The Select

  "Did you get mugged or something?" Quinn said, looking him up and down.

  He smiled and thought: In a way, yes.

  He'd stayed up all night playing five-card stud. The other players had been stand-offish at first—because of his youth, Tim assumed—but after they'd seen he could play, they'd warmed to him. Even started buying him drinks after a while. Jack Daniel's. Many Jack Daniel's.

  Good ol' Tim. C'mon back anytime.

  They loved him. Why not? He'd dropped a couple of hundred.

  Poker. Not his game.

  "No. Just not enough sleep."

  "Well, come on. You're late, and Dr. Alston will cut you up into little pieces."

  "You go on ahead. I'm going to sit in the back. Way in the back."

  He watched her cute butt hurry off and followed at a slower pace.

  Dr. Alston's Medical Ethics: the semester's only non-regurgitant course. It was scheduled for only one hour a week but that hour fell at 7:00 a.m. on Wednesday mornings. Some days it was hell getting there, and today was pure murder, but Tim had never missed it; not simply because attendance was required and strictly monitored, but because the class actually was stimulating.

  I could use some stimulating now, he thought as he slipped into the last row and took a seat in a shadowed corner.

  Dr. Alston seemed to take delight in being provocative and controversial. His manner was brusque, witty, acerbic, and coolly intellectual, as if he were contending for the title of the William F. Buckley of the medical world.

  Tim vividly remembered the first lecture a couple of weeks ago...

  "Most medical schools don't offer this course," Dr. Alston had said on that first morning. He'd looked wolfishly lean in his dark business suit and one of his trademark string ties. The overhead lights gleamed off his pale scalp. His movements were quick, sharp, as if his morning coffee had been too strong. "I guess they expect you to become ethical physicians by osmosis—or pinocytosis, perhaps. And a few schools may offer something called Medical Ethics, but I assure you it's nothing like my course. Their courses are dull."

  Amid polite laughter he'd stepped off the dais and pointed at one of the students.

  "Mr. Kahl. Consider, if you will: You have a donor kidney and three potential recipients with perfect matches. Who gets the kidney?"

  Kahl swallowed hard. "I...I don't have enough information to say."

  "Correct. So let's say we've got a nine-year-old girl, a 35 year-old ironworker with a family, a 47 year-old homeless woman, and a 62 year-old CEO of a large corporation—who, by the way, is willing to pay six figures for the transplant." He pointed toward the rear of the room. "Who would you give the kidney to, Mr. Coyle?"

  "The little girl."

  "She has no money, you know."

  "Money shouldn't matter. I wouldn't care if the CEO was willing to pay seven figures for the kidney."

  "We wouldn't be indulging in a bit of reverse discrimination against a rich, older man over an indigent child, would we, Mr. Coye?" He turned to another student. "How about you, Mr. Greely? Think carefully and unemotionally before you answer."

  Tim was impressed. This was Dr. Alston's first lecture to the class and already he seemed to know every student by name.

  "I believe I'd also give it to the little girl," Greely said.

  "Really? Why?"

  "Because she's got the most years ahead of her."

  "Years to do what? You don't know what she'll do with her life. Maybe she'll perfect cold fusion, maybe she'll die at eighteen with a needle in her arm. Meanwhile you tell the homeless woman, the ironworker, and the CEO to go scratch?"

  He turned toward the second row. "Who would you choose, Miss Cleary?"

  Tim leaned forward when he realized Quinn was on the spot. He saw her cheeks begin to redden. She wasn't ready for this. No one was.

  "The ironworker," she said in that clear voice of hers.

  "And why is that?"

  "Because he's got a family to support. Other people are depending on him. And he's got a lot of productive years ahead of him."

  "What about the CEO? He's very productive."

  She paused, then: "Yes, but maybe he'll get twenty years out of the kidney. The ironworker might get twice that."

  "Perhaps, perhaps not. But the CEO's present position places him in charge of the livelihoods of thousands of workers. Without his management expertise, his corporation could go under."

  Quinn obviously hadn't thought of that, but she didn't seem ready to back down. Tim decided to buy her some time.

  "Are doctors supposed to be playing God like this?" he called out.

  Dr. Alston looked up and pointed at him. He didn't seem annoyed that Tim had spoken without being recognized.

  "An excellent question, Mr. Brown. But 'playing God' is a loaded phrase, don't you think? It implies an endless bounty being dolled out to some and withheld from others. That is not the case here. We are dealing with meager resources. There are barely enough donor organs available at any one time to fulfill the needs of one tenth of the registered recipients. No, Mr. Brown, we are hardly playing God. It rather seems more like we are sweeping up after Him."

  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 ge
t 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.

  True enough, perhaps, on paper. True enough according to the numbers the medical facilities had used to encode her diagnoses for the government computers.

  True enough: Her heart failure had been gauged as Grade II, which meant the old pump was failing, its reserve low enough to make a breathless chore of walking a single block, but still pumping well enough to keep her from being completely incapacitated; Grade II heart failure warranted only a limited work-up and certainly not aggressive therapy.

  True enough: Her Grade II gallbladder disease did not trigger attacks of sufficient severity to yellow her skin or generate enough unremitting pain to warrant emergency surgery, but her rattling gallstones did cause her daily abdominal distress and incessant belching, and she lived in constant fear of another attack, so much so that each meal had become a form of gastric Russian roulette.