Healthcare Rationing: Why Stalin Had it Right

By  |  July 18, 2009 |  15 

Princeton ethicist Peter Singer’s article in this week’s NY Times Sunday Magazine is creating lots of buzz. It is a classic utilitarian description of the case for rationing – QALYs and all – and a plea for a mature national dialogue about the dreaded R-word.

Joseph StalinDon’t hold your breath. To understand why, remember the words of Joseph Stalin: “A single death is a tragedy, a million deaths is a statistic.”

A society of grown-ups would read Singer’s article and say,

“Gosh, he’s absolutely right. If we don’t make some hard choices about whether to cover $50,000 palliative chemotherapy to extend a life of an 80-year-old by a few months, then we are choosing not to have enough money to provide universal health insurance, or to ensure that everybody has their pap smears and generic Lipitor (or, while we’re at it, to house the homeless, provide decent public education, or have viable auto companies).”

Rationing is inevitable – as I recently mentioned, talking about whether we should ration is like talking about whether we should obey the laws of gravity. The only question is how we do it. And what better time than now to have this difficult national conversation, being that we’re in the middle of retooling our entire healthcare economy, the fundamental obstacle is finding the money to pay the bill, and we have a president who truly understands the dilemma and is smart and mature enough to lead the discussion.

Yet rationing remains a political Third Rail, the Lord Voldemort of the healthcare policy debate.

The issue is not new, nor are its political trappings. It’s worth understanding a bit of this history to frame today’s debate – and lack thereof.

In 1984, Colorado Governor Richard Lamm famously opined that the elderly had a “duty to die” in order to free up resources for the young. He was vilified.

In 1987, Oregon stepped into the mess that is healthcare rationing, and spent much of the next decade scraping off its metaphorical shoe. In the face of exploding Medicaid costs, the state legislature decided not to fund transplants (including bone marrow transplants) in order to preserve limited funds to cover other services.

This was in the early years of bone marrow transplant, when BMT had a 50-50 success rate for certain types of childhood leukemias (it’s better now), and cost about $100,000. The state did the math, and found that for the same $100K, several lives could be saved by plowing the money into other healthcare needs, including prenatal care. And so BMT became an uncovered service. A perfectly rational decision if you live in Utilitarian, Most-Good-for-the-Most-People, World.

But that’s not the world we live in.

What happened next was utterly predictable. A 7-year-old boy named Coby Howard developed acute leukemia, Oregon denied his BMT coverage under Medicaid, and his mom went ballistic (any parent, including this one, would have done precisely the same thing). The only question was which megaphone she would grab first to make her case: the media, her local congressman, or a lawyer (ultimately, of course, she used all three). Here’s how it sounded on ABC’s Nightline:

[Ted Koppel] began the program with footage of Coby Howard and said: “When the State of Oregon decided to stop funding organ transplants, it allowed this boy to die.” Koppel later asked: “Is the cost of modern medical technology forcing public officials to play God?”

?In the end, Coby received his BMT, paid for by private donations, but sadly died later that year. Under the leadership of state senate president (later governor) John Kitzhaber, a former ER doc, and in the face of withering post-Coby criticism, Oregon developed a more explicit rationing plan – of course, it covered BMT. Kitzhaber and his staff later described the pressures they felt after they took on healthcare rationing,

“Our detractors consist mainly of uninformed members of threatened interest groups who delight in comparing the Oregon plan to a perfect world.”

Stalin could have predicted this, of course. The Oregon rationing plan (both the ad hoc decision to deny BMTs and the more explicit “prioritized list” that followed) depended on a hard-boiled tradeoff between a single identifiable life – in this case, a cute child with a determined mother – and many unidentified lives. We’ll never know which kids were saved by better prenatal care, or whose strokes were averted by primary care and hypertension control. These statistical lives make for a pretty dull interview on Nightline – and they don’t blog.

Where do docs fit into all of this? Our ethical model is to do everything we can for the patient in front of us – we are socialized from the first day of med school to believe that the single death is indeed a tragedy (the late Norman Levinsky made this point in a wonderful piece in the NEJM called “The Doctor’s Master”). Although as responsible citizens, we care about society and the unidentified lives outside our office or our ICU, it is not our job to weigh the impact of our choices on them. And, of course, we won’t be sued by society for plundering its resources, but might well be sued by the family of an individual patient who feels that we didn’t do everything possible to save their loved one.

