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∂CSL Professor Diana Dutton↑Division of Health Services Research
↓School of Medicine∞

Dear Professor Dutton:

	Many thanks for the four items you sent me of yours and
Bart Bernstein's.  I have read them with interest and have the
following reactions.

	1. I find myself in substantial agreement with the initial
attitude taken by Congressmen in the 1960s.  The technology of the
artificial heart has such great potential for human welfare that it
should be pursued at full speed.  Of course, there have been setbacks,
and this is inevitable when the problems are not fully understood.

	2. Here are some factual questions for which I didn't see the
answers in you papers.

		a. Why the limitation to people under 65?  Is this
a decision based on priorities?  If so it could be reversed when
more facilities are available.  Or is there some medical opinion
that it can't work in people over 65?  With it almost working in
Clark who was so sick and 61, one would suspect that 65 isn't a
medical limit.  The limit removes the majority of the potential
market.

		b. How does the $200 million spent on artificial
hearts compare with medical research expenditures on other problems.
It is hard to imagine anything more cost-effective if one takes
an optimistic view of the potential.

	3. None of the reports take a definite position on
the issues.  There seems to be a rhetorical style which substitutes
"questioning" for taking a position.  It is more suited for
expressing opinions about who should have power than about what
should be done.  Here are some questions.

		a. Was Government support of the development of
dialysis a mistake?

		b. If the answer is yes, should the Government have
merely neglected the possibility, or should it have taken active
steps to prevent it from being developed.  Perhaps the bureaucratic
mechanisms didn't exist then, but now the FDA has the power to
forbid the trial of new devices and treatments.

		c. Given that dialysis was developed should the
Government have supported treatment?  Incidentally, I think that
Scribner's 1964 estimates of the cost of this turned out substantially
correct, although I don't remember what he advocated.

		d. If the Government should not have supported dialysis
treatment should it have prevented it?

		e. Should support of dialysis be continued?

		f. Should the Government support further work on
artificial hearts?

		g. Should it actively try to prevent such work in
the U.S.?

		h. What should be done about the likely possibility
that who gets an artificial heart will depend partly on who can pay?

	Your group has been thinking about the problem long enough
so that it seems to me that you have an obligation to offer proposals
and not merely raise questions.  Such "questioning" merely offers
a drag on doing anything.

	4. Moral issues.  It seems to me that your papers contain
moral presumptions with which I don't agree.
Now that artificial hearts exist, admittedly as a consequence of
Government support, has the Government the right to prevent someone
from having one for reasons of social policy?  My opinion is that
the Government has no moral right to do this and no Constitutional
right either.  Namely, it conflicts with the individual's right to
spend his own resources on his own behalf.  While the articifial
heart was developed with Government assistance, now that it exists
the individual (even if rich) has the right to use it.

	If I'm right about that, then the discussions of Government
policy don't take into account possible limitations on the right
of the Government to have a policy.