One of the most dramatic differences between this time--the close of the industrial age--and all earlier ones is that people now have an entirely different attitude to disease and to the practice of medicine. Until the late nineteenth century, death was ready to knock at every door at any time in the form of plague, smallpox, diphtheria, typhus, polio, and a host of other diseases. In developed countries, none of these need be feared today because of the widespread use of antiseptics, antibiotics, and vaccinations. Smallpox has now been completely eradicated, and many of the others on the old list of killers have been reduced in certain countries to rare cases of little more than nuisance value to society as a whole. This has come about because hospitals are kept clean, patients are segregated from one another and from the healthy, and drinking water is treated at central locations to remove contamination. It is difficult for moderns to appreciate the scope of these changes. Until less than a century ago, the practice of medicine other than surgery was based on little more than superstition, and a sick person was in many cases better off dying in peace than calling a doctor.

Will this trend continue to the point that most communicable diseases eventually become a thing of the past? Pessimists point to modern population mobility and suggest that some new disease (natural or deliberately engineered) could even now sweep the earth in record time and carry away a large percentage of the population before a cure could be developed. A disease as deadly as AIDS but as easy to catch as the flu could infect most of the world's population in a matter of weeks. No defense could be devised in time to save any except by the small percentage who would be naturally immune. Moreover, people in the developed nations have become complacent about vaccinations against what they regard as rare diseases, and may have made themselves vulnerable. Optimists are sure that new drugs combined with new methods of tailoring enzymes, proteins, and "fake" viruses to stimulate antibody production will all but eliminate the transmission of disease in the next few decades.

The hardest problems to solve are those of viruses, the semi-living capsules of genetic material that invade the body's cells and take them over as factories to replicate themselves. Some, the so-called "retroviruses", are capable of hiding in the body for years before being triggered to begin or continue their damaging behaviour. These include the viruses that cause herpes and AIDS.

One line of research has concentrated on curing or preventing the symptoms of retroviruses, possibly by forcing them back into dormancy with the hope that eventually, a way may be found to remove them from the body altogether. Another line focuses on interfering with the virus in such a way as to prevent its reproduction or to foil its mode of attack on the body. Still others seek to tailor molecules that can bind with the DNA of the virus directly to kill or inactivate it. All hold the promise that eventually all viral disease can be eradicated.

When the human immune system and its behaviour with viruses is sufficiently well understood to achieve this, a true watershed will have been passed--the last barrier major to the elimination of communicable disease will have been eliminated. The "cure for the common cold" is an old touchstone in such research; achieving that implies the ability to defeat almost all viruses.

Recent experience with antibiotics, however, ought to sound a cautionary note. These work by selectively killing off most of the target organism population. Usually, the smaller numbers that remain are then taken care of by the body's immune system on its own. However, the prolonged use of antibiotics guarantees that the only remaining bacteria will be the ones that were resistant to the antibiotic. Even if this resistance is conferred by an otherwise unfavourable or recessive mutation, eventually the entire population of the organism will be resistant. Such "superbugs" can then defy modern medicine in wreaking their havoc on humankind. This selection of the existing bacterial population for resistance has some potential for catastrophe, and it cannot be denied that a similar caveat may hold for the treatment of viruses. However, the human population had, by the end of the twentieth century, a much better strategic position in the war against both kinds of disease than it had fifty years earlier.

Neither has medical progress been confined to the problem of communicable diseases; numerous surgical procedures are routinely performed today that were unheard of a century ago. Appendicitis is now seldom a killer, and many kinds of cancer and heart disease can be beaten. The people of industrialized countries live longer, are healthier, and are more active and productive later in life than at any time in the past. They have forgotten the times when the limited skills of surgeons were exercised without antiseptic or anesthetics and hospital patients usually died--if not of trauma, then of infection. Instead, most live long enough to become the victims of cancer, heart disease, accident, or suicide rather than of surgery, infection, or communicable disease.

Those advances have not come without cost, for medical science now allows more people with genetic defects or chromosomal damage to live and pass on those defects to the next generation. Old age comes more slowly than it ever has, but death is postponed only at an ever increasing cost for more sophisticated medical techniques and larger extended-care facilities. Thus, the modern medical system is under constant pressure, forced to make difficult choices over the allocation of scarce and costly resources. The resulting ethical questions concerning the application of life-saving or life-prolonging technology can be divided into three kinds--those of facilities, those of cost, and those of appropriateness.