I just finished a couple of weeks on the wards, and once again cared for several patients – cachectic, bedbound, sometimes stuck on ventilators – in the late stages of severe and unfixable chronic illnesses whose families wanted to “do everything.” As I wrote last year, there are limits (like chest compressions) on what I am willing to do in these circumstances, but they are mostly symbolic – basically, I am a bit player in this crazy house, with no choice but to flog the helpless patient at a cost of $10,000 a day in a system that is nearly broke and whose burn rate threatens to ruin our country. Go figure.

Is there anything we can do? The favored solution, a board resembling the UK’s National Institute for Health and Clinical Excellence (NICE) with the teeth to limit certain new drugs and technologies, is hard enough. But even if we were able to get a NICE-like organization in place (doubtful), that doesn’t really address the brutally tough issue: is our ethical model one in which we do everything possible, irrespective of cost, for every patient when there is any chance of benefit, or one in which we place limits on what we’ll do in order to do the most good for the most people. An American “NICE” isn’t going to limit ICU care for 80-year-olds with metastatic cancer. That will require a much broader public discussion, and even harder choices – since they will need to be made at the bedside.

As Singer notes, every society that rations provides a safety valve for the wealthy disaffected. In the UK, you can buy private insurance that allows you to jump the queue for your hip replacement. Canada’s safety valve is called the Cleveland Clinic. We don’t talk about the percent of our GNP we are spending on Starbucks lattes, or on iPods, or on vacations. People pay for these things out of pocket, and receive no tax advantages when doing so. Given the American ethos of self-determination and consumerism, any rationing plan will need to allow people who can afford care that isn’t covered by standard insurance to buy it with their own money (with absolutely no tax advantage). Two-tiered medicine, sure, but I see little problem with this as long as we are using the money in the communal pool to provide a reasonable set of benefits to the entire population.

How might a thoughtful structure to support rationing be organized in the U.S.? When considering new technologies and drugs, it will probably entail an independent board empowered to make coverage recommendations based on cost-effectiveness, just as NICE has done in the UK. But just as importantly, at the level of individual hospitals or healthcare organizations, there will need to be committees of providers, administrators, and patient advocates that can set and defend limits on care. Such decisions would not automatically mean that grandpa can’t stay on the ventilator, but would mean that ongoing care would no longer be fully covered by insurance. Of course, these decisions would have to be all-but-immune from litigation threat.

Will this happen? Probably not. Twenty years ago, the great Princeton healthcare economist Uwe Reinhardt observed that there are two kinds of rationing: “civics lesson rationing” and “muddling through elegantly.” In the former, a NICE-like federal board, or local panels such as the one I’ve described above, weighs the evidence and makes these tough rationing decisions algorithmically and prospectively. The muddling through option, which Reinhardt felt was far more likely, involves limiting the resources available – the number of ICU beds, or MRI scanners, or CT surgeons – and allowing docs, patients and administrators to duke it out at the bedside. The evidence is that they do a decent job at triaging to provide the most good for the most people.

Of course, these limits are naturally present when resources are truly scarce – like livers for transplantation – and in these circumstances we have developed thoughtful rationing approaches. The point is that health care dollars increasingly resemble livers.

I’m pleased Peter Singer and others have dared to speak of the R-word in public, because it is so central to today’s healthcare policy debate. But will the society that brings you Rush Limbaugh and Glenn Beck (or, I’m beginning to think, some of our Democratic representatives) deal with it in an effective, mature way? I truly doubt it.

Why not?

Joseph Stalin would know.


  1. menoalittle July 19, 2009 at 4:34 am - Reply


    As you have experienced, the cost of care of the patient transitioning from life to death is disproportionately high.

    One simple solution to enable a cost effective transition lies in advanced directives. Though not always precise and not all citizens will forgo prolongation of the dying process even in cases of futility, and there will always be guilt ridden family members who want every thing done, the costs of futile care will be much less when the approach to end of life care has been predetermined by the patient.

    Nevertheless, rather than establishing complex barackracy with boards of pontification to determine the treatment of cancer in a 90 year old or the ideal number of ICU beds or PET scanners, there ought to be a Federal law requiring that each citizen establish a living will document as an absolute condition of receiving medicare or medicaid.

