provements as well as initial research and development costs must be spread over fewer and fewer units. The rising prices of new technology in turn compel health care organizations to make often excessive use of it as a means of spreading and recovering costs. To the extent that technological generations become shorter, as they may have been in recent decades, the effect of escalating original cost and shorter production runs is aggravated.
Costs tend to rise because the easy steps are taken first. Technical difficulty tends to increase exponentially. We can see this in the effort to establish the genetic basis of disease: those illnesses determined by a single gene were identified first; then those influenced but not determined by one or two genes; finally, and we are far from there yet, those whose genetic basis is much more complex--multiple genes, undeciphered relations among them in influencing the probability of disease. We see this in environmental research. Chlorination to destroy microorganisms in the water supply and pasteurization were simple. Identifying chemicals that cause cancers or a variety of noninfectious ailments from among a great number of prospects and isolating their influence from that of other causal agents is extraordinarily complicated. Producing vaccines that outwit the mutating variants of viruses and bacteria is not like devising the original smallpox vaccine. This is the basis of Nicholas Rescher's argument that technology faces diminishing returns. 40 If we compare the large amounts spent on research in recent years with the comparatively minuscule amounts spent in the 1930s and 1940s, which led to the sulfa drugs and antibiotics as well as to a number of valuable vaccines, one would have to agree. Yet the limitations of the steam engine were circumvented by the internal combustion engine and in turn by the jet engine. Each technological regime faces diminishing returns but is replaced by successors. It may just be that new technologies originally developed far from the health care industry--molecular genetics and computers and the arts of miniaturization--will give us a fresh start beyond the limits of the chemist and the scalpel.
There is another aspect to diminishing returns: the nature of the human species. We have come so far in the past two or three centuries, from an unhealthy life expectancy of less than thirty years to one that may soon approach eighty, much of it relatively free of sickness and debility, how much further is there to go?