1453

Health Watch

THE OLD, THE VERY OLD, AND THE TOO OLDrACED by the Keagan aomimstration s contmued

trimming of the Federal social budget, frightened,dependent, and needy groups are fighting one another toretain their share of public social expenditures. Someprogrammes have been deliberately thrown together infunding clusters ("block grants"), encouraging a kind ofgladiatorial combat. At present young people generally, andchildren in particular, are being pitted against the old. Socialsecurity costs, for example, are said to be sweated out of thepresent generation of working young people-sums that willnot be available to provide this generation with pensions intheir old age. The cruellest contest is the one slyly provokedin the implication that services for children, the saving ofinfant lives, immunisations, and the like, are being barteredfor maintenance of the level of payment for medical care forold people.

It is true that, even for the young, the costs of medical careare running well ahead of general inflation; and at the sametime, the old (65 + ) are living to be the very old (85 + ), whouse even more in the way of medical services. It is also truethat children are being short-changed in social goods-insufficient care and attention to their health and nutrition;insufficient support for their educational and recreationalneeds. We are not providing a "level playing field" forchildren to make the best of their capabilities and advance totheir fullest in this society. President Reagan’s stance asdefender of the elderly, with his earnest protectiveness of thesocial security system, has served to accentuate the

underlying strife. Lobbyist groupings have arisen to opposethe social security principle and are making bold efforts todismantle the entire social support system that social

security represents.In these generational wars the elderly face an assault from

another quarter, mounted with the support of medicalethicists. When their discipline began life, it concentrated onthe rights of patients-informed consent with respect tohuman investigation or new treatments and procedures, forexample-but lately the medical ethicists have taken on thetask of promoting equity in access to and receipt of medicalcare. It is from this sally into social ethical concepts, ratherthan the personal obligation hitherto their concern, that theethicists stumbled into the generational conflict. DanielCallahan, Director of the Hastings Center, a solidlyestablished institute for ethical studies, in his new book,Setting Limits,l gently and a bit sorrowfully concludes that itis too expensive-the social cost is too heavy-to continue toprovide all the required medical care without constraint toall old people. Some form of rationing is necessary; theeconomics of medical care have persuaded Callahan, aphilosopher and not a physician, that it is the duty of oldpeople who are ailing and unlikely to recover--critically andchronically ill, that is to say, and not just those who are braindead-to accept the ending of their lives at that point. Whilethey might live longer, or even sometimes recover (sincemedical diagnosis and prognosis are hardly infallible)economic considerations require that a line be drawn.The theme is bothersome for many reasons. Not the least

of them, for your reporter, is his own age; more to the point,the book urges a social decision that is bound to be codifiedinto law eventually. Such a law, permitting "voluntarydeparture" (after soothing parting explanations from the

doctor and presumably the ethicist) will inevitably becomemandatory. Somehow, the idea of compulsory euthanasia isrepulsive.

If resources for medical care are limited-a doubtful

proposition anyway, and usually propounded by thosebenefiting from the status quo-are there not some

alternative social decisions that could be taken, short ofeuthanasia? A less wasteful medical care system might beone saving measure; even a modest limitation of physicians’income might do the trick. Sharing the burden bymoderating the totality of medical care services for all is notunreasonable-after all, the present older people are theones who made the sacrifices in their youth to raise thechildren and grandchildren who would be the beneficiariesof Callahan’s concern. There is no question that this topicneeds public airing and it is brave of Callahan to offerhimself as the sacrificial lamb, for he will certainly earn theenmity of the generational group to whom he offers thislethal advice. The rising antagonisms between the youngand the old do need to be resolved, and quickly. Fullerdiscussion may bring out more and more widely rangingalternatives. It would be unfortunate if euthanasia became amatter for politics, and residual legatee of the century-longdrive for a fair and effective system of medical care.

