ORIGINAL

ETHICAL IMPERATIVFS AND THE NEW PHYSICIN :
JII I RESPONQING TO THE HANDICAPPED PATIFNT

COMMENCEMENT ADDRESS BY

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

        OF THE

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

PRESENTED TO THE GRADUATING CLASS OF
    BAYLOR MEDICAL COLLEGE
      HOUSTON, TEXAS
      MAY 27, 1988


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(GREETINGS TO GUESTS, HOSTS, FRIENDS, ETCJ

   IT'S A GREAT PERSONAL PLEASURE TO BE HERE TO DELIVER YOUR

COMMENCEMENT ADDRESS THIS EVENING,  IN A WAY, MY VISIT WITH YOU

TODAY IS A SMALL, PARTIAL RE-PAYMENT FOR THE SUPPORT, KINDNESS,

AND THOUGHTFUL CRITICISM GIVEN ME BY MEMBERS OF THE BAYLOR

COMMUNITY DURING MY TWO TERMS AS YOUR SURGEON GENERAL,

   I GET A LOT OF CREDIT FOR KNOWING A GREAT DEAL ABOUT A GREAT

MANY PROBLEMS IN MEDICINE,  "SURGEON mALIST" WOULD PROBABLY

BE A MORE ACCURATE TITLE FOR THIS POSITION,


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NATURALLY, I APPRECIATE THOSE EXPRESSIONS OF RESPECT,

  BUT I COULD NEVER HAVE BECOME THE GENERALIST I AM TODAY,

WERE IT NOT FOR THE SIZABLE ARMY OF FRIENDS, CRITICS, AND
PARTISANS ALL OVER THE COUNTRY WHO CONTRIBUTE TO MY STORE OF

INFORMATION mm, PEOPLE LIKE THE MANY FACULTY HERE AT BAYLOR WHO

HAVE HELPED STIMULATE FRESH THINKING ON MY PART ON A VARIETY OF
MEDICAL AND PUBLIC HEALTH ISSUES , , , AND WHO ALSO GUARANTEE THAT
I WILL BE SENSITIVE TO THE HUMAN SIDE OF PUBLIC HEALTH AS WELL,

TO ALL OF YOU, I SAY, "THANK YOU,"


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AND IN THAT SAME SPIRIT OF FRIENDSHIP AND FELLOWSHIP, I'VE

PLANNED SOMETHING A LITTLE DIFFERENT 11, A LITTLE SPECIAL mm. FOR

THIS COMMENCEMENT ADDRESS, IT IS, IN FACT, PART OF A CYCLE OF

COMMENCEMENT ADDRESSES I'M GIVING THIS SPRING TO THE GRADUATING

CLASSES AT SIX MEDICAL SCHOOLS AROUND THE COUNTRY,

  ALL SIX ADDRESSES ARE CONCERNED IN SOME WAY WITH THE

"ETHICAL IMPERATIVES" FACED BY NEW PHYSICIANS, WHO STAND, AS YOU

DO TODAY, ON THE THRESHOLD OF A LIFETIME OF SERVICE IN MEDICINE,

LATER THIS SUMMER, EACH MEMBER OF THE CLASS OF '88 WILL

RECEIVE ALL SIX ADDRESSES, EMBELLISHED WITH A FEW FOOTNOTES


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  IN MY ADDRESS THIS EVENING I WANT TO LOOK AT A MAJOR AREA OF

ETHICAL DEBATE AMONG PRACTICING PHYSICIANS 11, A DEBATE THAT WILL

SURELY GROW IN COMPLEXITY IN THE YEARS AHEAD.

