VIEWSrnFrom Health Care to Discriminationrnby Garrett HardinrnAs we try to improve our lives with a national health carernplan we must not forget the “law of unintended consequences”rnto which Robert Merton alerted us in 1936. Two examplesrnillustrate the danger. Few people foresaw that federalrnsupport for poor mothers with dependent children would contributernto the breakup of black families, but it did. Nor did peoplernforesee that rent control would contribute to the trashing ofrncities, but it did.rnWith those failures in mind, what can we say about the possiblernunintended consequences of well-intended health carernlegislation? I suggest that one of the most important consequencesrnwill be this: we will be forced to reexamine the wordrn”discrimination” and the actions that result from it. Lest I bernmisunderstood, let me say that the attack on race discriminationrnmade in the 60’s was by no means a mistake. Far from it.rnBut the condemnation of discrimination has extended far beyondrnthat eariy application. A national health care system canrnsucceed only if discrimination—appropriate, defensible discriminationrn—is made an integral part of it.rnThe need for discrimination is most apparent in the applicationrnof medicine to the far end of life. Medicine has notrn”conquered death,” nor does it seem cither desirable or likelyrnthat it ever will. But modern medicine has certainly postponedrnour deaths and increased their costs. Even worse, delaying mor-rnGarrett Hardin is professor emeritus of human ecology at thernUniversity ofCaUfornia, Santa Barbara. His most recent bookrnis Living Within Limits: Ecology, Economics, andrnPopulation Taboos (1993).rntality with fancy medicine too often increases the suffering ofrnthe dying. A jungle of high-tech apparatus can keep life goingrnlong after the possibility of enjoying it has been lost.rnThe cost in money can be monumental. A few months ofrnheroic medicine can cost more than all the medical carernreceived during the preceding years. If being given the mostrnexpensive terminal care were made the “right” of all—and ifrnmost people availed themselves of this right—a national healthrncare system would soon be bankrupt.rnThose who reject high-tech medicine, allowing life to endrnnaturally, are often accused of “playing God.” But how can therncritics be so sure that God delights in seeing a human beingrnsuffer the indignity of having tubes stuffed up his nose while arnheart stimulator and a breathing apparatus take over his mostrnvital functions? Syringes drip medicines and nutrients into thernveins; king-size diapers take care of the incontinent midsection;rnspeech is often impossible, the “beneficiary” indicatingrnhis wants by blinking his eyes, assuming he can hear whatrnis asked of him.rnAmericans rightly fear yielding power to the state, but inrnsome matters the trend runs the other way. The law used tornprevent anything that looked like suicide, even if it was no morernthan passively withholding medicine that would prolong arnpainful life. In recent years the Hemlock Society has made notablernprogress in getting the public to see the justice of not forcingrnterminally-ill people to endure avoidable suffering. Morernand more eldedy people are now signing “living wills,” whichrnlimit the medical care to be given at the end of life. Once peoplerndecide that refusing expensive and unwanted artificialrn14/CHRONiCLESrnrnrn