against specialists, salaried doctors against those who still work in fee-for-service arrangements, doctors who care for the young against doctors who care for the old.
Our non-system encourages physicians to look after their narrow interests. We are supposed to trust in the invisible hand of the market to organize these competing interests into lower prices, higher quality, and responsiveness to consumer preferences. Those who don't organize and lobby for their own interests get left behind. Faith in the market allows us to avoid asking questions about what a health-care system should look like or about the role doctors ought to play.
Dad retired to Maine, where he seems pretty happy, sipping martinis by the lake and watching the loons. He told me a joke recently about the director of a large HMO who died and went to heaven. St. Peter asked him, "What did you do on earth?" "I was the director of a large managed-care organization," he replied. "Hmmm, that's a tough one, wait here." St. Peter went in, punched away at his computer for a while, and eventually returned, saying, "Good news! I got you three days."
What interests me about this joke is the odd compliment it pays to health care. It's as if we all want to be in hospitals for eternity. Such a vision is not of heaven, but of hell. The better we get at keeping sicker and sicker people alive, so that everybody gets longer and longer stays in the ICU, at greater and greater cost, the worse off everyone will be. The utopia of modern medicine is a curious one indeed, in which the ultimate value of longevity and individual rights goes unquestioned. The American bacteriologist René Dubos noted that "all changes, even the most desirable, are always fraught with unpredictable consequences. The scientist must be beware of having to admit, like Captain Ahab in Melville's Moby-Dick, 'All my means are sane. My motives and objects are mad.'"
Bethann's resuscitation began as medicine but gradually became madness. We pumped and breathed away, the two doctors, providing what we optimistically call "basic life support," but which was actually a grisly sort of last rites. For a moment, I realized that all I was really doing was kissing Bethann good-bye, but then I heard the sirens and blocked the thought from my mind. The paramedics took over and continued the ritual all the way to the hospital.
After Bethann died, Nancy and I tortured ourselves with questions. Did we do everything right? Might we have done better, or was her resuscitation futile from the start? We felt we had failed.
But a funny thing happened. Everybody else told us how glad they were that we were there, and how comforting it was to know that Bethann had received CPR. They had the feeling that, although she died, she had somehow died properly. We harbored doubts, but others were secure. We may have failed technically, but in their minds, we had succeeded ritualistically.
William Carlos Williams, a pediatrician and poet, knew better than most that, in the end, the doctor's task must be assessed by something other than mortality statistics. Cost-benefit analyses identify but cannot solve moral dilemmas. Williams has an almost stoical acceptance of suffering when he writes, "We know the plane will crash, the train will be derailed. And we know why. No one cares, no one can care. We get the news and discount it, and we are quite right in doing so. It is trivial. But the haunted news I get from some obscure patient's eyes is not trivial. It is profound: Whole academies of learning, whole ecclesiastical hierarchies are founded upon it...."
For Williams, the mysteries of science are dwarfed by the mysterious process through which he, as a physician, becomes drawn in by his patients. He is not interested in impossible systems that promise to relieve human suffering. Instead, he is interested in our capacity to respond to the claims that others make upon us with their looks, their sighs, or their sobs.
Fifty years from now, doctors will do things we cannot imagine,
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