IT CONCERNS THE ETHICAL RESPONSE OF PHYSICIANS TO PATIENTS

WHO ARE HANDICAPPED OR DISABLED IN SOME WAY,

  AT ONE TIME, SUCH PATIENT ENCOUNTERS WERE RARE, THE REASON

IS FAIRLY OBVIOUS: OUR ABILITY -- AND OUR COMMITMENT -- TO SAVE

DISABLED ADULTS AND INFANTS WERE BOTH VERY LIMITED,


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BUT THE SITUATION IS NOW QUITE DIFFERENT, RECENT ADVANCES

IN BIOMEDICAL TECHNOLOGY HAVE GIVEN US A GREATLY ENHANCED ABILITY

TO SUCCESSFULLY TREAT DISABLING CONDITIONS OF ALL KINDS,

  AND CERTAIN FACTS REGARDING THE FUTURE DEMOGRAPHY OF AMERICA

COMPEL US TO RE-THINK AND RE-INVI GORATE OUR COMMITMENT TO TREAT

ALL DISABILITIES EXPERIENCED BY PEOPLE OF ALL AGES,

  I KNOW I'M SPEAKING AS IF THERE ACTUALLY WERE A SINGLE,

"OFFICIAL" LIST OF HANDICAPS AND DISABILITIES, BUT THERE IS NO

SUCH LIST, HOWEVER, IF A PERSON Da PUT TOGETHER A LIST OF THE

ONES THAT ARE GENERALLY ACCEPTED BY MEDICINE AND GOVERNMENT --

ACCORDING TO VARIOUS CRITERIA -- IT WOULD RUN ON FOR SEVERAL

PAGES IN ANY GOOD TEXTBOOK,


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  THE LIST OF DISABILITIES INCLUDES MILD TO SEVERE MENTAL

RETARDATION, HYPERTENSION AND OTHER CARDIOVASCULAR DISEASES,

DIABETES, ASTHMA AND CYSTIC FIBROSIS, DENTAL DISEASES, MUSCULO-

SKELETAL AND ORTHOPEDIC HAND I CAPS, DEVELOPMENTAL DISABILITIES,

AND SENSORY DEFICITS OF EVERY KIND, WITH POOR VISION AND POOR

HEARING TOPPING THE LIST,

  THERE ARE, IN ADDITION, A NUMBER OF CONDITIONS THAT DON'T

NEATLY FIT INTO ANY ONE CATEGORY: EMOTIONAL AND BEHAVIORAL

HAND1 CAPS, FOR EXAMPLE, SUBSTANCE ABUSE AND ADDICTION, AND

CERTAIN IMMOBILIZING PHOBIC RESPONSES TO THE HUMAN OR PHYSICAL

ENVIRONMENT,


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   WHICH OF YOUR PATIENTS ARE LIKELY TO PRESENT THESE KINDS OF

HANDICAPS AND DISABILITIES? DEFINITELY YOUR OLDER PATIENTS

TODAY, FOR EXAMPLE, THERE ARE APPROXIMATELY 3 MILLION MEN AND

WOMEN OVER THE AGE OF 65 WHO ARE LIVING IN THEIR OWN HOMES,

DESPITE ONE OR MORE HANDICAPPING OR CHRONIC HEALTH ABERRATIONS

-- CARDIOVASCULAR, ORTHOPEDIC, SENSORY, AND SO ON,

   THAT FIGURE OF 3 MILLION SHOULD DOUBLE OVER THE NEXT 20

YEARS, NO OTHER POPULATION GROUP WILL HAVE THIS SHARP A RISE IN

NUMBERS OR SO LARGE A SHARE OF THE NATIONAL POPULATION TOTAL AS A

WHOLE,


