ORIGINAL

ETHICAL IMPERATIVES AND THE NEW PHYSICIAN :
JV, RESPONDING TO THE AGING PATIFNT

COMMENCEMENT ADDRESS BY

C, EVERETT KOOP, PLD,, Sc,D,
   SURGEON GENERAL

        OF THE

     U,S, PUBLIC HEALTH SERVICE
UA DEPARTMENT OF HEALTH AND HUMAN SERVICES

PRESENTED TO THE GRADUATING CLASS OF

KIRKSVILLE COLLEGE OF OSTEOPATHIC MEDICINE
      KIRKSVILLE, MISSOURI
        JUNE 6, 1988


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(GREETINGS TO HOSTS, GUESTS, FRIENDS, ETCJ

  I AM DELIGHTED TO BE YOUR COMMENCEMENT SPEAKER THIS YEAR,

AND IT'S A SPECIAL PLEASURE TO BE HERE IN KIRKSVILLE, WHICH YOUR

CLASS PRESIDENT, MITCHELL ADAMS, REMINDED ME IS THE "HEARTLAND OF

OSTEOPATHIC MEDICINE."

  I FEEL A SPECIAL KINSHIP FOR OSTEOPATHIC MEDICINE BECAUSE OF

ITS CONSISTENT AND ABIDING CONCERN FOR THE ROLE OF THE FAMILY IN

THE CONTEXT OF GOOD PATIENT CARE,


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   I MIGHT ADD THAT FAMILIES AND CLOSE FRIENDS PLAY AN

IMMENSELY IMPORTANT ROLE IN THE PREPARATION OF PHYSICIANS, ALSO,

I AM SURE THAT THERE ARE MANY YOUNG MEN AND WOMEN AMONG THIS

GRADUATING CLASS TODAY WHO SIMPLY WOULD NOT HAVE REACHED THIS

HAPPY DAY, WERE IT NOT FOR THE LOVE ,,a THE MORAL SUPPORT ,a, AND

THE HARD CASH THAT WAS FORTHCOMING FROM THE PEOPLE WHO LOVE YOU

AND CARE ABOUT YOUR FUTURE,

SO FAMILIES AND CLOSE FRIENDS ARE PERSONALLY IMPORTANT, TO

BOTH PATIENTS m PHYSICIANS,


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  IN FACT, DURING MY 40-YEAR ASSOCIATION WITH PEDIATRIC

SURGERY, I RELIED AS MUCH UPON THE PARENTS AND SIBLINGS OF MY

PATIENTS AS I DID ON MY OWN MEDICAL AND TECHNICAL STAFFS, AND I

ASSURE YOU THAT THOSE STAFFS WERE -- AND STILL ARE -- TOP-NOTCH

AT THE CHILDREN'S HOSPITAL OF PHILADELPHIA,

  BUT ODDLY ENOUGH, IN THE 7 YEARS SINCE I LEFT MEDICAL

PRACTICE TO BECOME YOUR SURGEON GENERAL, I HAVE BEEN EVEN MORE

CONSCIOUS OF THE IMPORTANT ADJUNCT ROLE OF THE FAMILY IN

CONTEMPORARY HEALTH CARE,


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HOWEVER, I'VE ALSO BECOME MUCH MORE AWARE OF THE MANY

SUBTLE WAYS IN WHICH OUR EXCELLENT SYSTEM OF HEALTH CARE HAS

BEGUN TO PUT CONSIDERABLE AND OFTEN UNRFASONABLE STRESS UPON THE

FAMILY UNIT ANJJ UPON THE FAMILY-CENTERED PRACTITIONER,

   AND DURING MY FEW MINUTES WITH YOU TODAY I'D LIKE TO TALK

ABOUT THAT, MY PARTICULAR FOCUS, HOWEVER, WILL BE ON THE NATURE

OF THE ETHICAL CHALLENGE BEING PRESENTED TO PHYSICIANS TODAY,

ESPECIALLY TO THOSE WHO PROVIDE MEDICAL AND HEALTH CARE FOR OUR

ELDERLY,


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   MY CHOICE OF TOPIC IS NOT ALL THAT ARBITRARY, EARLIER THIS

YEAR, AS I LOOKED OVER MY SPRING SPEAKING SCHEDULE, I NOTED THAT

I WOULD BE PRESENTING 6 COMMENCEMENT ADDRESSES TO GRADUATING