It is often the case that a hospital is severely constrained in its ability to provide complex services. For instance, the number of open-heart repair procedures that can be performed at a given facility in a year is limited by the availability of both operating rooms and qualified surgical teams. Some means of scheduling the clients of such services must always be devised. This may be strictly first-come-first-served, or surgery may be prioritized by the severity of the case, or it may be dependent on some attempt to place a value on the client. This value may derive from the perceived contributions of the person to society (i.e., a famous scientist or artist versus a common criminal or skid road habitue). It may be a monetary value (i.e., the ability to pay for priority treatment). It may be potential value to society--a young person with a whole life to live being given surgical priority over an aged one whose contributions are in the past. The more severe the shortage of resources and the more fundamental the issue--here it is life--the greater the pressure both on those who must wait and on those who control the resources.

In addition, new diagnostic and treatment techniques are always very limited in availability, sometimes for a protracted period. For example, two of the latest are magnetoencephalography (MEG), which measures the magnetic fields of brain cells, and nuclear magnetic resonance (NMR), which is a means of scanning and mapping the internal body organs. The former is useful in the diagnosis of brain disorders such as epilepsy, cysts, and tumors. The latter can produce whole body images and even a spectroscopy, or chemical map, to pinpoint subtle imbalances in the body's functioning. It also can pinpoint tumours and soft tissue damage. Such machines represent very high technology, and come with an equally high price tag. They are expensive and complex to build and operate, and their results require special training to interpret. As a result, they are relatively scarce, as the latest techniques in medicine always must be.

Limited availability of resources is a broad and growing problem to modern medicine. As the population ages, and as new ways are developed to prolong the life of some people, the shortage of facilities and trained personnel become ever more severe, as do the problems of rationing--deciding who will get sophisticated treatment, who will get basic treatment, and who will get none. An act-oriented ethic may seem to demand the maximum possible medical effort to be available for all. A utilitarian one demands the greatest net medical benefits for the largest number of people. But, these are both ideals, for as long as resources for diagnosis and treatment are scarce--and it seems inherent in the present system that they always will be--there may be no solution to the problems of allocation that can possibly satisfy everyone. Consequently, it becomes necessary for both practical and ethical reasons to pursue the development of medical services that can be delivered with the least of scarce and expensive facilities and personnel. One such method is the delivery of treatment at home rather than in a hospital, and by personnel with less training than a physician (perhaps even be self-administered).

At the same time, it is necessary to seek technological solutions to certain problems caused by existing techniques. For example, diagnosis is often achieved only by batteries of complex tests, sometimes using scarce and expensive machines or drugs. It is impossible to deploy such facilities for every doctor in the world, so it is necessary to devise cheaper, more automatic diagnostic techniques in order to make even the existing level of medical knowledge usable.

In addition, society itself, by its very industries, sometimes creates new medical disorders that require sophisticated diagnosis and treatment. Examples include chemicals such as urea formaldehyde and a variety of pesticides, substances such as asbestos, and damage from radiation accidents.

The problems of paying for new types of treatment is also becoming more acute with each passing year. For instance, should the person who receives a heart or lung transplant be required to pay all, part, or none of the cost? Does it make any difference if the person's own life-style (smoking, drinking, driving) contributed to or caused the problem in the first place? Should the employer be responsible if the procedure was necessary because of some job-related activity? Should the government pay just because the person is a citizen? What if the patient is not a citizen?

As diagnostic techniques and drugs increase in sophistication, they increase in cost as well. Complex treatments, particularly when new, may require hundreds of thousands of dollars, amounts far beyond the ability of most individuals to pay. Neither can medicare programs grow indefinitely without bound, for they will consume the entire budgets of governments that sponsor them long before any end to their growth is in sight. It is not possible to afford every possible medical technique for every patient, yet the physician who does not perform them risks a malpractice suit. Insurance premiums to cover such legal expenses push up medical costs even more. In addition, there is the expense of training medical personnel so that they stay abreast of latest developments. Thus, from a cost perspective alone, it is clear that new and expensive technologies will always be rationed. There will always be the question of whether a procedure should be performed just because it is possible, or only when it is affordable. There will also be the question of who should make such decisions--patients, doctors, lawyers or politicians?

For instance, suppose that the president of the United States, a billionaire industrialist, and a poor but Nobel-winning cancer researcher are all dying. Each requires a liver transplant within twenty-four hours and only one surgery can be performed. Which should be given the treatment? Suppose the issue is complicated because both the first two could make hard-to-refuse offers to the medical facility that would see it grow in size and in the ability to treat others. Treating many people like the poor researcher could, on the other hand, put the facility out of business, even though treating a cancer researcher might eventually cause more benefit to more people. Can the course of action likely to cause the most good to the largest number of people be determined? Can the right thing to do be determined? On a larger scale, can medical practitioners ever refuse necessary treatment to groups of people who cannot pay, while advancing it to those who can? What about the same question asked of unnecessary (say, cosmetic) treatment that is requested by a patient?

