February 1988 IX/6


In the state of Oregon recently, a seven-year-old boy died of leukemia. Shortly before his death, state health officials refused public funds for a potentially life-prolonging bone marrow transplant. Last month, in the same state, a young mother was refused public funding for a liver transplant. Both actions resulted from a new policy of state health officials to refuse funding for bone marrow, pancreas, heart or liver transplants.(1) The decisions in Oregon have been portrayed as a preview of the decisions that will soon be necessary by officials in other states and by officials: representing the federal government. The economic decisions which limit the access to health care have ethical implications. People will live or die as a result of these decisions. With this in mind, a closer investigation of the decisions in Oregon are in order.

The Principles

Is there a general principle which will ensure an ethical distribution of public funds to those in need of health care? In Oregon, the painful decisions to withhold funds was based upon the assumption that basic health care should be provided before advanced or experimental care. (1) Hence, the state officials in Oregon pointed out that basic health care was being provided for 24,000 more low income people without any increase of funds by reason of the new policy. Moreover, they pointed out, "1500 pregnant women will receive prenatal care with the same amount of money that would pay for thirty organ transplants." Many commentators and editorial writers, applauding the wisdom and courage of the Oregon allotment policy, declared that Oregon should be a model for federal agencies faced with the same decisions. A consensus seems to be present in the public forum then, that basic care for the most people possible should be the principle upon which access to health care for lower income people is determined.

The Oregon decisions occur at a time when many people are searching for principles to regulate the amount of our national assets devoted to health care. In a recent provocative book, Setting Limits, (2) Callahan maintains that a new norm for funding health care for the aging must be developed. At present, the health care research and therapy in the United States seems to be directed toward keeping people alive as long as possible, no matter what degree of function they might retain. Callahan persuasively questions whether this is a realistic norm, given the limited resources of our society and the certainty of death. He suggests that a more valid norm would be to afford as many people as possible the opportunity to live a beneficial life. Making such a radical readjustment in health care planning would direct funds away from the aging toward the younger members of society. Callahan realizes that his idea is prophetic, stating that it will not be accepted until his grandchildren are adults.


The policies initiated in Oregon give some guidance for the future. Moreover, Callahan's ideas, which are explained much more intelligently and compassionately in his book, must be considered as the issue of allotting funds for research and health care therapy is discussed. However, both in Oregon and in Callahan's discussion, there is a vital question which has not been considered sufficiently. At the present time, are we devoting a fair share of national assets to health care for low income people? While we may posit limited resources for health care, have we reached the reasonable limits of our resources? For the past 15 years, the proportion of our gross national product (GNP) devoted to health care has been a prominent discussion topic. While this is a legitimate concern, studies indicate that the citizens of our country devote a significant percentage of the GNP to items which can only be deemed ephemeral. Are there many goods included in the GNP which are more important than access to health care? Moreover, is it that simple to distinguish between basic and advanced health care? If the criterion for distinguishing between basic and advanced health care is the success of the procedure, then some types of organ transplant may at present be designated as basic care and other types will soon be in that category.

A prominent health care economist, Uwe Reinhardt, when testifying before the Senate Commission on Aging, pointed out that Americans are delighted when figures indicate that the automobile industry is flourishing because this "is good for the economy and good for the country." He asks whether the same attitude is not fitting insofar as health care is concerned. While not fostering a laissez faire attitude toward health care costs, we must admit Reinhardt is right in one regard. If we compare present and past percentages of the GNP devoted to health care, we are comparing apples and oranges. Though medicine still has the same goals it had 40 years ago, the means and methods of reaching these goals have changed significantly.


According to the great Swiss theologian Karl Barth, a society must be judged upon its willingness to care for its weak and impoverished members. Although health care procedures should be carefully evaluated for cost efficiency, and although the function of a patient should be considered when evaluating the effectiveness of health care procedures, it seems equally important to evaluate whether or not our states and the federal government are at present devoting enough of our assets to offering access to health care for lower income people.

Kevin O'Rourke, OP


1. Washington Post, February 5, 1988.

2. Setting Limits: Medical Goals in An Aging Society. New York: Simon and Schuster; 1987.

© Kevin O'Rourke, O.P.