CLASSES OF NEW PHYSICIANS,  IT SEEMED LIKE A GOOD OPPORTUNITY TO

DEAL WITH A VARIETY OF ETHICAL QUESTIONS IN THE COURSE OF THOSE 6

ADDRESSES,

  AND THAT'S WHAT I'VE DONE, BEGINNING EARLIER THIS MONTH, AT

THE UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES, AND

ENDING IN MID-JUNE, AT THE UNIVERSITY OF HEALTH SCIENCES/CHICAGO

MEDICAL SCHOOL, I AM SHARING WITH SOME 1,200 GRADUATES IN

ALLOPATH IC AND OSTEOPATHIC MEDICINE THESE THOUGHTS ON THE RANGE

OF "ETHICAL IMPERATIVES" FACED BY THE NEW PHYSICIAN,


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SOMETIME THIS SUMMER I HOPE TO SEND EACH OF YOU A FINAL

PUBLISHED COPY OF ALL 6 ADDRESSES,

  HENCE, TODAY, I WANT TO RAISE WITH YOU SEVERAL OF THE

ETHICAL QUESTIONS SURROUNDING HEALTH CARE FOR THE AGED,

  I NEED NOT DWELL ON THE SIGNIFICANCE OF THE TOPIC BECAUSE

I'M SURE YOU ALL KNOW THAT BY THE TIME YOU ARE AT YOUR PEAK IN

YOUR OWN MEDICAL PRACTICES -- IN, SAY, 15 OR 20 YEARS -- A

SUBSTANTIAL PORTION OF THE AMERICAN POPULATION, CLOSE TO 20

PERCENT, WILL BE OVER THE AGE OF 65.


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AND WITHIN THAT GROUP, THE FASTEST-GROWING SEGMENT WILL BE

THAT OF PERSONS WHO ARE AGE 85 OR ABOVE.

  HENCE, A SUBSTANTIAL

BE OVER THE AGE OF 65 maa

PORTION OF YOUR OWN PATIENT CENSUS WILL

AND EVEN OVER THE AGE OF 85,

  THIS WILL BE A GRADUAL, AND EVOLVING DEVELOPMENT, I

CERTAINLY DON'T ANTICIPATE -- NOR SHOULD Yfl -- ANY SUDDEN "AGE

SHOCK" IN YOUR PRACTICE,


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  ALSO, I WOULD ASSUME THAT ACCESS TO PHYSICIAN CARE WILL BE

AS GENERALLY PROBLEM-FREE FOR OLDER PEOPLE IN THE NEXT CENTURY,

AS IT IS TODAY,

  THERE MAY BE SOME UNHAPPINESS AMONG PHYSICIANS WITH THE WAY

THEY'RE REIMBURSED FOR THE MEDICAL CARE THEY DO DELIVER TO OLDER

PEOPLE, WE HEAR ABOUT THAT TODAY, IN REGARD TO REIMBURSEMENT

SCHEDULES UNDER MEDICARE ASS1 GNMENTS

  NEVERTHELESS, IT IS GENERALLY ACKNOWLEDGED BY MOST OLDER

PEOPLE AND THEIR ADVOCATES, AS WELL AS BY GOVERNMENT, THAT AN

OLDER PERSON IN THIS COUNTRY WHO NEEDS MEDICAL CARE WILL GET IT,


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THE RUB COMES WHEN THE ATTENDING PHYSICIAN MUST MAKE THE

JUDGMENT -- AND IT'S AN ETHICAL AS WELL AS A MEDICAL JUDGMENT --

REGARDING THE NATURE AND THE EXTENT OF THE MEDICAL CARE TO BE

GIVEN TO THE OLDER PATIENT,

   IDEALLY WE WOULD RATHER MAKE OUR JUDGMENTS SOLELY ON THE

BASIS OF WHAT IS GOOD MEDICINE, AND ESSENTIALLY I BELIEVE THAT'S

STILL WHAT AMERICAN PHYSICIANS ARE DOING,

  BUT THEY ARE ALSO BEING PLACED UNDER GREATER AND GREATER

PRESSURE TO SLOW DOWN -- IF NOT REVERSE ALTOGETHER -- THE RISING

COSTS OF HEALTH CARE,


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  TAXPAYERS .a a HOSPITAL ADMINISTRATORS a 1 m THIRD-PARTY PAYORS