Some examples may be extreme, but similar ones are commonplace. Consider the dilemma faced by the administrators of medical insurance plans when asked to fund complex, expensive, and risky transplant operations for children at remote places. The cost for one such operation may well be greater than that of keeping a hospital bed at home open for a year. How many such special procedures can be afforded before the whole system deteriorates in its ability to provide care for society as a whole? How many community appeals for such special cases will distraught parents be able to make before both sympathy and wallets become exhausted? Should elective surgeries be funded just because the patient wants them, or should only the ones needed be paid for--and who is to decide which ones are needed?

Choices may also arise between expensive and inexpensive treatments. For example, a patient with poor eyesight might be treated with a prescription for glasses or contact lenses at a cost of under a hundred dollars or might be given an expensive laser treatment to reshape the cornea and eliminate the need for external correction. Should there be (in this case, or any other) different treatments depending on the wealth of the patient? Who should pay for the poor man's glasses, or the rich woman's corrective surgery? As the cost of medicine rises, so does the number of people who cannot afford even basic services, let alone exotic new techniques.

If MRI diagnosis is needed to determine if a person has a tumour and there is a six-month backlog, should the person be allowed to have the procedure done privately if willing to pay (this may not be an issue in countries that have no public medicare)? Or, should exactly the same opportunity be available to everyone, regardless of their wealth and the time it would take? What if the private clinic's purchase of a machine means that none is available for a public hospital? What if the hospital can charge for some procedures and use the money to finance more hours for public clients?

The wealthy Western nations make important choices all the time when they elect to make resources available for expensive surgeries whose cost could fund thousands of simple, sight-restoring eye operations in third-world countries. Rarely are things so simple that it is apparent to those directly involved that such a choice is being made, but any comparison of medical facilities in different parts of the world makes it obvious that some nations choose to afford far more than others possibly can.

Organ transplant surgery will always have such limitations because of the problem of finding donors and matching the tissue type with the intended recipient. Even if transplant operations become as simple as appendectomies or plastic surgery, ways will have to be found to increase the supply of spare body parts. Today, the presumption in Western countries is that such parts can be removed from a fresh cadaver only with prior authorization from the deceased or the permission of the immediate family. If the individual did not make a point of granting such permission while living, medical staff are understandably reluctant to ask relatives immediately after death, for fear of giving offence to the grieving relatives.

On the other hand, if a potential donor comes into a hospital after, say, a traffic accident, and there is another patient there in need of the badly injured patient's heart, will the potential donor get the best medical care, even when their death could mean life for the other, and vice-versa?

One possibility for alleviating the shortage of organs would be to move to the opposite legal presumption--that the body parts of the newly dead are the property of society and freely available to the medical profession unless authorization has been specifically denied. However, what is more important, the right of the dead to privacy or the need of the living for a new organ? Surely, life must take precedence over privacy in any ethical hierarchy, and yet there is something at the very least dissatisfying or even ghoulish about the idea of routinely harvesting body parts from the deceased, without express prior approval.

Yet, if this seems unattractive, what are the alternatives? One could argue that human organs ought to become commodities like gold, pork bellies, or coffee. After all, the Red Cross already buys blood in many parts of the world (Some countries, such as Canada, have in the past forbidden the purchase of blood from donors and commercial transactions in organs). If blood can be a commodity, then perhaps kidneys, lungs, or even limbs could be treated as such. What is more important, the need to make body parts available when and as needed, or people's reluctance to engage in something that could be likened to the operations of a used automotive parts business?

It should be noted that in countries where people are sufficiently desperate, there is a temptation to make money by selling one's own body parts to the citizens of "enlightened" western countries. Alternately, sufficiently repressive states in need of foreign exchange could decide to farm such organs from its citizens without their consent. Meanwhile, western governments might find the prospect of benefiting their own citizens in this way to be politically irresistible. Who ought to have the authority to allow or deny such transactions? Is it even possible to stop them? Perhaps not, for there is already a lively traffic in such organs from third-world countries to the operating rooms of the West, with only sporadic and ineffectual outcry.

