medical procedures is not playing God, e’er more 7nen andrnwomen will prefer to minimize their suffering rather thanrnmaximize the length of life. Seeking their o\ n interest, indi-rn iduals in a national health care system can advance the interestsrnof the general body politic b)- refusing the most heroicrnmedicine.rnBut the quasi-suieide made possible b a living will is easierrnto accept than one person “turning off the switch” for someonernelse. Many people call this murder. When someone goesrninto a eoma, the vegetative condition may continue for years.rnhi the absence of a living will the financial cost of keeping arn”human egetable” alive may run into the millions of dollars.rnThe emotional cost maybe even greater: imagine the sufferingrnof the parents of 15-vear-old Suzanne Pacttc, who became comatosernfollowing a tonsillcetomv in 1956. After 20 ears ofrnliomc care b her mother, the daughter died without regainingrnconsciousness. Those who support turning off the switch onrnunconscious incurables must answer to charges that they arerntring to create a “Brave New World” a la Adolf Hitler. Theyrnare warned about the “slippery slope” of ethics. The dangersrnare real; the criticisms must be met.rnThe expensive prolongation of a kind of life the individualrndoes not want may also be contrary to the interests of thernstate. The key issue is this: the resources aailable for doingrngood are al\as limited. Money is limited, but argumentsrnbased on moncv often do not earrv much conxietion withrnpeople who arc undisturbed by the increase in the nationalrndebt. Our indifference to the al^straetion of monev has corruptedrnour judgment. More importantU, the phsical realitiesrnbehind the abstraction—medical resources such as hospitals,rnphsieians, and nurses—are also limited.rnFaced with demands that exceed resources, what should wcrndo? C)biously, we have to ration the resources. But how? Arnlottery would, by definition, be fair; but would such indiscriminaternrationing satisfy us? I think not. What we want isrndiscrimmaiive rationing. But what criteria should we use for discrimination?rnFor the far end of life a rational path has alread been blazedrnin Kngland and Canada. Though the details ar, in bothrncountries expcnsic high-risk operations such as heart and kidnc”rntransplants are denied to patients o’er the age of 80.rnThree considerations weigh into this decision. First, the probabilityrnof surviving the operation is less for older people. Second,rnsince their expectation of life has alread’ been greatly reducedrnby age, the operation may cssentialK be wasted. Third,rnif the medical resources devoted to the aged were diverted tornearing for the young, more total ears of life would be saved. Asrnan economist might put the matter: geriatric medicine comesrnat a high “opportunity cost.” That is, there are much greaterrnopportunities for doing good by devoting the same resources tornyounger patients.rnTurning our attention from the far end of life to the nearrnend—to fetuses and newborn babies—we discover bothrnsimilarities and differences. The medical specialty “neonatolog”rndeals with problems of the newborn. As for the yct-to-beborn,rnit used to be that little could be done to correct abnormalitiesrnat this stage, but the competitive spirit amongrnsurgeons has produced surgery in utero, that is, operations onrnthe unborn fetus. Thus has neonatology been augmented byrndnfenatology, the two comprising perinatology {peri: near,rnaround). Operations performed before birth are almost unbelievablernin their delicacy; and of course the more delicate thernoperation, the more colossal the expense. T’he cost of perinatalrnmedicine is adxaneing much faster than the Gross NationalrnProduct. Surgeons as a group are famous for their enormousrnegos; it is likeK’ that the competitive spirit drives them to seernwho can operate successfully on the youngest embryo (at therngreatest expense, of course). Perinatology might be classifiedrnas an Olympic event, were it not for the fact that microsurgeryrncan never be a spectator sport for the thousands. Onernc[ucstions the use of public funds to support such an esotericrnventure.rniscrimination byrnwhole classes isrnboth wasteful andrncruel when the classes are races,rnas we learned a generation ago.rnBut discrimination in the light ofrncommunity need and individual meritrnis both efficient and just.rnThere is one important difference between medicine at therntwo extremes of life: there is no chance of consulting an embryornor a ver young infant to find out what its preferencernmight be. This does not bother some physicians. Dr. C. EverettrnKoop, before he became Surgeon General of the UnitedrnStates, proudlv reported his role in 22 of the 37 surgeries performedrnon a single baby. The ultimate effect on the subsequentrnlife of the patient has not been reported. Enthusiasts ofrnneonatal interention need to be reminded that a considerablernproportion of the “successes” actually end with serious functionalrnproblems in later life. Reporters are seldom aroundrnwhen the delaed consequences become apparent.rnhi the absence of the “informed consent” of infantile patientsrnwe must try to determine the economic and emotionalrncosts imposed on parents and the community by neonatal intervention.rnThere are cases on record of operations and postoperativerncare costing more than a half-million dollars, hi recentrnyears, babies born to drug-addicted mothers havernintroduced a new drain on the economy. The Los AngelesrnGounty Hospital reports that intensive care of drug-exposedrnnewborns can mount to $1,768 per day. On the other coast,rnone such baby ran up a bill of more than a quarter-million dollarsrnduring its 247-day sta in the floward Uniersity I lospital.rnOne cannot but wonder how many more lies could havernbeen improved, and even saved, by channeling the samernamount of medical resources to regular checkups and immunizationsrnfor children who had far better prospects of living arnnormal life.rnAlready the state of Oregon has bit the bullet of discrimination.rnIn administering federal Medicare funds the state refusesrnto pay for artificial insemination or in vitro fertilizationrnlUNE 1994/15rnrnrn