I I I GOVERNMENT OFFICIALS 1,s AND PATIENTS THEMSELVES ARE

QUESTIONING THE HIGH COST OF MEDICAL CARE AND THEY ALL WANT TO

SEE PHYSICIANS DO THEIR PART BY EXERCISING GREATER COST CONTROL.

  THE ARGUMENTS, BY THE WAY, USUALLY CONCERN THE EXCESSIVE

COSTS OF CARING FOR THE PATIENT IN THE NEXT BED ati, NEVER ONE'S

OWN,

  IN ANY CASE, THE ELDERLY HAVE BECOME A RATHER CONVENIENT

TARGET BECAUSE, NO MATTER HOW SUCCESSFULLY YOU CARE FOR AN

ELDERLY PATIENT, HE OR SHE WILL HAVE THE POOR TASTE TO DIE WITHIN

JUST A FEW YEARS --IF NOT A FEW MONTHS,


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   THIS RATHER OBVIOUS PHENOMENON HAS PROMPTED SOME CRITICS TO

ADVISE OLDER PEOPLE TO SOMEHOW "GET OUT OF THE WAY," AS GOVERNOR

LAMM OF COLORADO HAS SO DELICATELY PUT IT, IN ORDER TO CONSERVE

PRECIOUS RESOURCES -- INCLUDING, OF COURSE, MONEY.

   SUCH AN ARGUMENT REVEALS A FRIGHTENING OVER-SIMPLIFICATION

OF A MAJOR HUMAN CONCERN,  IT ALSO DEMONSTRATES A PROFOUND

MISUNDERSTANDING OF THE HUMAN AGING PROCESS

  WHEN PEOPLE TURN 65, THEY AUTOMATICALLY DO NOT BEGIN TO DIE.

THAT'S RIDICULOUS, EVEN AN OLDER PERSON WHO IS ILL IS NOT, IPSO

FACTO, KNOCKING AT DEATH'S DOOR,


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  FOR SUCH PEOPLE, WHO CLING TO LIFE, DANIEL CALLAHAN OF THE

HASTINGS CENTER HAS A SPECIAL LABEL: HE CALLS THEM *BIOLOGICALLY

TENACIOUS,"  BUT THERE'S A LOT MORE AT WORK IN THE FIGHT FOR LIFE

THAN JUST ONE'S OWN FERMENTING BIOLOGY,

  THE PLAIN FACT IS THIS: WE DON'T KNOW PRECISELY WHEN A

PERSON'S "TIME IS UP,"  THEREFORE, WE AS PHYSICIANS MUST OPERATE

WITHIN AN ETHICAL SYSTEM THAT REQUIRES US TO GIVE A PATIENT ALL

THE LIFE TO WHICH HE OR SHE IS ENTITLED,


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  WE SHOULD DO THAT FOR PATIENTS OF A,Ny AGE, BUT IT IS

ESPECIALLY SIGNIFICANT FOR OLDER PATIENTS, WHO ARE ALREADY

PERCEIVED BY YOUNGER PEOPLE AS BEING SO MUCH CLOSER TO DEATH AND

THEREFORE ,a, VIRTUALLY DEAD,

  SOME, WHO HAVE HEARD ME MAKE THIS ARGUMENT, HAVE COUNTERED

THAT ALL I WANT TO DO IS PROLONG THE ACT OF DYING,  I ACKNOWLEDGE

THAT THERE IS SUCH A THING mm m BUT I WOULD NOT ENGAGE IN IT,


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   I HAVE ALWAYS BELIEVED THAT THERE'S A VAST DIFFERENCE

BETWEEN GIVING A PERSON AS MUCH LIFE AS HE OR SHE IS ENTITLED TO

AND READY FOR aa, AND MERELY STRETCHING OUT THE AGONY OF DEATH,
I AM ALL 'IN FAVOR OF THE FORMER , , , I DON'T CARE AT ALL FOR THE