The complexity of these issues is also illustrated by the difficulty experienced by doctors wishing to use transplant parts from newborn but nonviable infants. Sometimes a child is born with much of the brain missing (anencephalic) and will surely die in a matter of hours or days. Some doctors are unhappy that even when parents' permission is given, it may be legally impossible to use organs from such an infant for transplant purposes until breathing ceases, at which point the parts are much less useful. One rationale for forbidding earlier transplants is that the child is a human being--though a very much injured one--and therefore entitled to be allowed to die in peace without being torn apart for spare parts while still alive. Some hospitals attempt to steer a middle course, keeping the doomed infant well oxygenated and healthy, so that the organs will be in good condition when death does come. However, even this practice is controversial, for the definition of death as the cessation of brain activity is hard to apply when much of the brain is missing.

The success of the pro-abortion movement in effectively re-defining an unborn child as a non-person and thus part and property of the mother's body raises the possibility that cash-starved mothers could sell the parts of her unborn child. After all, attempts to prosecute pregnant women for child abuse for taking drugs, or murder for shooting their unborn child have already been dismissed by the courts because the child in the womb has no legal personhood.

The danger in breaking new legal ground in such respects is in defining that severely injured or malformed infants are not human and can therefore be scavenged. If that could be done in such an admittedly extreme case, there would be pressure to do the same to those born with, say, cerebral palsy or Down's syndrome. If those cases were also permitted, then any child deemed unacceptable by the parents for any reason--say, by being the wrong sex--might be at risk. Moreover, there could be no compelling reason to limit this to infants once such a practice were begun, for the precedent would be set whereby anyone could be declared insufficiently human and subject to salvage, such as for failing in school or for being too old. The state that had the power to do these things could also define the members of a race, religion, or banned political party to be subhuman and available for spare parts. Under current North American law, it would seem that even healthy children could be disassembled and sold for parts while still in the womb even if not after birth. After all, it is already common practice to harvest stem cells and other tissue from aborted children, in some cases without any authorization being necessary.

On the other hand, under a hierarchical ethic of the type developed in Chapter 3, even the most severe "defects" would not disqualify a person from the right to live, for such disablements reflect on the quality of the child's future life, not on the fact of it. Life itself clearly has a higher priority than its quality.

A related and equally contentious issue is the use of tissues from miscarried or aborted infants in transplants, corrective surgeries, and other experimental purposes. It has long been known that such tissue has growth and restorative potential not shared by the corresponding tissue from a mature human. Thus, if bone marrow, skin, liver cells, and other organ parts are required to grow well after transplant, there may be no better source than fetal tissue. Whatever one thinks of the ethics of abortion or of the status of the unborn, such a practice has some unique ethical hazards. If the use of such parts were to become an important medical technique, they would become a correspondingly important commercial commodity. Not only would there be a lively trade in such tissues by hospitals and abortion clinics, there might even be a sufficient economic incentive for destitute women to become pregnant and sell the right to abort the child to the highest bidder.

Such outcomes may seem bizarre and repulsive to those who regard the human body at all stages as something much more than a convenient assemblage of chemicals into tissue. To others, such practices are simply the logical and normal outcomes of regarding the parts of the human body as commodities like any other. That is, the conclusions one draws on these and similar issues depend on one's view of the human body. If the body is held either as sacred and inviolable (on the one hand) or as entirely material but constituting the whole of a person (on the other), then it could be argued that the body's parts ought to be left alone. Two normally opposed groups find common ground here--one because of a transcendent view of the body and the other because of the belief that the body is the whole of a person. Members of the former group would want to bury the dead respectfully--and by that they mean intact. Members of the latter group might suggest instead freezing the body against the day when it could be thawed out and brought back to life with all parts intact. Respect is the common theme here.

An entirely different conclusion might be drawn by those who emphasize the immaterial aspects of what they see in a human being. A human being is sometimes viewed as a body and soul dichotomy, or as body, soul, and spirit trichotomy, and there are those who regard the material body as by far the least important of these. With such an emphasis, the dead body is not the whole person and not at all sacred. It is just part of the material baggage left behind when the essence of the person (the soul) departs. Since there is in this view no reunion of personality with that body, the previous owner has no more use for its parts, at they might be used to benefit someone else. Other combinations of these ideas are also possible, and the two conclusions about the value of the body can be reached by other means, so there is little agreement on such issues.

