The Select (15 page)

He returned to the dais and surveyed
the class for a moment before speaking again. Tim found Dr. Alston
a bit too pompous but the subject was fascinating.

"In an ideal world," Dr. Alston said,
"there would be a donated organ waiting for every person who needed
one, there would be a dialysis machine for every chronic renal
failure patient who was a difficult match, bypass surgery for every
clogged coronary artery, endarterectomy for every stenotic carotid,
total replacement surgery for every severely arthritic hip and
knee...I could go on all morning. The sad, grim truth is that there
isn't. And there never will be. And what is even grimmer is the
increasing gap between the demand for these high-tech, high-ticket,
state-of-the-art procedures and society's ability to supply
them.

"Consider: there are now
around thirty million people over age 65 on Medicare. In the year
2011, when you are in the prime of your practice years, the first
baby boomers will hit Medicare age. By the year 2030 they will
swell the Medicare ranks to 65 million. That is nothing compared to
what will be going on outside our borders where the world
population will have reached ten
billion
people."

Dr. Alston paused to let his words
sink in and Tim struggled to comprehend that figure. Ten billion
people—almost twice the planet's present population. Who the hell
was going to care for all of them?

As if reading his mind, Dr. Alston
continued.

"Don't bother cudgeling your brains to
figure out how to care for the world's population when you'll be
hard-pressed enough satisfying the demands of the geriatric baby
boomers. And believe me, those demands will be considerable. They
will have spent their lives receiving the best medical care in the
world and they will expect to go on receiving it."

"
Is
it the best?" a voice challenged
from the rear.

"Yes, Mr. Finlay. It is
the best. You can quibble about delivery, but when those who can
afford to go anywhere in the world need state-of-the-art treatment,
where do they come? They come to America. When foreign medical
graduates want the top residencies and post-graduate training,
where do they apply? To their own country's medical centers? No.
They apply here. The U.S. can't handle more than a fraction of the
foreign doctors who want to take residencies here. Conversely, how
many U.S. medical school graduates do you hear of matriculating to
Bombay, or Kiev, or even Brussels, Stockholm, Paris, or London?
Have you heard of
one
? At the risk of sounding chauvinistic, this is where the
cutting edge of medicine gets honed."

Tim felt a guilty surge of pride. If
the U.S. had the best, then certainly he was enrolled in the best
of the best. He made a little promise to himself to put what he
learned at The Ingraham to good use.

"But back to our elderly baby boomers:
Who is going to supply their enormous demand for medical care? That
demand will eat up a proportionally enormous portion of the GNP.
The national debt was one trillion in 1980. It is now approaching
five trillion. Who can guess what it will be by the time the
twenty-first century rolls in? Who is going to pay for all that
medical care? In an ideal world, it would be no problem. But in
this world, the real world, choices will have to be made. In the
real world there are winners and losers. Some will get their
transplant, their endarterectomy, their chance to resume a normal
life; others will not. Who will decide? Who'll be making the list
and checking it twice, deciding which ones receive a share of the
finite medical resources available, and which ones do
not?

"Is that playing God? Perhaps. But
someone must make the decisions. Ultimately the guidelines will be
drawn up by politicians and administered by their
bureaucrats."

Tim lent his groan to the others
arising from all sides of the lecture hall. Dr. Alston raised his
arms to quiet them.

"But you
can
have a say.
Ultimately you
will
have a say. Often the final say. Look at the tacit decision
you all made this morning. How many of you considered the homeless
woman for the transplant?"

Tim scanned the hall from his rear
seat. Not a hand went up.

Dr. Alston nodded slowly. "Why not,
Mr. Jessup?"

Jessup started in his seat like he'd
been shocked. "Uh...I...because it seemed the other candidates
could put the transplant to better use."

"Exactly! Societal worth is a factor
here. There are individuals who give much more to the human
community than they receive, and there are those who put in as much
as they take out. And then there are those who contribute
absolutely nothing but spend their entire existence taking and
taking. In the rationing of medical resources, what tier should
they occupy? Should they be classed with the hard-working majority
where they can siphon off valuable health care resources in order
to continue their useless lives at the expense of the productive
members of society?"

"No one's completely useless," said a
female voice. Tim recognized it as Quinn's.

Good for you,
babe.

Dr. Alston's eyes gleamed. "How right
you are, Miss Cleary. And someday it might fall to you to help
these people become useful, to guide them toward making a
contribution to the society they've sponged off for most of their
lives. But more on that another time. The purpose of this course is
to give you the tools, the perspectives to make the monumental
moral and ethical choices which will become an everyday part of
medical practice in the future."

So saying, Dr. Alston had ended his
introductory class in Medical Ethics. Tim had felt intellectually
alive for the first time since classes had begun. He'd vowed then
never to miss one of these classes.

He was remaining true to that vow this
morning, hangover and all.

WHERE ARE THEY
NOW?

Quinn and Tim had stopped before the
huge pin board in the main hall of the Administration Building, the
companion to the one in the caf. She'd glanced at the display in
passing on a daily basis, but this was the first time in a while
she'd stopped to look at the list of graduates of which The
Ingraham seemed the proudest. Tim stopped beside her.

As she read through the names and
their locations all across the country, she was impressed at how
far and wide the Ingraham's graduates had spread from this little
corner of Maryland. They ran inner-city clinics or nursing homes
from Los Angeles to Lower Manhattan to Miami, Chicago, Houston,
Detroit, and all points between. And all were active staff members
of a KMI medical center which was never far away.

