Advancing technology, especially the demand for "heroic intervention," is driving up costs far faster than the ability to pay for them. Insurance availability is becoming more restrictive, with risk being spread over fewer numbers of people. Instead of a community (national, state) rating, the focus is more towards the company, the family, the individual.

The recent Medical Savings Account is the ultimate, self-insurance. Not-for-profit, teaching, and research hospitals and HMO's are threatened by investor based systems. Medical practitioners are increasingly curbed by business practitioners -- allowable procedures, allowable time to administer procedures.

The ethics of dying: Kevorkian exists, not always because an alternative for the patient is unavailable, but it is unavailable to that patient because of cost. Piecemeal legal and medical legislation allows procedures and intervention delivery to persons who instead may be better off with hospice care. A needy person, who would benefit from more appropriate procedures, cannot afford them.

Partly, the unevenness of delivery is due to two factors: ignorance and naiveté of the patient or family of propriety of treatment and an individualism that demands treatment under highly emotional circumstances, regardless if it is appropriate medically. This individualism extends to the attending physician. 

Let the specialists decide, do not interfere.

There is gradual emergence of alternative care, and the economic value of hospice and of chaplaincy services is being documented. "Parish nurses," Ministries of Care (RC) and the Steven Ministries, and contract ministerial services are available. Healthcare and care of the terminally ill are becoming oriented toward business decisions. A procedure, intervention, or service must be proven "cost-effective," economically justified.

There are real opportunities to improve delivery of medical care. Over buying and over building of medical facilities can be avoided. Whether to use procedures in high risk, low return medical situations can be made by a medical board that reflects the community it serves, and that has the ability to acquire the relevant knowledge. The community goal is a socially and spiritually responsible healthcare system.

One model, used in some states, pools several resources: private insurance, federal, and state, to provide a basic healthcare system available to its citizens. Covered medical procedures are listed, and the total amount spent is capped. People are free to buy supplemental insurance, if they wish. A person will not receive the same coverage between various systems. We currently have Medicare, Medicaid, CHAMPUS (military), privately paid (farmers, for example), company paid, and the working poor, with none. The system is riddled with gaps and overlaps, and whether a person is "worthy" of medical coverage is an economic decision.

This report represents the knowledge and experience of chaplains, students and healthcare workers who participated in the discussions. We want to distribute it to others, and a full length copy can be obtained from CCRS, Room 338, at the Lutheran School of Theology, 1100 E. 55th Street, Chicago IL 60615. We can also e-mail you a non formatted (text only) draft. To reach CCRS: Phone (773) 256-0670, e-mail blionel @aol.com, mail, or -- if you live in the area -- just come by.