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  TO PROPERLY SERVE THAT OLDER POPULATION -- BOTH TODAY AND

TOMORROW -- WE NEED NEW GENERATIONS OF TECHNOLOGY a,, THE KIND

THAT WILL HELP US TO OBTAIN EARLY AND MORE SOPHISTICATED

DIAGNOSES OF POTENTIALLY HANDICAPPING CONDITIONS,

   AND, OF COURSE, WE'LL NEED THE TECHNOLOGIES FOR TAKING

EFFECTIVE, CORRECTIVE ACTION, ALSO, THESE MAY BE IN THE FORM OF

NEW DRUG THERAPY, PHYSICAL THERAPY, AN IMPROVED DIET, CORRECTIVE

SURGERY, OR THE USE OF A NEW DEVICE OR APPLIANCE, EITHER ATTACHED

OR IMPLANTED,


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  AND IN THE FIELD OF HOME HEALTH CARE WE ALREADY NEED

COUNTLESS NEW AND SIMPLE DEVICES THAT CAN HELP AN ELDERLY PERSON

WITH ONE OR MORE CHRONIC CONDITIONS -- EMPHYSEMA, SAY, OR

ARTHRITIS -- TO NEVERTHELESS LIVE AN INDEPENDENT, NON-

INSTITUTIONALIZED LIFE,

SIMILAR DEVELOPMENTS ARE TAKING PLACE AT THE OTHFR END OF

THE AGE SCALE, ALSO,

THANKS TO A VARIETY OF NEW DEVELOPMENTS IN OBSTETRICS,

PEDIATRICS, AND EMERGENCY MEDICINE, WE'VE BEEN ABLE TO SAVE AND

IMPROVE THE LIVES OF TENS OF THOUSANDS OF INFANTS BORN EACH YEAR,

AS RECENTLY AS A GENERATION AGO, A LARGE NUMBER OF THEM WOULD

OTHERWISE HAVE DIED AT BIRTH OR SHORTLY THEREAFTER,


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  MOST DELIVERIES IN THIS COUNTRY ARE TROUBLE-FREE AND MOST

INFANTS ARE BORN HEALTHY, SO IT IS UNDERSTANDABLE WHEN MEDICAL

STAFFS BECOME QUITE SKILLFUL AT KEEPING PATIENT RELATIONS BRIEF

AND SUPERFICIAL,

   AND I'D GUESS THAT MOST PATIENTS PREFER IT THAT WAY,

SURELY MOST NEW PARENTS TAKE THEIR BABIES HOME WITH THE STRONG

WISH THAT THEY NEVER HAVE TO SET FOOT IN A HOSPITAL AGAIN,

AND I WOULD BE THE FIRST ONE TO SAY "AMEN" TO THAT,


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  BUT THEN THERE IS THE INFANT BORN WITH DOWN SYNDROME OR

SPINA BIFIDA am, THERE'S THE CHILD WITH A CONGENITAL BIRTH

DEFECT -- A DAMAGED ORGAN SYSTEM, A MISSING OR DEFORMED LIMB --
OF ONE OF ANY NUMBER OF DISABLING CONDITIONS,

  IN THESE CASES, THE PARENTS TURN FIRST TO THE MEDICAL STAFF
AND THE QUESTIONS COME POURING OUT:

"WHAT DOES IT MEAN? aam WHAT'S THE PROGNOSIS FOR LIFE? Brna
WHAT KIND OF LIFE WILL THE CHILD HAVE? 11, IS IT THE RESULT

OF SOMETHING w+. DID? mta IS IT BECAUSE WE DID m DO

SOMETHING?"