A thought struck her.

"Doesn't anybody come out of The
Ingraham and practice medicine in the suburbs?"

"Maybe," Tim said. "But I don't think
they're listed here."

"Weird, isn't it," she said as they
walked on. "Dr. Alston's always talking about ranking patients
according to societal value, and the way he talks you'd figure he'd
place inner-city folks at the bottom of the list. But here you've
got all these Ingraham graduates spending their professional lives
in inner-city clinics."

She couldn't say exactly why, but
somehow the "Where Are They Now?" board gave her a vaguely uneasy
feeling.

THE WORLD'S LONGEST
CONTINUOUS

FLOATING MEDICAL BULL
SESSION

(I)

"Not tonight," Quinn told Tim as he
tried to get her to sit in on the bull session when it moved into
his room. "I've got to crunch Path."

"Lighten up or you'll wind up like
Metzger," said a second-year student she didn't know.

"Who's Metzger?" Quinn
said.

"Someone from our year. He studied so
hard he began hearing voices in his head. Went completely
batty."

"Or how about that guy in the year
before us?" said another second-year. "The guy who went over the
wall. What was his name?"

"Prosser," said the first. "Yeah. Work
too hard and you might pull a Prosser."

"What does that mean?" Quinn
said.

"One night he upped and left. Vanished
without a trace. No one's heard from him since."

"Okay," Quinn said. "I'll stay. But
not too long."

"All right!" Tim said, making room for
her beside him. "Where were we?"

It was some sort of tradition. No one
knew how it got started, but it had been going as long as anyone
could remember. The floating bull session, wandering from room to
room, from floor to floor, changing personnel from night to night,
hibernating during class hours and sleep time, but reawakening
every night after dinner to pick up where it had left
off.

Quinn rarely got involved in the
sessions; she had too much work to do, always seemed just on the
verge of—but never quite—catching up. But when she did sit in, the
topic almost always gravitated toward Dr. Alston's lectures. Like
tonight.

"I was up," Judy Trachtenberg said. "I
was just saying that if rationing of medical services is
inevitable, maybe the elderly should be put at the ends of the
waiting lists."

"Sure," Tim said. "I can just see you
telling your grandmother she can't have that hip operation because
she's over 75."

"So, I'd find away to squeeze her in,"
Judy said with an expressive shrug.

Her casual attitude offended Quinn. As
much as she wanted to avoid getting mired in one of these endless
conversations, she had to speak.

"Either you believe in what you're
proposing or you don't," she said. "You can't say this is how we're
going to do it, these are the rules and they apply to everyone
equally—except my friends and family."

Judy laughed. "Quinn,
where have you been for the past thousand years? This is the way
the world works.
What
you know is nowhere near as important as
who
you know."

Quinn felt herself reddening but
pressed on.

"But then you run into the corruption
of the magnitude of old USSR-style Communism, where the size of
your apartment and the amount of meat on your plate depended on how
buddy-buddy you were with the local commissar. I don't think that
kind of system is the answer."

"Well, we need
some
kind of system,"
Judy said. "Like a national health insurance program that will keep
costs down so we can distribute the services as broadly as
possible."

"And end up like the
Brits?" Tim said. "No thanks. Their system is broke and they're
already rationing care to the elderly. A million people on waiting
lists. Nobody over 55 gets dialysis. Chemotherapy and coronary
bypasses are strictly rationed too. That's pretty cold. That kind
of system seems to insure that everyone gets
some
health care but no one
gets
great
health
care. And I'm one hundred per cent against rationing."

"So am I," Judy said. "But since I
don't plan to practice in Shangri-La, what do we do when we can't
treat everybody on demand?"

"Do it on a need basis," Tim said.
"The guy whose heart has the worst coronary arteries and is just
about to quit gets first spot on the list, and the next worst gets
second, and so on."

Quinn said, "But what about the guy
who's far down the list with only one bad coronary artery, but his
angina's bad enough to keep him from running his fork lift? Does he
have to wait till he's in cardiogenic shock before he gets some
help?"

"If he gets worse, we move him up the
list."

"In other words, under your system
people will have to get sicker before they can get
well?"

Tim scratched his head, his expression
troubled. "You know, I never looked at it like that."

"Okay, Quinn," Judy said. "Now that
you've shot everything down, what's your solution to the
mess?"

"The
coming
mess," Quinn said. "Dr.
Alston talks like it's already here, but it's not. And with the way
medical knowledge and technology are advancing, the entire practice
of medicine could be revolutionized by 2011. It might be nothing
like what we see today. We'll have new resources, new methods of
delivery, we might be able to handle —"

"You can't count on that," Judy
said.

"Technological growth is exponential,"
Quinn said. "As the base broadens—"

"You still can't count on
it."

Quinn sighed. Judy was right. No
matter what happened, the Medicare population was going to double
in the next thirty to forty years, but medical resources weren't
going to double with them.

She had a sudden vision of the future.
She found herself in the worn-down and rusted-out body of an
elderly woman, seventy-six years old, with a failing heart,
gallstones, and arthritis, trudging from specialist to specialist,
clinic to clinic, hospital to hospital, trying to find relief, and
being told repeatedly that none of her conditions met the
established criteria that would allow immediate medical
intervention, so she'd have to wait her turn.