Henry, William. In Defense of Elitism. New York: Anchor,
1994: 135-37

The third illustrative episode came in August 1992, when the Bush administration rejected Oregon's plan to ration health care. The plan involved numerically ranking treatments and services by their likelihood to prolong or improve life and barring Medicaid payment for roughly the bottom twenty percent. Some treatments, such as therapy for the common cold, were barred because they were not necessary. Others, such as treatment for traumatic brain injury or for AIDS patients believed to be in the last six months of life, were excluded because they were expensive and unlikely to do much good. Some, such as liver transplants for people with alcoholic cirrhosis, seemed to be ruled out as a moral judgment that the patient had brought his problem on himself and a practical judgment that his behavior might well recur. Perhaps the toughest and most unpopular decision was to withhold payment for cancer treatments for patients whose prospects of surviving at least five years were less than ten percent. In the face of cancer, most Americans believe a patient should be entitled to try anything, regardless of how high the cost or how low the likelihood of success-as was evidenced by the epochal $77 million jury award in December 1993 to the heirs of a California woman who was denied money for a highly experimental late-stage cancer treatment (which she then financed privately and which failed anyway). Although most of the excluded conditions in Oregon were diseases, at least some, such as foot deformities and certain kinds of epilepsy, were disabilities. AIDS, although a disease syndrome, also has been officially labeled a disability, thus affording its sufferers a broad range of legal protections.

In denying Oregon's proposal, Secretary of Health and Human Services Louis W. Sullivan asserted that the rankings were based on the premise that "the value of the life of a person with a disability is less than the value of a life of a person without a disability." That presumption, he added, would violate the Americans with Disabilities Act. The core issue, of course, is value to whom. The life of a disabled person is worth an infinite amount to him or her; it is the only one he or she has. But its value to society is by definition finite. Even if we do not place caps on medical treatment, we do on subsistence and "entitlement" payments. Oregon officials had the courage to make choices. As Oregon's Democratic congressman Ron Wyden pointed out, the Bush administration chose in a reelection year to be "politically safe." While American society is clearly not ready to confront legislation or administrative regulations that question the value of those no longer sentient at either end of life-severely retarded children and elderly people in a chronic coma-the time may be coming when we face up to a basic economic reality. Almost everything anyone proposes to spend public money on is in some sense worthwhile. But there is not enough money to do everything, and as technology improves, the gap will only widen. Modern medicine does not simply make more people healthy. Its larger effect is to keep more chronically sick people alive. At some point the elitist impulse must be recognized as the only tenable one: to say, at least by the inaction of withholding treatment, that some lives are in deed worth less to society than others. Ideologues will denounce this as fascism. It is really just candor.

Carl Gutierrez-Jones,

Department of English

University of California

Santa Barbara, CA 93106

E-mail: carlgj@humanitas.ucsb.edu