This book is about the excruciating and complex decisions that must be made as we allocate increasingly scarce health care resources. I have purposely introduced controversy here because I believe that only through debate and deliberation over these sensitive issues will we be able to minimize the emerging crisis in medicine. Although as a society we may never reach a consensus on how best to distribute health care, we can at least agree to engage in an open dialogue among all affected parties and come to agreement on some of the steps necessary to ameliorate the situation. Unless we act to limit the current expectations of the public and make hard decisions now, the scope of the problems we will pass on to our children is staggering.
"Rationing" is a term that incites strong reactions from many persons and groups. When applied to health care, the idea of rationing generates even more severe opposition on ethical and political grounds. The suggestion that we shift our emphasis away from curative medical technologies toward primary care and prevention contradicts the powerful cultural and economic forces that favor a "technological fix" for health problems. To argue further that this preventive approach be designed to include consideration of individual responsibility for ill health caused by personal behavior is to risk condemnation. On all of these points, this book will elicit controversy. I hope that it will also contribute to the rational discussion of these volatile issues and provide a useful addition to the dialogue on the allocation and rationing of health care in America.
In order to illustrate the dilemmas facing us, four areas of health care are followed throughout the book: organ transplantation; treatment of seriously ill newborns; reproductive technology; and fetal health. I have intentionally avoided the inclusion of AIDS. Although . . .