The Painful Prescription: Rationing Hospital Care.

Britain are achieved by a simple rationing, with long queues, poor quality, and bureaucratic rigidity. Aaron and Schwartz seek to show how the practice of medicine really differs in the two countries, with a special emphasis on the use of various types of medical technology. The most valuable part of the book is a discussion of specific technologies, including dialysis and kidney transplantation, hemophilia, cancer therapies, bone marrow transplantation, total parenteral nutrition, hip replacement, coronary artery surgery, computed tomographic scanners, and diagnostic roentgenograms. In some instances, such as bone marrow transplantation and radiotherapy, the British provide services at levels comparable to those in the United States. In other instances, such as coronary artery surgery and hemodialysis, the British provide services to far fewer patients. The authors did not choose their case studies randomly. They had cer¬ tain hypotheses that they wanted to explore and therefore chose technolo¬ gies that would provide illuminating contrasts. For example, the British come close to the US model in the performance of total hip replacement surgery yet are much more conserva¬ tive in their provision of coronary artery surgery. Both are major surgi¬ cal procedures, primarily affecting the quality of life of elderly patients. Aaron and Schwartz argue that the different patterns of provision may be attributable to the more obvious disability of hip disease, its impact on other social services if untreated, and the alternative of medical therapy for those with angina. One of the most important aspects of the book is its discussion of ration¬ ing, especially for services such as hemodialysis among the elderly. Even though treatment is rarely provided to patients over the age of 65 years, there are no explicit rationing crite¬ ria, and nephrologists rarely have to turn away patients. Instead, general practitioners use implicit criteria, such as comorbidities, to provide the rationalization for their reluctance to refer patients who they know are unlikely to be treated. This incorpora¬ tion into judgment of the availability of services has clear implications for the discussion of var¬ iations in clinical practice patterns in the United States. The current emphasis on health