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  AT,THAT POINT, THE PHYSICIAN-PATIENT RELATIONSHIP IS NO

LONGER CASUAL OR SHORT-TERM, THE PHYSICIAN HAS TO TRANSLATE

COMPLICATED MEDICAL TERMINOLOGY INTO WORDS A PARENT CAN

UNDERSTAND AND NOT FEAR,   PARENTS MUST BE ABLE TO ABSORB AND

UNDERSTAND THIS NEW INFORMATION, IN ORDER TO RATIONALLY TACKLE

FAMILY, FINANCIAL, EMOTIONAL, AND OTHER ISSUES LATER ON,

  IF THAT'S THE CASE, THEN PHYSICIANS AND SURGEONS NEED TO BE

PREPARED FOR THEIR OWN INVOLVEMENT IN LONG-TERM RELATIONSHIPS

WITH CERTAIN HANDICAPPED PATIENTS AND THEIR FAMILIES a,, RELA-

TIONSHIPS THAT CAN BE HIGHLY SENSITIVE ON BOTH A MEDICAL AND A

PERSONAL LEVEL,


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  I BELIEVE THERE m WAYS TO TRAIN MEDICAL STAFF TO DEVELOP

HELPFUL, LONG-TERM RELATIONSHIPS WITH PARENTS OF DISABLED

CHILDREN, FOR EXAMPLE, BUT SUCH TRAINING IS NEEDED BY

PHYSICIANS OF 9u, AGES, I MIGHT ADD, AND IT'S ESPECIALLY

IMPORTANT TO THOSE -- LIKE YOURSELVES -- WHO ARE ABOUT TO BEGIN

YOUR PRACTICE,

   YOU ARE LEAVING AN EDUCATIONAL SYSTEM -- GOOD AS IT IS --

THAT NEVERTHELESS MEASURES SUCCESS ALMOST EXCLUSIVELY IN TERMS

OF CURING AND REPAIRING PATIENTS AND RETURNING THEM TO A SO-

CALLED "NORMAL* STATE FOR THE REST OF THEIR LIVES

AND THEIR LIVES MAY BE BRIEF ,,m OR LONG,


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YOU'LL NEED TO UNDERSTAND THAT AND COME TO TERMS WITH IT

BOTH PERSONALLY AND PROFESSIONALLY,

  WE ARE OUTRAGED AT PARENTS WHO PHYSICALLY ABANDON THEIR

CHILDREN,  AND I'M OUTRAGED AT PHYSICIANS WHO INTELLECTUALlY

ABANDON THEIR PATIENTS, OUR SOPHISTICATED DIAGNOSTIC EQUIPMENT

CAN LABEL A CASE AS "HOPELESS," BUT THE SURVIVAL POWER OF THE

HUMAN BEING -- EVEN IN ITS TINY NEWBORN STATE -- CAN BE TRULY

AWESOME,


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   I COULD GIVE YOU THE NAMES OF MANY INDIVIDUALS -- MANY OF

THEM MY OWN PATIENTS -- WHO ARE NOW HEALTHY AND HAPPY, BUT WHO

HAD BEEN WRITTEN OFF AS "HOPELESS CASES" WHEN THEY WERE BORN 20,

30, AND EVEN 40 YEARS AGO,

  LONG AGO WE GOT RID bF THE NOTION THAT CHILDREN WERE SO MUCH

CHATTEL, COUNTED ALONG WITH THE ANIMALS AND THE FURNITURE, MORE

RECENTLY WE STOPPED LOOKING UPON CHILDREN AS "TINY ADULTS"

  AS WE'VE BEGUN TO SEE CHILDREN AS CHILDREN, A NEW CONCEPT

HAS BEGUN TO TAKE SHAPE:


