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.