LATTER,

   AN ADDITIONAL COMPLICATION IN ALL OF THIS IS THE

FASCINATION WE ALL HAVE WITH THE WORD "QUALITYs" I USED IT JUST

A FEW MOMENTS AGO, IN THE PHRASE "QUALITY MEDICAL CARE," I THINK

I KNOW WHAT "QUALITY MEDICAL CARE" MEANS, ALTHOUGH I ADMIT IT'S

LARGELY INTUITIVE ON MY PART ma, VERY SUBJECTIVE AND VERY

PERSONAL,


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   AND THE SAME IS TRUE OF THE PHRASE "QUALITY OF LIFE," EACH

OF US HAS AN INTUITIVE UNDERSTANDING OF WHAT "QUALITY OF LIFE"

MEANS ,a, BUT ONLY FOR ONE'S SELF, I CAN ASSURE YOU, AS A 71-

YEAR-OLD WHITE MALE IN THE GOVERNMENT, THAT B IDEA OF "QUALITY

OF LIFE" IS PROBABLY QUITE DIFFERENT FROM THE IDEAS IN THE HEADS

OF ANY YOUNG GRADUATE HERE TODAY,

   I'M NOT WRONG, OF COURSE, AND NEITHER ARE YOU. BUT

OBVIOUSLY I CAN'T DECIDE WHETHER OR NOT TO EXTEND YOUR LIFE BY A

FEW MONTHS ON THE BASIS OF ITS "QUALITY" FOR You ma a NOR SHOULD

YOU MAKE ANY JUDGMENTS ABOUT THE "QUALITY OF LIFE" FOR I"&


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   THIS IS A NAGGING CONCERN OF MINE, SINCE I HEAR THE PHRASE

USED MUCH TOO OFTEN NOT ONLY IN THE CONTEXT OF MEDICAL CARE FOR

THE AGED, BUT ALSO IN THE CONTEXT OF EMERGENCY MEDICAL CARE FOR

HANDICAPPED NEWBORNS.

  ODDLY ENOUGH, SOME PHYSICIANS -- WHO PROFESS SOME CONCERN

ABOUT THE "QUALITY OF LIFE" -- HESITATE GIVING THEIR OLDER

PATIENTS GOOD ADVICE REGARDING THE PREVENTION OF DISEASE AND THE

PROMOTION OF GOOD HEALTH,

  MAYBE THAT'S PART OF OUR PREOCCUPATION WITH HIGH-TECH

MEDICINE, FOR EXAMPLE, WE SEEM TO BE MORE INTERESTED IN

TRANSPLANTING DISEASED HEARTS AND LUNGS THAN WE ARE IN TEACHING

PEOPLE NOT TO SMOKE IN ORDER TO PREVENT HEART AND LUNG DISEASE

FROM OCCURRING IN THE FIRST PLACE,


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  BUT OLDER PEOPLE SHOULD GIVE UP CIGARETTES, SHOULD WATCH

THEIR DIET, HAVE A ROUTINE REGIMEN OF EXERCISE, SHOULD GO EASY ON

THE ALCOHOL, AND SHOULD WEAR SEAT-BELTS m t m JUST LIKE YOUNGER

PEOPLE,

  THE AGING PROCESS, AFTER ALL, IS A 4IVING PROCESS,
                     IT IS

NOT AN ILLNESS AND, THEREFORE, IT'S NEITHER TREATABLE NOR

REVERSIBLE,

  BUT HUMAN AGING CAN BE SIGNS-FE, DISFASF-FREE, JUST

LIKE ANY OTHER PERIOD IN ONE'S LIFE, AND IF YOU UNDERSTAND THAT

-- TO REPEAT WHAT I SAID EARLIER -- THEN YOU UNDERSTAND THE

DIFFERENCE BETWEEN LIVING AND THAT SEPARATE AND SPECIAL EXPERI-

ENCE CALLED "DYING,"


