favorable to the procedures is ad-
ded, though this evidence is most
often not scientifically compar-
able to that from controlled stu-
dies. Overall, the report obviously
reflects a political situation in the
government and in medicine in
which the appearance of science
holds sway and frowns upon the
policy use of real science.
Hidden in the complex bureau-
cratic proposals for how to use
the information from scientific
studies of medicine are comments
very revealing of this situation.
The most direct way to use this
information would be to have the
FDA base regulatory decisions
upon it, as it already does for
drugs and to some extent for in-
struments. This alternative is not
taken seriously by the report,
however, since the "FDA is basi-
cally a regulatory agency and may
not be able to attract the scient-
ists necessary for regulating pro-
cedures. Furthermore, FDA's ne-
gative image with the practicing
community would hamper its
work (p. 102)....Physicians would
undoubtedly resist such regula-
tion. The process would be expen-
sive and could retard innovation"
(P- 104).
The information must be ga-
thered and synthesized from his-
torical and ongoing controlled
clinical trials, and NIH currently
funds the greatest number of such
trials. According to the OTA re-
port, however, "a system for iden-
tifying technologies that need as-
sessment could be developed in a
number of agencies at various le-
levels....NIH has exhibited a
stronger interest in developing me-
dical technologies than in assess-
ing them (p. 99)....NIH could as-
sume a larger role in testing both
new and existing technologies for
efficacy and safety. Not only has
6 0 NIH been reluctant to assume
such an expanded role without ing their own tax and insurance
new funding, but also NIH has re- burdens, and indeed they have
sisted becoming deeply involved
in existing medical practice
(p. 101)....NIH could undertake
the task of synthesizing efficacy
and safety information; however,
NIH has shown little inclination
to make judgements that could be
used by regulatory agencies
(p. 102)....NIH could refine and
expand its (information) dissemi-
nation efforts....However, NIH is
reluctant to expand its role in this
area, particularly in regard to
practicing physicians" (p. 103).
These comments about the
FDA, NIH and other government
bodies assume added signficance
when we realize that they are
practically quotations of what the
heads of these agencies said to the
OTA panel in interviews, as the
first draft of the report notes.
With the obvious ways of solv-
ing the problem politically exclud-
ed, the report focuses on a num-
ber of government agencies which
have been legally established to
control reimbursement depending
on the quality, efficacy and safety
of procedures; but, according to
the report, all such agencies have
either lacked the expertise or the
political clout to carry out the
task, or, like the PSROs, have been
dominated by the medical profes-
sion and therefore rendered inef-
fective. In response to the OTA
report, Congress has just passed a
bill, which President Carter is ex-
pected to sign, establishing yet
another such agency in the goven-
ment at $25 million a year (46).
A careful reading of the OTA
report therefore raises a curious
and troubling question: Now that
science is finally possible in medi-
cine, who will bell the cat? One
might think that conservative mid-
dle-class government cost cutters
would see this as a way of lighten-
been an important political force
in the closing down of public hos-
pitals and clinics. But these clos-
ings, far from limiting the useless
and dangerous parts of medicine,
have instead had the greatest im-
pact on the preventive and pri-
mary care end, and have done no-
thing to slow the avalanche of
new high technology treatments
of dubious merit. This result is
really not surprising, since this
constituency is composed in part
of doctors, researchers, statisti-
cians, accountants, construction
company managers, drug com-
pany personnel, admen, banking
executives and a myriad of others
whose personal self-interest is
bound up with the triumph of the
leading growth industry.
Corporate planners interested
in cutting benefit costs of control-
ling worker unrest on occupation-
al health issues might be possible
candidates, through corporate-
sponsored HMOs of Nixonian de-
sign (47). While it is true that
HMOs generally have lower rates
of hysterectomy or other dubious
medical procedures than fee-for-
service institutions (48) and that
important evaluation studies have
been done in England under the
pressure of enforced budget ceil-
ings or outright reductions, the e-
conomies in these organizations
are not necessarily related to effi-
cacy. Further, these organizations
still show great excesses of
unnecessary curative medicine,
and are little better at preventing
the social causes of disease, des-
pite the putative financial incen-
tive in this direction (49). Perhaps
in estimating their future one
should be reminded that scientis-
t s medicine was legally establish-
ed and massively funded by the
corporate foundations not be-