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THAT IS, THAT CHILDREN -- FROM THE VERY MOMENT OF BIRTH --

OUGHT TO RECEIVE THE FULL PROTECTION OF THE LAW nmm THE SAME

PROTECTIONS, IN FACT, THAT ARE AFFORDED ALL ADULTS

AND, AS I'M SURE YOU KNOW, THERE IS STRONG SENTIMENT IN THIS

COUNTRY FOR PROVIDING THAT SAME CONSTITUTIONAL PROTECTION TO

CHILDREN EVEN BEFORE BIRTH,

  FOLLOWING THAT SAME LOGIC, WE'VE SAID THAT A NEWBORN INFANT

WHOSE LIFE IS PUT AT RISK BY A PARENT, A PHYSICIAN, OR WHOMEVER

-- THAT SUCH A CHILD IS STILL A CITIZEN AND MUST BE GIVEN THE

FULL PROTECTION OF THE STATE,


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  THE CLEAREST EXAMPLE OF THIS WAS THE NOW-CELEBRATED CASE OF

"BABY DOE," THE HANDICAPPED BABY BOY BORN IN BLOOMINGTON,

INDIANA, IN EARLY APRIL OF 1982,

  "BABY DOE" WAS BORN WITH AN OBSTRUCTION OF THE ESOPHAGUS,

ESOPHAGEAL ATRESIA, AND WITH DOWN SYNDROME, HIS PARENTS WERE

ADVISED BY A PHYSICIAN THAT "BABY DOE" WOULD BE SEVERELY RETARDED

AND THAT THE SURGERY TO CORRECT THE ESOPHAGEAL PROBLEM HAD A

MORTALITY RATE OF MORE THAN 50 PERCENT,

THEREFORE, THE PHYSICIAN ADVISED THAT THE PARENTS NOT PERMIT

CORRECTIVE SURGERY TO BE DONE AND, IN ADDITION, THAT ALL

PARENTERAL NOURISHMENT BE WITHDRAWN AS WELL,

IT WAS A DEATH SENTENCE, FROM WHICH "BABY DOE" COULD NOT

ESCAPE,


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  FROM A MEDICAL POINT OF VIEW, THAT PHYSICIAN DID NOT GIVE

GOOD ADVICE, FOR EXAMPLE, NO ONE CAN ACCURATELY PREDICT THE

LEVEL OF PERFORMANCE OF A DOWN SYNDROME NEONATE, WE HAVE NO TEST

AND NO INSTRUMENT TO DO THAT, ALSO, THE MORTALITY FOR CORRECTION

OF ESOPHAGEAL ATRESIA COULD BE ZERO, AT LEAST, IT WAS AMONG u

PAT I ENTSm

BY THE TIME I LEFT PRIVATE PRACTICE TO BECOME SURGEON

GENERAL, I HAD PROBABLY OPERATED ON MORE "BABIES DOE" THAN ANY

OTHER PEDIATRIC SURGEON IN THIS COUNTRY, DURING MY LAST 8 YEARS

IN PEDIATRIC SURGERY, I NEVER LOST A BABY AS A RESULT OF THAT

SURGERY,

  I MIGHT ADD THAT NO PARENTS EVER QUESTIONED MY DECISION TO
TRY TO SAVE THEIR BABY'S LIFE, AND, YEARS LATER, NO GROWN-UP u-
PATIENTS EVER ASKED ME WHY I BOTHERED TO SAVE THEM, EITHER,


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  YOUPROBABLY RECALL THE END OF THE "BABY DOE" STORY, IN

SPITE OF A FLURRY OF COURTROOM ACTIVITY, WHICH I WON'T GO INTO

NOW, "BABY DOE" DIED mm, 7 DAYS AFTER HIS BIRTH,

  HOWEVER, FOLLOWING THIS TRAGIC EPISODE, A CONCERTED EFFORT

WAS MADE TO REGULATE THE MEANS OF PROTECTING ALL CHILDREN AGAINST

ANY LIFE-THREATENING ACTIONS BY PARENTS, PHYSICIANS, LAWYERS,

SOCIAL WORKERS, OR w ADULT, FOR THAT MATTER,

THE RESULT WAS THE ENACTMENT OF NEW CHILD ABUSE PREVENTION

LAWS AT THE FEDERAL LEVEL AND IN ALL STATES AND TERRITORIES,


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I WAS PART OF THAT EFFORT TO WRITE NEW REGULATIONS AND NEW

FEDERAL LAW BECAUSE OF THE VITAL ISSUES AT STAKE.

  FIRST, THERE WAS THAT CONSTITUTIONAL PRINCIPLE I MENTIONED A

MOMENT AGO THAT EVERYONE -- AT BIRTH -- WAS A CITIZEN AND,

THEREFORE, WAS ENTITLED TO THE FULL LIFE PROTECTION OF THE STATE,

  SECOND, THERE WAS THE ETHICAL OBLIGATION THAT EVERY

PHYSICIAN ASSUMES FOR DOING SOMETHING FOR HIS OR HER PATIENTS,

WHEN THEY SHOW UP SICK, YOU PERSONALLY MAY NOT KNOW WHAT TO DO

-- OR YOU w KNOW WHAT TO DO, BUT YOU YOURSELF CAN'T QQ IT,
                         IN

THAT CASE, YOU ARE OBLIGED TO LOOK FOR SOMEBODY WHO CAN DO

SOMETHING,


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  THIRD, "BABY DOE'S" PARENTS AND THEIR PHYSICIAN -- AND MANY

PEOPLE NOT CONNECTED WITH THIS CASE -- MADE THE TOTALLY

MISINFORMED AND UNFOUNDED ASSUMPTION THAT, IF "BABY DOE" WERE

ALLOWED TO LIVE, HE WOULD EXPERIENCE A VERY POOR "QUALITY OF

LIFE,"