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  A GOOD PHYSICIAN, IN MY BOOK, RECOGNIZES THE ETHICAL

IMPERATIVE TO ASSIST HIS OR HER PATIENTS TO TAKE. ADVANTAGE OF ALL

THE LIFE THEY CAN,

  I REALIZE, OF COURSE, THAT WHAT I JUST SAID HAS SOMETHING OF

A ROMANTIC RING TO IT. IT IS THE IDEALIZED PHYSICIAN-PATIENT

RELATIONSHIP, IN WHICH ALL YOU HAVE TO WORRY ABOUT IS THE

SUCCESS OF YOUR DIAGNOSIS AND TREATMENT,

  BUT THE REAL WORLD OF MEDICINE IS NOT QUITE THAT NEAT, YOUR

ELDERLY PATIENTS MAY HAVE THOUGHTFUL, CARING ADULT CHILDREN, OR

THEY MAY BE ABANDONED BY THEIR CHILDREN AND GRAND-CHILDREN,


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  WHEN. THEY LEAVE YOUR OFFICE, THEY MAY GO BACK TO THEIR GROUP

HOUSE, WHERE THEY LIVE ALONG WITH OTHER SUPPORTIVE MEN AND WOMEN

THEIR OWN AGE, OR THEY MAY RETURN TO A ONE-ROOM FLAT WHERE THEY

LIVE ALONE IN ISOLATION AND DEPRESSION,

  THEY MAY BE SWEET PEOPLE WHO DESERVE THE BEST POSSIBLE CARE,

OR THEY MAY BE CRANKY AND SELFISH PEOPLE -- BUT DESERVING OF THE

BEST POSSIBLE CARE ANYWAY,

  OF COURSE, YOU MAY NOT KNOW ENOUGH ABOUT YOUR ELDERLY

PATIENTS TO MAKE EVEN THESE KINDS OF JUDGMENTS,


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        CHANCES ARE THAT MANY OF YOU -- MAYBE EVEN A MAJORITY OF YOU

     -- WILL HAVE ELDERLY PATIENTS IN THE FINAL STAGES OF TERMINAL

      ILLNESS em, AND YOU WILL WANT TO SERVE THEM AS BEST YOU CAN, EVEN

     THOUGH YOU WILL KNOW LITTLE OR NOTHING ABOUT THEM 11, THEIR

     FAMILIES mm, THEIR OUTLOOK ON LIFE mm, OR THEIR ATTITUDE TOWARD

      DEATH,

  THAT'S QUITE DIFFERENT FROM WHAT THE SITUATION USED TO BE,

YOUR GREAT-GRANDPARENTS -- AND MAYBE YOUR GRANDPARENTS AS WELL

-- VERY LIKELY DIED IN THEIR OWN HOMES WHILE UNDER THE CARE OF A

PHYSICIAN THEY HAD KNOWN FOR YEARS aam PERHAPS MOST OF THEIR

ADULT LIVES,


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I LIKE TO CALL THAT "PRACTICING WITHIN THE REALM OF TRUST

BETWEEN PATIENT AND PHYSICIAN/'

