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

1
(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,

2
   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,

3
  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,

4
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,

5
   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,

6
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.

7
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,

8
  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,

9
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,

                   10
  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,

11
   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,

12
  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,

13
  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,

14
   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,

15
   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"&

16
   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,

17
  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,"

18
  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,

19
  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,

?                          20
        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,

21
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,

22
  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,

23
   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,

24
  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,

25
  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.

26
   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.'

27
  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?

28
   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/'

29
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,

30
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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