    The ONC and HIT Policy Committee may finally render HIT meaningfully useful by enabling money saving advanced directives to be digitally memorialized on these otherwise meaningfully user unfriendly devices.

    Best regards,


  2. tjl July 19, 2009 at 11:53 pm - Reply

    Excellent post. Just as Barack Obama was warned that he should stay away from thoughtfully discussing the real experience of black Americans during the Primary in 2008, and fortunately–for all of us–ignored this advice, he is likely similarly being counseled to stay away from a more thorough discussion regarding the appropriateness of end-of-life spending, especially during this fractious healthcare debate.

    In the meantime–a suggestion to educate the coming generations of healthcare utilizers: That all high school seniors in government class receive an educational component on the role of our government in health-care delivery, payment & incentives, that includes information on advance directives, the role of Hospice, the importance of establishing a medical home, and maintaining a healthy lifestyle.
    And that all patients about to undergo elective procedures view a pre-admission video, or attend a pre-admission class that discusses the typical hospitalization experience, the role of hospitalists, discharge planners, and how to manage the transition from hospital to home, as well as information on advance directives, Hospice, and palliative care. Elderly patients should be encouraged to bring in family members for this orientation.

    As a former public health nurse, and now professor of health policy, and health care attorney & policy specialist for a major health system, I was surprised to learn that my father, then suffering from Alzheimer’s but otherwise healthy, was eligible for Hospice, after aspirating on his food and developing pneumonia twice. That second hospitalization, at great cost to Medicare and incredibly painful for our family, needn’t have occured.

    If I didn’t know the eligibility criteria for Hospice, I suspect many families do not.

  3. Legacy Flyer July 20, 2009 at 10:52 pm - Reply

    I think there is hope for reining in medical costs if we can use a little common sense and muzzle the lawyers (not likely with this Congress and President)

    Specific example: I work in Diagnostic Imaging as a “Nighthawk” reading XRays, CTs, etc. from ERs. I see about 50 CTs of the Chest every night and see one positive for PE once every other night. Therefore the “hit rate” is about 1%.

    This is a very expensive and wasteful endeavor. There is no doubt that the number of CTs could be cut substantially with nearly the same yield of positive cases by applying some kind of criteria and or scoring formula to these patients. Two things would be required:
    1) An agreed upon set of criteria or scoring system for who should get a CT for PE
    2) PROTECTION from lawsuits for those who follow the criteria/scoring sytem.

    I sympathize with ER docs who order CTs of the Chest on patients who have a VERY low probabillity for PE because they are scared of what would happen if they don’t. Nevertheless, it is bad policy and very expensive.

  4. gene spiritus July 21, 2009 at 4:32 am - Reply

    This past Saturday while discussing the present health care bill with a member of a large “K” street firm I suggested to him that the real question was rationing. It is the elephant in the room that appears to be a third rail for most politicians and frankly the Medical community has not really addressed the issue. In fact tonight the New York Times features and article suggesting maintenance therapy for lung and ovarian cancer despite the lack of good peer reviewed data. How happy I was to pick up my magazine section and read this wonderful thought provoking essay. I have been sending the link out to friends and applaud your featuring this on your blog. We need to do much more to face this situation of providing no care to 45 million and excessive care to those lucky enough to be well insured. EMS

  5. MedicalContrarian July 26, 2009 at 8:17 pm - Reply

    No realm exists where all legitimate wants and needs are fulfilled. Resources to fulfill human needs are always in short supply. Scarcity is an invariant aspect of the real world. Health care is not unique.

    How is scarcity is dealt with in non-healthcare domains? Historically scarce resources have been allocated via a variety of mechanisms. However, the above discussion addresses only part of the equation. Resources to fulfill medical needs and wants need to be both created and allocated. To focus soely on the allocation piece is a problem.

    We could easily fulfill more medical needs if we simply confiscated everything else and shunted all resources toward patient care. Unfortunately this approach would have the unintended effect of destroying our ability to create resources needed to fulfill all human needs, even healthcare needs in the future.

    Obviously no one is proposing such a draconian solution to our healthcare dilema, but the question still stands at which point does forced allocation to healthcare needs begin to undermine the ability of the system in general to generate the resources to fulfill other needs? When do we run the risk
    of killing the goose that lays the golden eggs?

