Philadelphia Physicians for Social Responsibility, Pennsylvania, United States“Have I got this right? When you … eh … reach eighty points … you’re gone.”“Yes sir. That’s right.”“But if you have seventy-nine … you’re still here.”Harry Crenshaw looked into the faces around the conference table. Why didn’t the hospital research committee take his project seriously? The study was valid and clinically applicable. Maybe Janine was right; he shouldn’t have called it “The Gone-A-Gram.”“Your statistics, the numbers, seem fine son, but you might have trouble with public acceptance,” old Doc Scattergood warned, benignly shaking a gnarled and speckled finger at Crenshaw.“Will a man understand if you tell him that dear Uncle Mortimer is going to die because he has eighty-three points, just three over the limit? It certainly is a pity to kill someone for a few lousy points.”“Sir, we don’t actually kill anyone,” Crenshaw protested hoarsely. “We just stop taking care of them.”With that, Charlie Scattergood, who had been around since the days when a surgeon could go to church and take out an appendix in the same suit, twisted in his chair. He was no longer smiling.
“Stop taking care of patients, you say?” Scattergood, pulling on his ear, thought that his hearing was not what it once was.
Lance Needleman, representing the Department of Surgery, threw down the remnant of a salami sandwich that had survived three earlier interviews and a trip to the bathroom. “So you use your computer to terminate care?” Needleman shouted in a tone usually reserved for overworked, sleep-deprived interns with the temerity to pass out on his operative field—not for a research fellow who was presenting the findings of a three-year study.
“No, that’s not what I mean,” Crenshaw stammered. “We just use the Gone-A-Gram as an objective indicator of the patient’s chances of recovery. When patients reach eighty points, they cannot survive. Mortality is one hundred percent.” Harry seemed anxious to make that his concluding statement.
Most of the committee seemed equally anxious, but Burt Phillips, the Director of Nephrology, had one final question, “Do you ever have double-coupon days?”
Crenshaw squinted without answering, clearly unprepared for the question. Undoubtedly, he had not considered any introductory offers or promotions.
“I mean, do you ever have discount days, one-cent sales or bonus points?” Phillips asked. “Buy one, get one free?”
“No, sir. We don’t use gimmicks.” Crenshaw was sweating freely. “It is simple. We just add up the points. One point for every antibiotic after the first two. They are free.” His collar was now darker than the rest of his shirt, and his tie was a bit spongy.
“Add eight points for every week on a respirator and five if your blood pressure is low for seventy-two hours. The chart on page twelve lists what you get if your pupils are unequal, if you vomit blood, or if one of your big toes falls off. When you have more than four IV lines, you ….”
“That’s fine Harry,” Dr. Hastings, the committee chair, interrupted. “We have the full list. That part is quite clear, but since you do not terminate care at eighty points, what is the purpose of your system?”
Crenshaw filled his lungs quickly and explained, as he wrung out his tie, that it was a guide to assist families in making decisions about further high-tech studies and other lifesaving treatments, such as baboon heart pumps and pig liver perfusion, “If the patient has more than eighty points, we would tell the family not to do it.”
“And, of course, the families listen to that advice.”
“No sir, that’s one problem with the Gone-A-Gram,” Crenshaw responded flatly, wiping his face with pages forty-seven and forty-eight of the report. “The families never listen.”
“Why do you suppose that is?” Hasting wondered.
“I can’t say for sure, but maybe at those critical times they react emotionally rather than logically.” The committee appeared ready to accept that premise. “But,” Crenshaw continued, “sometimes the families have motives that we don’t know about.”
No one on the committee knew what that meant.
“Well, eh, turn to page thirty-seven, for example: the case of Arnold T. Sylvester. He was admitted last August with a massive stroke. His blood pressure was high; his blood count was low; and his kidneys shut down when he had eighty-nine points.”
The men around the table opened their red, covered booklets. Scattergood’s was upside down.
“We told his wife that he would die if he didn’t have dialysis, but we didn’t recommend it because he had too many points. Mrs. Sylvester said, ‘Do it anyway.’”
“Didn’t you explain that according to the computer, her husband had no chance of recovery?” Hastings asked.
“We did, but she said, ‘Do it anyway.’ So we did it. We had to. Then a week later, a social worker told me that Mr. Sylvester gets a monthly disability check. If he were dead, he would not be considered disabled, and his wife wouldn’t get the six hundred and forty-seven dollar monthly payment. Mrs. Sylvester and his sister Irene need the money. If they couldn’t come up with a sickly relative when Arnold dies, one of them would have to find a job.”
“You don’t mean that he’s still alive?”
“Yes sir, he’s alive … well, sort-of. He’s all curled up, and we can’t uncurl him. He has a feeding tube, a trach, and a pacemaker; and we had to sew his eyes shut to keep them in their sockets.” Harry puffed out his chest. “He has four hundred seventy-seven points.”