590 Ellsworth Avenue,New Haven, CT 06511, USA

GEORGE A. SILVER,Professor Emeritus of

Public Health

1. Callahan D Setting limits. New York Simon and Schuster, 1987

Round the World

From our CorrespondentsUnited States

PROTECTION FOR THE OZONE SHIELD

LAST spring top-level Reagan officials met privately to review atentative international pact designed to retard the depletion of thestratospheric ozone shield. The agreement called for worldwidereductions in the consumption of chlorofluorocarbons (CFCs) andcertain industrial chemicals called halones. They were told that thechlorine from these chemicals as they decomposed was damagingthe shield, permitting more solar ultraviolet radiation to reach theearth. Left unchecked, the radiation was expected to cause largeincreases in skin cancer in the decades ahead. The ultravioletradiation is also expected to contribute to higher globaltemperatures and melting glaciers and to cause sea levels to

rise-the greenhouse effect.At the meeting, Mr Donald Hodel, Secretary of the Interior,

complained that US participation in the pact was inconsistent withthe administration’s policy of avoiding industrial regulation. MrHodel proposed instead a Government public-relations campaignto encourage Americans to buy more hats, sunglasses, and suntanlotions for their protection. There were horse laughs amongenvironmentalists after the Hodel plan was leaked to the WashingtonPost. Mr David Doniger, of the National Resources DefenseCouncil, pointed out that other living things threatened by theradiation, whether plant or animal, are unable to take protectivemeasures. Fish, he noted, cannot wear sunglasses.

In a victory for the Secretary of State, Mr George Shultz, thepublic-relations plan was dropped and the US took a leading role ingetting the agreement approved by 24 nations and the EuropeanEconomic Community in Montreal on Sept 15. According to MrRichard Benedick, the US chief delegate, the strongest resistance tothe United-Nations-sponsored pact came from European chemicalcompanies. The British Government and the giant British firm,Imperial Chemical Industries, were said to have been particularlyrecalcitrant. There is no question that corporate profits are

threatened. The pact calls for a freeze, at 1986 levels, of CFC

1454

production in 1990, followed by rollbacks of 20 % in 1993 and 30 %in 1998.The Europeans as well as the Japanese were reported to be

unhappy because they believed the agreement gave an unfairadvantage to US corporations. The E. 1. duPont de Nemours & Co,as an example, has spent millions of dollars on research to developsafe alternatives to CFCs, which are used in refrigeration, air

conditioning, insulation foam, and manufacture of plastics used inpackaging hamburgers, and, except for the US, where they arebanned, as propellants in aerosol cans. Halones, the other affectedchemicals, are used in fire extinguishers. -

It took only sixteen years to provide the data base for this pact. Inthat time, scientists examined the relation between ozone depletionand supersonic aircraft, the space shuttle, and CFCs. The linkbetween even modest reductions of ozone and the incidence of skincancer1 was established by epidemiological data during that period.From a policy viewpoint, however, the surprising discovery two

years ago of a large decrease in ozone over Antarctica-the ozonehole-remains unfinished business. The delegates in Montrealwere instructed not to consider this evidence in their deliberations.

At that time, Mr Michael B. McElroy, chairman of thedepartment of earth and planetary science at Harvard University,agreed with that approach. Given the new data that haveaccumulated since then, he recently told a Senate subcommittee inWashington, such caution is no longer warranted. He is nowconvinced that the ozone hole "will persist for a hundred years evenif we effect a complete and immediate ban on release of CFCs."Now, he said, the question is whether such huge ozone depletionswill also affect the Arctic and even the mid-latitudes. The need for a

policy response, he maintained, is urgent.For now, though, the business at hand is to get the pact approved

back home by each of the signatories. If they act on it, the firstinternational agreement to control an air pollutant will take effect.1 Russell Jones R Ozone depletion and cancer nsk. Lancet 1987; i 443-46

In England Now

I was never much of a one for Togetherness until the other day,when I heard that medical conferences and pharmaceuticalcompanies’ product-launches were being held on luxury cruiseships in the Mediterranean.That night I had a long and complicated dream. It began aboard a

great ship nosing its way out of the Vieux Port of Marseilles, lightsblazing, and the Getting to Know You dance in progress. I foundmyself a subsidised delegate to a conference on Onychogryphosis: aNational Emergency. From an obscure comer I watched the

glittering throng in full evening dress with decorations, chains ofoffice, gardenias, and gold-mounted identification badges withpharmaceutical logos. On the Captain’s right sat the President of theRoyal College of Onychogryphologists, and on his left was thesenior representative of the participating drug companies.