   IT MAY SOUND GOOD --BUT IT'S IMPOSSIBLE FOR ANYONE TO

PREDICT HOW AN INFANT WILL DEVELOP n m m HOW HE OR SHE \iILL RESPOND

TO TREATMENT mm, HOW THE FAMILY WILL RESPOND ,a, OR WHAT THE

COMMUNITY AND SOCIETY WILL DO FOR THAT CHILD,


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  YOU ABSOLUTELY CANNOT PREDICT THAT am, EITHER FOR HEALTHY

BABIES OR FOR SICK BABIES,

   AND I'LL GO ONE STEP FURTHER, YOU'RE ON THIN ICE IF YOU

TRY TO PREDICT VERY MUCH ABOUT THE FUTURE "QUALITY OF LIFE" OF

w PATIENT OF w AGE,

  "BABY DOE" LIVED FOR JUST ONE WEEK m,m AND THEN DIED, YET,

WE MUST BRING HIM TO MIND AT AN OCCASION LIKE THIS, BECAUSE "BABY

DOE" MAKES US CONFESS HOW WE REALLY FEEL ABOUT OUR FELLOW HUMAN

BEINGS,


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  HIS.MEMORY PRODS US INTO REVEALING WHETHER WE m -- OR ARE

NOT -- THE FRIENDS OF THE HELPLESS, THE WEAK, THE HURT, THE

INJURED, AND THE TROUBLED,

  AND "BABY DOE" REMINDS US THAT, FOR MANY DISEASE AND

DISABLING CONDITIONS, WE SIMPLY HAVE NO CURES, AND SO HE PRODS

US INTO OFFERING PATIENTS SOMETHING ELSE THAT IS JUST AS

VALUABLE: A LOT OF GENUINE C&m

  PATIENTS STILL NEED US AS PEOPLE, EVEN WHEN WE CAN'T DO

ANYTHING FOR THEM AS PHYSICIANS,


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  BUT WE m DOING MORE, NEW SCIENCE em, NEW LAW mm, AND THE

OLD MEDICAL ETHICS ALL CONTRIBUTE SUBSTANTIALLY -- YEAR AFTER

YEAR -- TO THE LOWERING OF THE INFANT MORTALITY RATE IN THIS

COUNTRY,

  DURING YOUR TIME HERE AT BAYLOR, I HOPE YOU'VE COME TO

APPRECIATE THE FACT THAT NO MEDICAL SUCCESS -- OR FAILURE --

OCCURS IN A VACUUM, HENCE, OUR SUCCESS IN SAVING HANDICAPPED

INFANTS IS DIRECTLY LINKED TO ANOTHER SITUATION 1,. THE FACT THAT

ABOUT 6 TO 8 MILLION ADOLESCENTS -- OR 1 ADOLESCENT OF EVERY 5 --

HAS A SIGNIFICANT CHRONIC HEALTH PROBLEM OR HANDICAPPING

CONDITION,


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AND, A SMALL BUT SIGNIFICANT PERCENTAGE OF THEM ACQUIRED

THEIR DISABLING CONDITIONS AT BIRTH,

  FOR ABOUT A MILLION OF THESE YOUNGSTERS, THE ILLNESS IS

BOTH CHRONIC AND SEVERE: MUSCULAR DYSTROPHY ,,a SEIZURE DISORDERS

I I I CYSTIC FIBROSIS ,a, DIABETES 11, AND SO ON,

   THE OTHER MILLIONS OF AMERICAN CHILDREN BECAME DISABLED

LATER IN THEIR CHILDHOOD AS A RESULT OF AUTOMOBILE, PLAYGROUND,

OR HOUSEHOLD ACCIDENTS OR AS A RESULT OF PHYSICAL ABUSE AND

NEGLECT t m m USUALLY AT THE HANDS OF THEIR PARENTS, I'M SORRY TO

SAY,


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  INCIDENTALLY, THESE NUMBERS ARE ESTIMATES FOUND IN THE

LITERATURE, BUT THE EXPERTS GENERALLY AGREE THAT THEY ARE GROSS

UNDERCOUNTS, SINCE THOUSANDS OF CHILDREN ARE NOT ADEQUATELY

SCREENED AND DIAGNOSED FOR MOST DISABLING AND HANDICAPPING

CONDITIONS

  THAT SHOULD BE THE END OF THE STORY, BUT IT ISN'T, SO I
WILL CLOSE WITH AN OBSERVATtON ABOUT YET ANOTHER IMPORTANT

OUTCOME OF OUR ETHICAL RESPONSE TO HANDICAPPED INFANTS,

CHILDREN, AND OLDER PEOPLED


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   AFTER WATCHING THIS FROM THE VANTAGE-POINT OF THE SURGEON

GENERAL, I'VE BECOME MORE AND MORE CONCERNED ABOUT THE EFFECTS

UPON THE FAMILIFS OF THE HANDICAPPED: THE PARENTS AND SIBLINGS,

IN THE CASE OF CHILDREN; AND THE CHILDREN AND GRAND-CHILDREN, IN

THE CASE OF HANDICAPPED ELDERLY PEOPLE,

  ALL THIS CALLS TO MIND THAT LINE BY TOLSTOY, THAT 18, "HAPPY

FAMILIES ARE ALL ALIKE, BUT EVERY UNHAPPY FAMILY IS UNHAPPY IN

ITS OWN WAY,"