  6. MedicalContrarian July 26, 2009 at 8:18 pm - Reply

    No realm exists where all legitimate wants and needs are fulfilled. Resources to fulfill human needs are always in short supply. Scarcity is an invariant aspect of the real world. Health care is not unique.

    How is scarcity is dealt with in non-healthcare domains? Historically scarce resources have been allocated via a variety of mechanisms. However, the above discussion addresses only part of the equation. Resources to fulfill medical needs and wants need to be both created and allocated. To focus soely on the allocation piece is a problem.

    We could easily fulfill more medical needs if we simply confiscated everything else and shunted all resources toward patient care. Unfortunately this approach would have the unintended effect of destroying our ability to create resources needed to fulfill all human needs, even healthcare needs in the future.

    Obviously no one is proposing such a draconian solution to our healthcare dilema, but the question still stands at which point does forced allocation to healthcare needs begin to undermine the ability of the system in general to generate the resources to fulfill other needs? When do we run the risk
    of killing the goose that lays the golden eggs?

  7. Emery August 13, 2009 at 6:20 pm - Reply

    I find it ironic that you use Joseph Stalin, arguably one of the most brutal mass murderers to ever live on earth, as an example of the “moral ethics” of rationing healthcare. I believe you can attribute about 40 million deaths to him alone. 10 million in the Ukraine alone when he cut off their food in 1933. Do you think they received end of death counseling from him? Stalin had it right? Try studying a little history. He was a monster. How many lives did he save?

  8. Hospitalist in Chattanooga August 16, 2009 at 2:13 am - Reply

    Thanks, Bob. I agree with you all the way. I catch your drift about Stalin too. However, as I watch the Glenn Beck show denouncing you, and recommending others to Google you on this matter, I would recommend your finding other examples of “smart rationing” to demonstrate your point. I do find Beck an ironic journalist. His apocalyptic view of the future “if we go on Obama’s path” is equally likely to occur if we go on the 3rd-party health care path we are on now. And equally likely to result in draconian rationing (as seen with both Hitler and Stalin during post-war times of economic calamity). Unfortunately, in this age of fearful soundbites, should we expect any different? How else would Lou Dobbs have a job?

  9. Jack Percelay August 16, 2009 at 10:38 am - Reply

    Also just saw the above mentioned Glenn Beck rerun at 6 am this morning along with other captivating infomercials. Being demonized with Peter Singer by Mr. Beck puts you, and hospital medicine in good company.

    I expect the most effective way for us to influence the debate with those who get their information from Fox News instead of NPR is to tell stories of individual patients and personalize health care reform just as President Obama did recently when he spoke about his Grandmother’s death.

  10. bladder weakness products August 16, 2009 at 12:40 pm - Reply

    I can’t fathom why to ration health care? This is a right and everyone deserves to have it no matter the race, the status and the color. There should be no if’s and but’s when it comes to affordable health care. We should even be more lenient with our seniors because they deserve our compassion.

  11. Sue Kimball September 26, 2009 at 2:34 pm - Reply

    The gloves are off. Either we let the market ration care via the insurance companies or the government will. Wonderful,our government operates with all the effiency of the Post Office and the compassion of the IRS. I know, I have been frustrated by Medicare bureaucrats for the last twnety nine years. Not to worry, if I am ill, they’ll just let me die if my case is deemed too expensive for the commmon good. The Baucus Bill clearly states the if a physician spends more than the 90 percentile of rescources ( NMotice how they omit the method for deriving this number. The devil is in the details.) in caring for his/her patient, they will have their reembursements cut. Even if the physican is willing to take the financial hit, their family and their employer will not be. See you under the bridge, Bob.

  12. reklammicke January 13, 2010 at 11:43 am - Reply

    Great post!

    And could someone please help understand what the hell is going on in washington. There in the middle of the conference committee on health care and their doin it behind closed doors. Obama told us multiple times on the campaign trail that it would be on c-span! WHy isn’t he doing anything!, to be honest, im tired of these politicians, I thought Obama would be a different type of politician but he is doing nothing about this problem.

    Please Please, someone explain to me why they are doing this in private, conference committees should be in the public, this better not be like that DNC meeting about Florida and Michigan delegate votes!!!