Orville Hastings rolled up the report and tossed it on the table, turning toward his colleagues for further questions or comments. Charlie Scattergood closed his eyes and shook his head. Skinny Darwin McAllister, the newest member, put his feet under his rump and drew himself up into a ball. Darwin wasn’t a clinician, and he clearly had no questions about this stuff.
“Thank you, Harry. Please go. I mean … eh … you are free to go,” Hastings said. “We will announce the winner of the Louis Pasteur-Walter Reed award in ten days.”
As Harry, his head down, slithered out, the committee members, now having completed all the interviews, scratched, stretched, yawned, and redistributed themselves amongst the reports of the young investigators. Everyone, that is, except Scattergood, who, while seemingly alive, was rigid.
Lance Needleman loosened his tie, tossed a chunk of salami from his lap and announced that the Gone-A-Gram was an incredibly sloppy piece of work, “I’m voting for Terry Robinson’s nuclear-powered, implantable gall bladder. It’s a great engineering concept.”
“Yeah, what an incredible breakthrough,” Phillips rebutted. “Can’t you see hordes of folks lined up to have radioactive pumps shoved under their livers so they can digest pepperoni pizza?”
“Well,” Needleman huffed, drawing his chin back, “it may not fill an immediate need, but it is a prototype for other parts. The plutonium sphere could be an excellent source of energy for a range of mechanical replacement parts.”
“Great, just great,” Phillips sneered, “now a doctor will never know when a water-cooled patient might walk into his office, blow up in his face, and level the city.”
Darwin McAllister, shaking, pushed his chair back from the table, dropped his head between his knees, and drew his legs up to his chest.
“Burt’s right,” Hastings added, patting McAllister on the head. “We need safe, practical projects like Tressler’s density-mass study. The technology is already in place, and there will be no meltdown or radioactive turds.”
“What’s more, it’s YOUR technology,” Phillips whirled in his chair to face Hastings, “and Tressler is in over his head. What does he know about radionuclide physics? He doesn’t even know which end of the stethoscope to put in his ears.”
“He doesn’t have a stethoscope,” Hastings protested. “But we’ve had some of the equipment for two years and have done fifty atomic absorbtion studies to determine average body density. That’s simple. When we install the new magnetic scanner, we will program it for total body volume.”
Phillips, looking over the figures, wondered why anyone would need precise body density and volume figures.
“That’s just the point,” Hastings added quickly, banging his fist triumphantly on the table. “When you multiply the volume and the density, you get the patient’s total body mass.”
Phillips had heard enough, “You can get the same results by stepping on a damn bathroom scale.”
“If you look at it that way, I guess you could,” Hastings acknowledged, clutching the table. “You could use a scale if you wanted to stop medical progress, but no one weighs patients anymore. And furthermore,” he continued, giving Phillips his best conspiratorial wink, “we can bill twelve hundred bucks for each study.”
“Yeah, I agree.” McAllister, the director of the genetics laboratory, stopped rocking, unfurled slowly, and looked up. “We must never stand in the way of imaginative, profitable technology. And that’s why I favor Bergman’s project,” McAllister squeaked. “Imagine, programming rhesus monkeys to do vascular surgery. Brilliant.”
With that, Needleman stopped peeling his banana and shoved it in the pocket of his bloody lab coat, “It’ll never work.”
“Why not?” McAllister asked. “Have you ever watched monkeys pick fleas out of their buddies’ ears? They have great small motor coordination. Bergman just inserts a computer chip in their right frontal lobe and programs it to direct those muscles appropriately. He is almost ready for a clinical trial.”
Needleman, who had, indeed, watched a few monkeys during his surgical training, suggested that McAllister might want to volunteer to be the first to have his aorta bypassed by a programmable hairy ape.
That woke Scattergood, “How will a person react when he meets his surgeon, and he’s bouncing up and down, scratching his belly?”
“That happens all the time,” Hastings snickered, “and the families almost never meet the surgeons. No one has to know.”
“Right,” McAllister chirped, “we can hide the cages and put human names on the bills. When you think about it, the thing really does make sense.”
Burt Phillips pressed the heels of his hands into his eyes, leaned forward, and did think about it. Smiling to himself, he wondered what would happen if the computer chip slipped and the monkey could only do orthopedic surgery? No longer smiling, he thought about some of the older projects: stents, newer antibiotics, pacemakers, and defibrillators. That was the golden age of medicine: new technology was our servant. Now is it our master?
“Come on fellas, time marches on,” Hastings announced. “As Hippocrates said, we cannot stand in the way of progress. Time to vote.”
JOEL L. CHINITZ, MD practiced nephrology in Philadelphia for 20 years and directed one of the nation’s first out-of-hospital hemodialysis units. As a volunteer physician for the Indian Health Service, he had assignments in the Hopi, Navajo and Shoshone nations. Subsequently, Dr. Chinitz completed an MPH program and served as a primary care physician at a community health center, a VNA Medical director, a Physician Assistant Program Medical Director, and a volunteer physician at a homeless clinic. He is active in the Philadelphia Physicians for Social Responsibility where, as the Community Health Coordinator, he developed programs in family violence prevention, firearm safety and bullying prevention.