There are two possible techniques for alleviating the supply difficulties associated with transplant operations. The first is to use animal donors, such as pigs or chimpanzees, to obtain the organs destined for human beings. This would have the advantage of solving the supply problem, though some people might be repelled at the prospect of having a pig's heart replace their own, and animal rights activists might also be offended. The second is to develop artificial hearts, kidneys, livers, and so on. This would also solve the supply problem, though the cost of such work has so far been very high, and there is no immediate prospect that such devices can be made and produced in the necessary quantity, with the required reliability and at a reasonable price. Nor does either of these solutions address the availability of surgeons and facilities, or the cost of performing the procedures. Mass availability of artificial hearts would not in itself mean that more transplant operations could be performed; other factors are at least as complex.

This discussion highlights the built-in limitations of surgical techniques--barring some dramatic changes in the availability of transplant parts and other costs, the application of such methods simply cannot increase without limit. Thus, the most sophisticated of today's surgical methods are unlikely ever to become available to much of the world's population. There will never be sufficient funds available to perform every necessary surgical procedure, much less every desirable one--and this is true even if robotic surgeons are developed. However, no one with any sensitivity would want to turn away the sufferer with no hope for relief. Again, necessity seems to force the conclusion that simpler and less costly methods must be found to replace the use of surgery and other complex procedures.

A third set of problems that accompany the allocation of scarce medical resources has to do with the appropriateness of treatment in some cases. For instance, should a doctor do an expensive heart transplant on a patient who is also suffering with a terminal cancer that will probably kill her within two years? Should expensive surgery be done to allow a child with Down's syndrome to live, even though it is known that the quality of that life will be impaired? Some, including courts called upon to judge such cases, have said "no." According to the ethical hierarchy developed in Chapter 3, on the other hand, the answer to both questions should be "yes." Denial of treatment can be supported for economic reasons--neither person is likely to be able to pay society back for the treatment. The expense of the procedure is therefore wasted. Those giving the latter answer could argue that the future cannot be known in advance and that the termination of a life is not an answer, but a reaction born of despair. What is more, everyone dies eventually, even if it is simply of old age. The physician who may be able to give a woman dying of bone cancer a few more years, although pain filled, does not know if tomorrow will bring a cure or a fatal traffic accident to the patient. Has the doctor a mandate to prejudge her life on the basis of an unknowable future?

Questions of appropriateness are also raised in connection with fertility problems, for treatment of such conditions can also be expensive and time consuming and can require repeated hospitalization. Neither is it easy to argue that a woman has a fundamental right to bear children. Moreover, there is already population pressure, and this grows steadily worse. In that light, it is difficult to justify using scarce resources to enhance fertility. On the other hand, it is hard not to sympathize with the plight of one who desperately desires children but is unable to have any, particularly when adoption is unlikely to be an option.

Other questions of appropriateness are quite different. Many concern cosmetic surgery. Should surgery to reduce a nose, enlarge breasts, change the smile, or "Westernize" the eyes be paid for by medical plans, or even allowed? After all, these take up a substantial portion of scarce hospital and surgical resources--ones which, it could be argued, would be better spent on those who are actually sick. How important to society as a whole is the self-image of some of its members? One might agree that correcting actual defects is good and should be done, but how does one respond to the argument that a nose perceived as less than perfect by its owner is a defect? As the population ages and life spans increase, cosmetic surgery will be in greater demand. Some argue that this area should be left rather unregulated, apart from defining "cosmetic" and excluding such surgery from public medical insurance plans. Even some of these might want the government to step in if cosmetic surgery took a bizarre turn. For instance, perhaps some future youth cult would find it "cool" to have orange cheeks, green lips, an elongated nose, and skin flaps instead of hair--all arranged by surgery. Is this different from what is often called "corrective cosmetic" surgery? Even if it is, it may be impossible to draw the line between the frivolous and the acceptable, so "user-pay" may have to rule this area. One could suggest that hospitals might make sufficient profit on such enterprises to subsidize other areas. On the other hand, such activities might make operating rooms and personnel unavailable for other types of work.

As long as current surgical methods are relied upon for replacement or repair of defective body organs, a regulated means of providing the necessary resources must develop, however unsatisfactory it may be. However, many of the surgical methods themselves are likely to remain complex, scarce, and expensive. In all likelihood, those methods will never become available to the world's general population, and the chief problems associated with them will continue to be how patients are selected and who pays rather than, say, the supply of organs as an economic mass commodity. What is required are different technologies--ones that use simple, cheap, and nonsurgical methods. In many cases, the functioning of human body systems are fairly well understood (on a macro level), and so are their dysfunctions--, in theory. This means that solving the problems may be more a matter of applied science or engineering than of pure science or understanding.