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APPENDIX A DISSENTING OPINION A William S. Yamamoto While I do not disagree with the findings or recommendations of the committee either singly or in their collective consequence, I am nevertheless left with a sense of disquiet. I am moved to write to try to identify the nature of that difficulty, which may concern others who examine this report. The limitations of the study and its scope are fully stated in the introduction. The limitations, on the one hand, justify the character of the entire report, but also avoid examination in this report of med- ical technology from other perspectives. After carefully cataloging items that belong under the rubric "equipment-embodied technology," we treat it as a conceptually simple aggregate like "merchandise." This approach ignores crit- ical differences such as: (l) how development of technology re- lates to advances in the sciences and medicine, (2) who made each item and why, (3) what medical purposes they are intended to serve, and (4) how other technological innovations not directed to the concept of large scale address the same medical problems. The report seems to assume that technology is an entity in existence and that the issue of technology in medical care is that of disposition, distribution, cost, and management. It does not inquire as to how new equipment-embodied technology should come into existence, but rather into how the motivations of those who use the technology manage it in order to be respon- sive to the current preoccupation of the society with medical care costs. However well considered, this report is most suc- cintly described as a document that states: Technology exists; it should be controlled for the purpose of keeping down costs. Its principal recommendations are directed at the production of disincentives through economic, financing, and, to a lesser 99
l00 extent, cataloging and control procedures. It may well be that issues that trouble me do not have a substantive body of schol- arly or public literature from which a committee can organize a perspective. It may also be that technological innovation proceeds under certain natural pressures and needs no scrutiny, or that the appropriate and final philosophy should be that someone shall create and the polity shall dispose. But the paradigm, "If 'merchandise' is a villain which causes people to spend money, the wisest course is to take money away or somehow make 'merchandise' undersirable," is disquieting.