  YOU AND I, ON THE OTHER HAND, ARE MORE LIKELY TO DIE IN A

HOSPITAL IN THE CARE OF A PHYSICIAN WE MAY HAVE KNOWN FOR JUST A

FEW YEARS ,,m OR EVEN JUST A FEW HOURS, WE ARE -- AS OSCAR WILDE

WROTE--- BORN AS KINGS AND DIE IN EXILE,

   LET'S HOPE THAT MANY OF YOU WILL BE BLESSED BY CARING FOR

YOUR PATIENT-KINGS AND -QUEENS WHILE THEY STILL WEAR THEIR

CROWNS AND YOU ARE THEIR PHYSICIAN AND THEIR FRIEND,


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  IN THIS REALM OF TRUST, WHERE AN ILLNESS IS TERMINAL AND NO

CURE WILL WORK, THEN CARE CERTAINLY WILL,
AND THAT MEANS LETTING

THE PATIENT KNOW THAT YOU RECOGNIZE AND APPRECIATE HIS OR HER

WORTH AND THAT YOU WILL BE BOTH PHYSICIAN AND COMFORTER,

  LET YOUR PATIENT KNOW THAT WHEN THE FEAR OR PAIN BECOMES TOO

GREAT, YOU WILL TREAT IT AS EFFICIENTLY AND AS EFFECTIVELY AS YOU

CAN,

  AND IF YOUR PATIENT DOES NOT WANT EXTRAORDINARY LIFE-SUPPORT

MEASURES TO BE TAKEN, LET THAT PERSON KNOW YOU WILL ABIDE BY

THAT DECISION,


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   YOU AND YOUR TERMINALLY ILL PATIENT SHOULD UNDERSTAND --

TOGETHER -- THAT THE TIME MAY COME WHEN THE ONLY USEFUL THING A

PHYSICIAN CAN DO IS TO STAND BACK AND ALLOW NATURE TO TAKE ITS

COURSE, AND THAT IS NOT EUTHANASIA, EITHER ACTIVE OR PASSIVE,

THAT IS SOUND, COMPASSIONATE MEDICINE,

   IN ORDER TO ACHIEVE SOMETHING THAT EVEN MIGHT APPROXIMATE

SUCH A "REALM OF TRUST BETWEEN PATIENT AND PHYSICIAN," YOU'LL

NEED TO DIG DEEP WITHIN YOU- TO COME UP WITH THE RIGHT

ANSWERS

  THAT KIND OF INTROSPECTION IS NOT EASY, BUT IT'S ESSENTIAL

FOR YOUR DEVELOPMENT AS AN INTELLIGENT AND ETHICAL PHYSICIAN

SERVING THE HEALTH NEEDS OF OLDER PATIENTS,


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  AND YET, THIS ISN'T A MATTER THAT CONCERNS ONLY YOUR OLDER

PATIENTS IN FACT, THERE IS NOTHING AGE-SPECIFIC ABOUT ETHICAL

BEHAVIOR, IF YOU DEAL ETHICALLY WITH YOUR OLDER PATIENTS, YOU

WILL DO SO WITH PATIENTS OF ALL AGES,

  AND THE REVERSE IS ALSO TRUE: THAT IS, IF YOU DO NOT

UNDERSTAND THE SIGNIFICANCE OF THE ETHICAL ISSUES SURROUNDING

HEALTH CARE FOR THE ELDERLY, CHANCES ARE YOU WON'T UNDERSTAND

THE ROLE OF ETHICS IN YOUR MEDICAL PRACTICE GENERALLY,

   I WAS TAUGHT THAT PARTICULAR LESSON 40 YEARS AGO, I WAS NOT

LONG OUT OF MEDICAL SCHOOL AND POST-GRADUATE TRAINING MYSELF,

WHEN, IN 1948, I CAME UPON AN ESSAY IN THE NEW ENGIAND JOURNAL OF

MEDICIN WRITTEN BY A DRm LEO ALEXANDER,


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  A NATIVE OF AUSTRIA, BUT BY THEN A RESIDENT OF BOSTON,

MASSACHUSETTS, DRa ALEXANDER TAUGHT PSYCHIATRIC MEDICINE AND

HAD SERVED AS AN EXPERT WITNESS AT THE NUREMBERG WAR CRIMES

TRIALS RIGHT AFTER THE SECOND WORLD WAR,

   HIS 1948 ESSAY DREW NOT ONLY UPON HIS EXPERIENCE AS A

WITNESS BUT ALSO UPON MATERIALS HE COLLECTED DURING HIS LONG

INTERVIEWS -- IN GERMAN -- WITH THE NAZIS WHO WERE BEING PUT ON

TRIAL.