  13. JackLounge January 18, 2010 at 6:06 am - Reply

    The “r” word… It is the dangerous word for the 1st decade of this new 2000 millinium. You are correct and for the most part careful in the presentation of your opinion. I am dumbfounded with the opener on Stalin. Rationing is inevitable. Your opener justs widens the divide between the NPR comerades and the FOX News teabaggers.
    The debate is not about rationing (we do it now ). Ideology takes over when we begin the discussion about who the Rationer will be. If it is the government, will we see unions getting rationed care in 2018? Or will Nebraska politic thier way to a more generous “limit of care” program than Alaska?
    There is too much political fortune in health care to fix the problems we share as a nation. We settle for temporary solutions to get us throught the upcoming elections.
    SHould the private sector be the Rationer? Is there a private sector in health care?
    As a primary care physician my revenue is mostly controlled by some organization that is either government based or heavily controlled by federal and/or state governments. My expenses are mostly free market however. I got that going for me.
    I am sure you are aware of the government funding of NPR. The reason is that it would not be viable in a free market. It needs the government ( or believes it needs the government) to insure its programing. This is the rationing of information. FOX can be accused of similar news rationing as well, but they are at least on thier own dime.
    If you want to establish a forum for national self discernment regarding rationing of health care, leave Stalin , Limbaugh and Beck out of your conversation. Ideologues do not come up with solutions, they prefer policies instead.

  14. Youporn January 19, 2010 at 9:39 pm - Reply

    We should even be more lenient with our seniors because they deserve our compassion.

