means to pay for treatment when an insurance claim is rejected have access to care that is closed to persons who are less affluent. In addition, the practice of denying coverage for treatment of preexisting conditions can severely limit many people's freedom to change employers and can cause enormous out-of-pocket expenses even for those with insurance.

As insurance companies try to manage their risks, so too do physicians. In our increasingly litigious society, malpractice suits against physicians are common place, especially as the personal physician is replaced by the more remote specialist. Operating under the threat of malpractice, physicians sometimes perform procedures that are medically unnecessary or marginal in order to protect themselves from the accusation that they did not do everything possible. Inappropriate use of tests and technology carries its own risks to patient health and raises the overall costs of health care, as do the large amounts of money paid by physicians for malpractice premiums.

Thus, these changes in the structure and financing of health care put persons in need of health care into a system that may ignore their dignity as individuals, impose on them or on society as a whole costs that are unfair, and distribute services in an inequitable fashion.

New Diagnostic and Therapeutic Capabilities in Medicine

There are many engines driving technological advance in the biomedical sciences, but it is not entirely clear that maximal stoking of those engines is necessarily the route to equitable distribution of the good that new knowledge can bring. Congressman George Brown, Jr., Chairman of the Committee on Science, Space, and Technology of the U.S. House of Representatives, has argued that the free-market drive to technology, based on the notion of sustained economic growth, may not be the most direct path to improved quality of life for all. He observes, on the contrary, that freewheeling market forces and the drive for high-technology solutions to our society's problems may in fact displace nontechnological, readily distributed preventive solutions in favor of inequitable, expensive, and sometimes even less effective solutions (Brown, 1993). Implied in his argument is the notion that high-technology solutions to biotechnological problems are more likely to produce ethically contorted and difficult situations than are the simpler, low-technology solutions that are driven by concern for the fair and equitable access for all to elemental human needs. Our country's experience with biomedical technology lends some credence to this idea.

During the latter half of the twentieth century, federal investment in research and development has fueled a steady stream of advances in science and technology in general and in biomedicine in particular. The federal government, through NIH, is the principal supporter of biomedical research in U.S. universities and research institutes. But despite the



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