pational exposures. It is always much easier to tell others to clean up their act than to modify one's own habits. If improvements in life expectancy are to be made.
There is a regrettable tensmoking: observations of British doctors. Br Med J 1964; 1: 1399-1410 dency at present to attribute all disease to environmental or occu- 5. Berry G, Newhouse ML, Antonis D: Combined effect of asbestos and pational exposures. It is always smoking on mortality from lung cancer much easier to tell others to clean and mesothelioma in factory workers. up their act than to modify one's BrJInd Med 1985; 42: 12-18 own habits. If improvements in life expectancy are to be made they have to come about from [Dr. Finkelstein replies:] changing behaviour, not chasing Readers who are familiar with will-o'-the-wisp whims. the literature of occupational medicine will know that not only W. Keith C. Morgan, MD, FRCPC Chest Diseases Unit has Dr. Morgan coauthored a fine University Hospital textbook on occupational lung London, Ont. diseases but also he is a habitual writer of acid-penned letters to References the editor. Regrettably, his letters are sometimes ill-conceived 1. Berry G, Newhouse ML: Mortality of owing to a lack of understanding workers manufacturing friction materi- of the original publications. For als using asbestos. Br J Ind Med 1983; example, Dr. Michael Jacobsen, 40: 1-7 2. McDonald AD, Fry JS, Wooley AJ et al: of the Institute of Occupational Dust exposure and mortality in an Medicine in Edinburgh, has reAmerican chrysotile asbestos friction cently responded to one of these products plant. Br J Ind Med 1984; 41: letters by writing that "Dr. Mor151-157 gan has misread, misunderstood, 3. Office of Population Censuses and Survey: General Household Survey, and misrepresented our account of what we did, what we found, 1972, London, 1975 4. Doll R, Hill AB: Mortality in relation to and what we concluded."' These
remarks are appropriate in the present instance as well. I wrote that "fragmentary data about smoking habits were collected in a 1981 telephone survey in which responses were obtained from 426 (26%) of the study subjects". Morgan, however, sets up his paper tiger by writing that "Finkelstein acknowledges that there were no smoking histories available and gratuitously adds that limited telephone enquiries were made into the smoking histories of some of the deceased workers", then he proceeds to vanquish it: "This is thoroughly inadequate. Retrospective smoking histories are notoriously unreliable, as any shoe-leather epidemiologist knows". In fact, the survey was of living workers. Since Tables II and III indicate a total of 124 deaths in the study population, it is hard to imagine how Morgan could conclude that the responses from 426 individuals came from a survey of next of kin of some of the deceased workers. A survey
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of living workers is subject not Irwin Kleinman and Frederick H. only to inaccurate reporting but Lowy, prompts me to comment also to another problem, selec- on a more general and often tion bias, and this fact is made neglected issue: the human beings that lie behind high-tech quite clear in the paper. medicine and its economic implications. Murray M. Finkelstein, PhD, MD, CM, CCFP In the medical community, Medical consultant often see economic imscientists Health Studies Service triumph over research peratives Ontario Ministry of Labour needs. Patients as well as cliniToronto, Ont. cians live out the frustrations inherent in the present cost-conReference tainment era. Despite the importance of 1. Jacobsen M, Marine WM: Reply to Morgan and Lapp. Am Rev Respir Dis economics, I cannot agree with 1988; 138: 1644-1646 the logic behind the authors' closing sentence: "Finally, the cost and administrative feasibility of the voluntary organ donation will have to be carefully program versus Economics whether analysed ethical acceptability the programto isdetermine practical as well as ethically acceptable." I do not fTS he article "Cadaveric believe that cost and feasibility organ donation: ethical can adequately measure ethical considerations for a new acceptability. Medicine already approach" (Can Med Assoc J has planners and administrators 1989; 141: 107-110), by Drs. who define what is acceptable in 660
CMAJ, VOL. 141, OCTOBER 1, 1989
dollars and cents. We all know that limitation of resources is an inevitable dictate of modem medicine. However, the enmeshment of medicine with economics betrays medicine's original purpose. The cost-benefit approach reduces man to the mechanistic summation of his organs. It sacrifices the patient on the altar of health-care business for the sake of productivity. What is costeffective and technologically feasible is far from necessarily being ethical. Reflection on what is ethical has to start with a sound appreciation of the mystery of man: a unique being, ontologically yearning for transcendence beyond his limitations. Man is more than the total of surgically interchangeable, genetically modifiable or psychologically determined parts. Man's spirit cannot be isolated from his body to satisfy the cost analysis of economists or the pragmatic observations of scientists. Science will never be