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   THE RECORD OF HORRORS THAT UNFOLDED IN THE COURSE OF THOSE

TRIALS HAUNTS MANKIND RIGHT UP TO THE PRESENT DAY, HOWEVER, SAID

DR, ALEXANDER,, ,

'WHATEVER PROPORTIONS THESE CRIMES FINALLY ASSUMED, IT

BECAME EVIDENT TO ALL WHO INVESTIGATED THEM THAT THEY HAD

STARTED FROM SMALL BEGINNINGS, THE BEGINNINGS AT FIRST WERE

A SUBTLE SHIFT IN EMPHASIS IN THE BASIC ATTITUDE OF

PHYSICIANS,'  THE NEW ATTITUDE, SAID DRa ALEXANDER, WAS THAT

"THERE IS SUCH A THING AS A LIFE NOT WORTHY TO BE LIVED.'


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  AT FIRST, SUCH LIVES WERE THOSE OF THE SEVERELY AND

CHRONICALLY ILL, BUT LATER, SAID DRIALEXANDER, THIS CATEGORY

INCLUDED THE "SOCIALLY UNPRODUCTIVE, THE IDEOLOGICALLY UNWANTED,

AND FINALLY ALL NON-GERMANS BUT," HE CONCLUDES, "IT IS IMPORTANT

TO REALIZE THAT THE INFINITELY SMALL WEDGED-IN LEVER FROM WHICH

THIS ENTIRE TREND OF MIND RECEIVED ITS IMPETUS WAS THE ATTITUDE

TOWARD THE NONREHABILITABLE SICK?

  AS I SAY, I READ DRm ALEXANDER'S ESSAY IN 1948 AND IT HAS

REMAINED BURNED INTO MY CONSCIOUSNESS TO THIS VERY DAY, AND THAT

EXTRAORDINARY PHRASE IN PARTICULAR a,, "THE NONREHABILITABLE

SICK?


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   THE UNITED STATES IS NOT -- AND I'M SURE WILL NEVER BE -- A

SOCIETY SUCH AS THE ONE THAT HELD SWAY IN GERMANY UP TO AND

THROUGHOUT WORLD WAR II, THAT'S UNTHINKABLE,

  BUT INDIVIDUALS ARE SOMETHING ELSE AGAIN, WE ARE MORE FRAIL

THAN SOCIETIES a,, AND POTENTIALLY MORE DESTRUCTIVE -- ONE-ON-ONE

-- THAN WHOLE NATIONS,

  IT IS POSSIBLE FOR A PHYSICIAN TO BECOME m AWARE OF THE

ECONOMICS OF HEALTH CARE m 1, -@Q CALCULATING ABOUT TREATMENT

PRIORITIES a,, AND LQn IMPATIENT WITH THOSE IN HIS OR HER CARE

WHO ARE AMONG "THE NONREHABILITABLE SICK/'


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AND CHIEF AMONG THOSE, WE MUST ADMIT, ARE THE ELDERLY,

  THESE, THEN, ARE SOME OF MY THOUGHTS ON THE ETHICAL CONCERNS

OF THE PHYSICIAN WHO SERVES THE ELDERLY, AND SINCE THE ELDERLY

WILL BECOME A MORE SIGNIFICANT POPULATION AND PATIFNT GROUP AT

THE VERY TIME YOU ARE BUILDING YOUR OWN CAREERS IN MEDICINE, I

CHOSE THIS TOPIC FOR MY ADDRESS,

  NOW, I WILL CLOSE MY REMARKS WITH A LITTLE BIT OF POETRY 1,.

SOMETHING YOU MIGHT WISH TO HAVE HANDY TO TELL YOUR PATIENTS, AS

THEY CONTEMPLATE THEIR OWN AGING PROCESS a,, AND THEIR OWN

MORTALITY,


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THE FEW LINES ARE FROM THE POEM, RABBI BEN EZRA, BY ROBERT

BROWNING, AND THEY GO LIKE THIS:

   "GROW OLD ALONG WITH ME!

  THE BEST IS YET TO BE,

THE LAST OF LIFE FOR WHICH THE FIRST WAS MADE:

   OUR TIMES ARE IN HIS HAND

  WHO SAITH, 'A WHOLE I PLANNED,

YOUTH SHOWS BUT HALF; TRUST GOD: SEE ALL, NOR BE AFRAID!"'

THANK YOU,

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