In my dream the next morning at sea was rough. After theKeynote Address slow-release antiemetics were distributed bywhite-faced junior reps. Few delegates were able to tackle theseven-course lunch and the ten-course dinner. The first of theconference sessions that afternoon, on the molecular biology,biochemistry, and pharmacodynamics of onychogryphosis, waspoorly attended, but the next day the papers on the pathology andthe treatment of the condition by acupuncture attracted a sizeablecrowd and samples of sun-tan lotion were given out.The drugs displayed at the alcoholic product-launches which

parallelled these and succeeding sessions were naturally mostlygrypholytics, but there were sets of surgical instruments for dealingwith refractory cas.es, and hypothermia blankets for

onychogryphosis sufferers unfortunate enough to find themselvescaught in a snowstorm in the Caimgorms. The belly dancer whocame aboard at Algiers carried in her navel a star-burst of newlyfabricated tranquillisers, and from her shapely bosom dependedtwo tassels of the latest H2-receptor antagonists, which rotated likecatherine wheels under the sparkling chandeliers.The enormous meals continued, supplemented by bowls of soup

in the morning and hot chocolate in the afternoon. Instead of bettingon the number of miles covered each day the punters bet on thequantities of antacids and antispasmodics dispensed by the cynicalship’s doctor.At the concluding Progress and Review session back in Marseilles

the Secretary of the College was presented with a matched set ofmonoclonal antibodies for his inspired organisation of the

conference, which had resulted in only five people delaying the shipwhen they were lost in the Acropolis and only two eluding thesearch parties in Pompeii. It was felt that an immense amount ofvaluable information had been exchanged, and to universal acclaimit was decided that, though no Recommendations were likely toresult, the subject was so important that increased Governmentfunding should be requested for a repetition of the cruise next year.

I was quite sorry to wake up in my own bed on a frosty wintermorning.

* * *

A SHORT autumn break in a favoured holiday area (as the estateagents say) plunged me, vicariously, into a furore over the latestmoney-saving NHS plans for the locality. The closure of a smallmaternity hospital and the scrapping of the hospital car service wereincluded in the package. The most vociferous protests were over thematernity hospital. Local people said-and it was not claimed bythe authorities that they were exaggerating-that this closure wouldmean that women in labour would have ambulance journeys of upto 70 minutes to get to the district general hospital-and longer insummer, when the roads become congested. We are told that a weekis a long time in politics; and I am fairly sure that 70 minutes is along time in childbirth, especially if there is some trivial little

complication like placenta praevia or the cord round the neck. Butwhat does that matter, if money is saved?The scrapping of the hospital car service seemed to me, as an

onlooker, too ridiculous for words. The drivers are all volunteers,and all they get is a mileage payment to cover petrol. Doubtless thereare administrative costs, if the forms we have to complete in our partof the world are anything to go by. But I cannot see where thesavings come. Of course, some people do abuse the system-butthey will manage to abuse anything. For the most part, thesejourneys really are necessary, especially in a thinly populated ruralarea where public transport is virtually non-existent, and where thepercentage of elderly in the population is well above the nationalaverage. So what are patients to do? Some will not come fortreatment: that will be a saving, of course, though not necessarily,from the patient’s viewpoint, a good one. Of the rest, the majoritywill be booked onto ambulances instead, so costing a lot moremoney to make a small saving. ’

Meantime if, because of these cuts and others like them up anddown the country, morbidity and mortality rates are raised, whowill be blamed? The medical staff, of course, who are expected, bypublic and by authority, to maintain higher and higher standards-indeed, achieve perfection-with less and less resources.

* * *

THE specialists, reported by your correspondent (Oct 31,p 1016), who found difficulty in making an early decision as to what2 plus 2 makes have something in common with one of the greatestof mathematicians. Bertrand Russell, it is said, spent seven years ofconcentrated thought on his treatise to prove to his own satisfactionthat 1 plus 1 equals 2. We are reminded of the great man when we goto the picturesque village in Snowdonia where he lived and worked.Our duty, to examine periodically the chests of quarrymen at theirplace of employment, requires an annual visit to the quarry there.No plaque commemorates Lord Russell’s work: the populacepresumably had never doubted the validity of the rules of simplearithmetic. In America it would have been different. We hear of asmall town in California at which a local genius had calculated theultimate prime number. This distinction is shown alongside thename of the town on the roadside sign at its boundary. Elsewhere, atan atomic research station, the name of the unit is suffixed by:E = mc2. Perhaps one day when we travel to the quarry we shall bemet by the welcoming sign: Croeso y Penrhyndaedreth. 1 plus 1

equals 2.