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  YOUR DECISION TO SAVE AND REPAIR A DISABLED CHILD, FOR

INSTANCE, CAN HAVE A DEVASTATING FINANCIAL IMPACT UPON HIS OR HER

FAMILY, IF THEY HAVE INADEQUATE HEALTH INSURANCE 111 OR NO

INSURANCE AT ALL,

  YOUR DECISION TO PROVIDE A FEW MORE YEARS OF LIFE TO A

DISABLED OLDER PARENT MAY STRETCH TO THE BREAKING-POINT THAT

PARENT'S ADULT CHILD,

THESE AND OTHER CIRCUMSTANCES ARE TRAGIC, TO BE SURE, BUT

THE PHYSICIAN'S FIRST DUTY MUST BE TO THE PATIENT NEEDING THE

IMMEDIATE MEDICAL CARE,


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  NEXT, IF AT ALL POSSIBLE, THE PHYSICIAN SHOULD ALERT THE

FAMILY TO WHATEVER COMMUNITY SERVICES ARE AVAILABLE, TO SOURCES

OF FUNDS, OR TO WHATEVER ELSE IS APPROPRIATE,

AND MAYBE RIGHT HERE IS WHERE WE NEED A NEW AND EQUALLY

STRONG ETHICAL RESOLUTION,

  WE NEED TO RESOLVE THAT, AS PHYSICIANS, WE WILL DO WHAT WE

CAN TO CORRECT THE FRAGMENTED AND DISJUNCTIVE MEDICAL AND SOCIAL

SERVICE SYSTEMS THAT EXIST IN MANY COMMUNITIES It a SYSTEMS THAT

CRUELLY WEAR DOWN AND CRUSH THE VERY FAMILIES WITH THE COURAGE

AND THE HEART TO RETURN HOME WITH A HANDICAPPED OR DISABLED

RELATIVE,


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  I DG NOT THINK THE ATTENDING PHYSICIAN OUGHT TO BE TOTALLY

RESPONSIBLE FOR MAKING ALL THE CALLS AND ACTUALLY GETTING HELP

FOR SUCH A FAMILY,

  NEVERTHELESS, MY OWN EXPERIENCE HAS CONVINCED ME THAT THE

PHYSICIAN IS THE BEST AT LEAST JO INITIATE THE

PROCESS FOR GETTING FINANCIAL AND OTHER KINDS OF ASSISTANCE TO

THE FAMILY OF A HANDICAPPED INFANT OR ADULT,

I BELIEVE THAT SUCH BEHAVIOR BY A PHYSICIAN REFLECTS THE

HIGHEST ETHICAL STANDARDS OF MEDICAL PRACTICE,


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HENCE, WHETHER YOU WELCOME IT OR NOT, THE MANTLE OF

LEADERSHIP FOR RESOLVING A VARIETY OF PROFOUNDLY SERIOUS ETHICAL
ISSUES NOW PASSES ONTO YOUR SHOULDERS IN THIS COMMENCEMENT

CEREMONY TODAY,

  IT IS MY EARNEST HOPE THAT EACH OF YOU WILL WELCOME THIS

MANTLE AND WILL WEAR IT a,, IN ALL THE YEARS TO COME In) WITH

WISDOM AND WITH HONOR,

THANK YOU,

#####


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  FOOTNOTE: I'M PLEASED TO SAY THAT, WHILE 1 WAS A PRACTICING

PEDIATRIC SURGEON, 1 PLAYED A VERY ACTIVE PART IN THAT HISTORY,

AN IDEA FOR WHICH I HAVE ALWAYS BEEN PERSONALLY VERY PROUD IS

THAT OF THE NEONATAL INTENSIVE CARE UNIT, A FACILITY THAT DIDN'T

EXIST UNTIL I INSTALLED THE FIRST ONE IN THE CHILDREN'S HOSPITAL

OF PHILADELPHIA IN 19 --I