  15. bumpkin October 8, 2013 at 8:55 pm - Reply

    Ah, a ‘Con-munist’ author. Call yourself a socialist? No. Not really. A Communist. The ONLY reason anyone (including you) even surmise we need healthcare rationing is to further you socialist/ Communist agenda of controlling the people. Consider this: IF America continued to stand on good, clean ‘Individual Capitalist’ ground, (NOT on Corporatist ground, which is primarily selfish and evil) people who WORKED for the privilege to have health insurance would have it, and those who did not, would NOT have it. Thus, if Hospitals were run as they SHOULD be, there would be no question of your “R” word. It would take care of itself. Hospitals would agree to provide a needed surgery that had no family money to pay for it, by having the family sign over the deed to their home or their car, or whatever, or employ the parents without benefits until the cost of the surgery was recovered, and give the same option to others… There are always housekeepers, groundskeepers, etc needed, and there are people who can barter what they already have. In the doing, these people would have gained new skills that are at least somewhat marketable. THAT is capitalism. Individualized. Docs could do the same. I once paid for my handicapped son’s tonsillectomy by hand-crocheting a king-sized bedspread for the Doc’s lovely wife. I had no money, but I found a way that was agreeable to all. She bought the thread. And I made payments to the hospital till it was paid for. I put hundreds of careful hours into that afghan, and Doc didn’t have to buy his wife a custom-made one. Additionally, there have always been kind folk who would donate to help a family in need (say, with a little child who needs healthcare but Mom and Dad never could apply themselves hard enough to gain an education rich enough to provide them with good income enough to buy good health insurance, or circumstances came down hard on them, if they were movers and shakers, and just had too much bad luck- like a house-fire, or cancer wiping out their savings then a child of theirs getting cancer… etc. Some folk are just unlucky, but are willing to work. Some people just lazy and cannot find that much focus. IF America did NOT provide free healthcare for those who don’t try to take good care of themselves and their families, then those that could afford it would have it, those that could not afford it would not have it, and people would try harder to live a healthier, cleaner life, if they KNEW nobody was going to pay for their illnesses and debauchery. AND, the lazy, weak, infirm, druggies, drunks, etc, would die sooner than later. They are going to die eventually. But not with any dignity. Can I speak with any authority on this? Yes. I was a MED-Surge RN for many years. I could not help but notice that the people who were poverty-stricken, (except for the few who had circumstances happen TO them, such as accident victims from a drunk driver or a healthy working Mom who got cancer) lived an I-Don’t-CARE-WHAT-HAPPENS-TO-ME life, many smoking, drinking, drugging often, and excitedly telling me of many ways they had found to rip off the generous, magnanimous government endowment system, in order to ‘get by’ better. To a wo/man, they all seemed VERY proud of their slyness/ their cleverness, in how to rip off the People Who Pay Taxes, only they called them an “IT”, using the word ‘it’ to describe the government as a single entity. Look. Every one of us are going to die. Nobody wants to, but all will have to. Cant get around it. WHY cant our ‘government’ managers simply create a law that only indigent children under 12 gets government health assistance, and no adults unless they are handicapped? -And the government managers need to keep Social Security exactly as the government PROMISED working Americans that it would be, when they forced it down America’s throat, – which they did solely to in order to create a fund they could rip off regularly. THINK of the money ‘we’ would save. (Except the gov managers would go crazy-busy trying to find other ways to spend our tax dollars in order to force their depraved will upon us.) Ah, but the government wants its collective hand in everyone’s business, and to enslave us all, by providing food stamps and healthcare to those who could actually do more to feed themselves- (even if they had to sell their big-screen TVs to get money for a meal). How did this control-freak business start? Did someone in government actually state that we weren’t humans at all if we didn’t provide social/financial alms for the poor? Even the Holy Bible admonishes us to not create a world of beggars by feeding a man a fish, but told us to teach the man to fish. Get him to do for himself, and, if he doesn’t show up for lessons, let the fool starve. Cause and effect. Put the responsibility onto the individual, instead of upon the government. This actually brings the potential for self-esteem and self-satisfaction to us. Refusing to acknowledge that we are all able-bodied individuals (before we get sick, ) and are responsible for ourselves 100%, is where the Communist comes from. The Communist sees the PEOPLE (government) as a single entity that is responsible to fill everyone’s needs, including their own. Politicians produce NOTHING but the need for more money to be spent. They call themselves managers of our money (taxes) then they mismanage it SO horribly that we believe we need them to continue in their current position in order to figure out where it all went. Taxes were originally created to be voluntary. So they always should be. The mismanagers of government all have a lust to spend OPM. Its a sickness much like gambling- very addictive, and thus, managers should be changed every two years across the board. As soon as the lust for OPM hit the managers of old, the (mis)managers of government quickly lowered their standards and let just anyone into the position, which helped the original thieves to have a better, more elevated opinion of themselves… and the loud, brazen thieving-hussy-types took over, by bawling like a calf to the other managers and to the people that we have to take total responsibility for others, OR we aren’t human, as they ripped off the people’s coffers… (Liberals) How stupid is that?! That VERY point steals away a man’s autonomy- his freedom to achieve. Freedom is individual. Its not collective. If freedom were truly ‘collective’ in reality, we would all pass gas at the same time every day. People are individuals. They were created as such, and should be treated as such, and they should have the RIGHT to be in control of their own situation, and the situation of any family they create. THAT is why capitalism is the ONLY decent way to run a country! It allows for individuals to succeed or fail as individuals. It allows people to find the bravery to realize their full potential. Communism/ Socialism does not. It creates a nation full of wimpy slaves who either receive the alms for the poor or have to provide them. We do NOT need rationing. We need less government buffoons screwing up the natural order of man and his freedom. And we need true Capitalism, and to outlaw Corporatism.

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About the Author:

Robert M. Wachter, MD is Professor and Interim Chairman of the Department of Medicine at the University of California, San Francisco, where he holds the Lynne and Marc Benioff Endowed Chair in Hospital Medicine. He is also Chief of the Division of Hospital Medicine. He has published 250 articles and 6 books in the fields of quality, safety, and health policy. He coined the term hospitalist” in a 1996 New England Journal of Medicine article and is past-president of the Society of Hospital Medicine. He is generally considered the academic leader of the hospitalist movement, the fastest growing specialty in the history of modern medicine. He is also a national leader in the fields of patient safety and healthcare quality. He is editor of AHRQ WebM&M, a case-based patient safety journal on the Web, and AHRQ Patient Safety Network, the leading federal patient safety portal. Together, the sites receive nearly one million unique visits each year. He received one of the 2004 John M. Eisenberg Awards, the nation’s top honor in patient safety and quality. He has been selected as one of the 50 most influential physician-executives in the U.S. by Modern Healthcare magazine for the past eight years, the only academic physician to achieve this distinction; in 2015 he was #1 on the list. He is a former chair of the American Board of Internal Medicine, and has served on the healthcare advisory boards of several companies, including Google. His 2015 book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, was a New York Times science bestseller.


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