First edition. John R. Hogness and Malin VanAntwerp; eds. 298 pages. Washington, D.C.: National Academy Press; 1991. $29.95.

The allure of mechanical circulatory support systems (MCSS) sparks debate among social and clinical scientists. A totally implantable artificial heart has become the Holy Grail for many, and assessment of federal support for their pilgrimage is required. This text considers the challenge and is admirably edited. It should be studied by everyone interested in "big ticket," sophisticated, highly focused health care technology.

This book contains a careful analysis of government's liaison with MCSS industry as well as of vexing social issues economists must resolve, such as payment plans for federally reimbursed health care beneficiaries. It is a timely text because we now have the first glimpse of a usable MCSS. Although numerous reports have capably detailed the progress made since 1964 by the National Institutes of Health (NIH), this landmark text is the first written by an independent, nonpartisan group formed by the National Institute of Medicine. Previous reports have not been produced by independent groups. The expert panel was asked to respond to nine probing questions and to recommend, specifically, whether federal funding should be renewed for the program and for how much longer. The process was spurred by the 1988 NIH decision to terminate total artificial heart development contracts.

This book catalogs the challenge spectrum; every time I desired a meatier bite of a piquant concept, it was served. For example, the thorny dilemma of joint NIH-industry support for MCSS development (an unusual partnership for the Institute) is thoroughly addressed in an entire chapter, "Roles of Government and Industry in Medical Technology Research, Development and Use." Of particular interest is the group's use of "cost-effective" and "quality-adjusted life year extension" analysis (creative ways of quantifying the cost and potential benefit of MCSS). The committee justifiably dodges, however, issues of broader funding priorities, particularly important when one compares the limited dollars being spent on MCSS development as compared with the cost of one B-2 bomber!

Without detailing the committee's recommendations, suffice it to say that they do encourage continued support for MCSS development for the next few years, but with studied, regular, objective reassessment. The group was foresighted, recognizing that MCSS development and introduction into the clinic creates a marvelous case study that forces consideration of dilemmas such as public access to high-technology health care. One weakness is a very cursory discussion of mechanical and physiologic aspects of the devices themselves. Still, this text is a marvelous, scholarly, readable summary of current independent thought about MCSS development.