Letters to the Editor

LETTERS TO THE EDITOR Dear Sir: In "States of Awareness during General Anesthesia" Dr. Jacobus W. Mostert states, "For certain heart operations an eminent American anesthesiologist has advocated retention of the patient's awareness of his surroundings ..." [1, p. 68]. I am compelled to write a clarification of this statement so that the proper emphasis may be placed on my 1955 work to which reference is made. At the time, when I was delineating the first stage of anesthesia, it was a common feeling among anesthesiologists that light levels of anesthesia were deleterious to the patient. In fact, it was felt that patients might very well die in ventricular fibrillation produced by a heightened reflex irritability. My work showed conclusively that light levels of depression were salutary to the cardiovascular system and that extremely ill patients could tolerate this level of depression without danger of sudden death. It is this level of depression that I advocated, and the fact that the patient could respond to the spoken voice was entirely secondary to the fundamental concept. It was indeed fortunate that in this level of depression the patient could distinguish whether a certain sensory input produced a painful sensation, and fortunately for our studies the patient was totally amnesic for the experience. Therefore, I trust I have clarified our intention—that it was not to produce awareness, but to produce a level of central nervous system depression which could be tolerated by the most precarious circulation. REFERENCE 1. Jacobus W. Mostert. Perspect. Biol. Med., 19:68, 1975. Joseph F. Artusio, Jr., M.D. Department ofAnesthesiology Cornell University Medical College New York, New York 10021 Dear Sir: Professor Gene Outka's attempt to provide a defense of a "right" to medical care [1] seems to be flawed in a number of ways. In this letter I will provide brief criticisms of several of his points and then examine one of his "refutations" in particular. In the first place I will note that his "standard conceptions of socialjustice" are Perspectives in Biology and Medicine · Spring 1976 | 447 poorly formulated. One can observe this by examining his first "standard conception ": "To each according to his merit or desert." This conception raises a further crucial question which Outka completely ignores: How is merit or desert to be determined? Outka supplies Miss Ayn Rand as a defender of this meritorious conception. While this may be somewhat accurate, it is completely useless insofar as it is intended to aid in explicating the categories. Rand's method of determining merit is precisely that which is given by Outka as "standard conception number three." It is therefore clear that to place Rand under conception number one rather than conception number three is at least insufficient. A second error occurs when Outka discusses Rand's opposition to need as a claim upon goods and services. "To denounce need so unreservedly," he states, "is to miss, I think, many of the complexities in our ordinary reflection about justice." It is clear that Outka fails to notice that Rand is arguing against the very authority to which he is appealing, namely, our ordinary conception ofjustice. Outka's antimerit argument seems to rest on a subtle piece of context shifting. Health crises are indeed, as he points out (sometimes), nonmeritarian; "they frequently fall without discrimination on the (according-to-merit) just and unjust ," etc. However, the relevant question is not whether the disease is a person's desert but rather whether the services of the doctor to deal with that disease are his desert. Since in my opinion position three is the proper basis for distribution of health care, I will not focus my attention on Outka's attempted refutation of that position . Dr. R. M. Sade's "Medical Care as a Right: A Refutation" is an excellent choice as a presentation of that position. Outka maintains that Sade's analogy between a doctor and a baker "surely misleads. To assume that doctors autonomously produce goods and services in a fashion closely akin to a baker is grossly oversimplified. The baker may himself rely on the agricultural produce of others, yet there is a crucial difference in the degree of dependence. Modern physicians...