ORIGINAL

   w PHYSICIAN :
PATS WITH AIDS

COMMENCEMENT ADDRESS BY
C. EVERETT KOOP. M.D., Sc,D,
   SURGEON GENERAL

        OF THE

    U.$, PUBLIC HEALTH SERVICE
US. DEPARTMENT OF HEALTH AND HUMAN SERVICES

PRESENTED AT CLASS DAY EXERCISES
  HARVARD MEDICAL SCHOOL

BOSTON, MASSACHUSETTS
  JUNE 9, 1988


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(GREETINGS TO HOSTS, GUESTS, FRIENDS, ETCJ

I AM VERY PLEASED AND HONORED TO HAVE BEEN ASKED TO DELIVER

THIS YEAR'S CLASS DAY ADDRESS HERE AT HARVARD,

   OVER THE YEARS I'VE DEVELOPED STRONG FRIENDSHIPS WITH MANY

MEMBERS OF THE HARVARD MEDICAL AND PUBLIC HEALTH COMMUNITIES

THEIR WISE COUNSEL AND PATIENT SUPPORT HAVE BEEN VERY IMPORTANT

TO ME AS YOUR SURGEON GENERAL,


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  BUT THOSE FRIENDSHIPS ARE WITH FACULTY ama WITH THE

"ESTABLISHMENT" ma, WITH THE MEMBERS OF THE "OLD BOY" AND NOW THE

"OLD GIRL" NETWORKS,

  YOUR INVITATION, THEREFORE, CARRIED WITH IT A MOST WELCOME

AND MOST HEARTENING MESSAGE: I HAVE FRIENDS AMONG YOUNG

PHYSICIANS, TOO,

AND THAT'S EXTREMELY IMPORTANT NOT JUST TO ME PERSONALLY,

BUT TO THE OFFICE OF THE SURGEON GENERAL, MY PREDECESSORS AND I

-- AND MY SUCCESSORS, ALSO -- DEAL NOT ONLY WITH ISSUES OF THE
HERE AND NOW, BUT ALSO WITH ISSUES THAT WE BELIEVE LIE JUST m

THE HORIZON -- OR EVEN JUST BEYOND IT,


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ON MY OWN WATCH, FOR EXAMPLE, SINCE 1981, I HAVE HAD

SOMETHING TO DO WITH SUCH PUBLIC HEALTH MATTERS AS TEEN-AGE

PREGNANCY, FETAL ALCOHOL SYNDROME, AND FAMILY VIOLENCE, THOSE

ARE THE "HERE AND NOW" ISSUES,

BUT I'VE ALSO BEEN CONCERNED ABOUT,,,

o

IMPROVING HEALTH SERVICES FOR THE HANDICAPPED,, ,

*   EXPANDING HEALTH SERVICES FOR THE AGED,, m



*

AND, OF COURSE, RESPONDING TO THE CHALLENGE OF AIDS,


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I WANT TO SPEND THESE FEW MOMENTS TALKING ABOUT AIDS, BUT

NOT IN A WAY THAT MIGHT ALARM OR UPSET YOU, YOUR FAMILIES, OR

YOUR FRIENDS ON THIS OTHERWISE GLORIOUS DAY, AND ANYWAY, THIS IS

A COMMENCEMENT ama NOT GRAND ROUNDS,

  SO, WITH YOUR INDULGENCE LET ME APPROACH THIS EXTREMELY

IMPORTANT HEALTH AND SOCIAL ISSUE FROM THE VIEWPOINT OF THE

SEVERAL ETHICAL QUESTIONS IT HAS RAISED FOR MEDICINE a,, AND,

INDEED, FOR ALL OF SOCIETY,


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  FIRST, I WANT TO TELL YOU THAT THIS ADDRESS IS THE 5TH IN A

CYCLE OF 6 MEDICAL SCHOOL COMMENCEMENT ADDRESSES I AM DELIVERING

THIS SPRING -- EACH ONE DIFFERENT, OF COURSE -- BUT ALL OF THEM

CONCERNED WITH THE "ETHICAL IMPERATIVES" THAT CONFRONT THE NEW

PHYSICIAN,

  I GAVE THE FIRST ONE A MONTH AGO IN WASHINGTON, DaCm   I

WILL DELIVER THE 6Tti NEXT WEEK IN CHICAGO, AND SOMETIME LATER

THIS SUMMER I HOPE TO SEND EACH OF YOU A FINAL PUBLISHED COPY OF

ALL 6 ADDRESSES, YOU SEE, I DON'T WANT YOU TO MISS A WORD OF IT,


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WHY AM I DOING THIS?  TO BEGIN WITH, THE SUBJECT OF

"ETHICS" SEEMS TO BE ON EVERYONE'S MIND THESE DAYS: LAWYERS,

EDUCATORS, GOVERNMENT OFFICIALS, BUSINESS MANAGERS, AND

PHYSICIANS,

  AND I NEED NOT REMIND YOU THAT TWO OF THE BIGGEST BOX-OFFICE

HITS FROM HOLLYWOOD THIS PAST YEAR WERE ML STREET AND

BROADCAST NEWS, BOTH OF THEM VERY TOUGH-MINDED STORIES ABOUT

PERSONAL ETHICS THAT WENT SOUR,


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  ALSO,.FROM MY OWN EXPERIENCE AS SURGEON GENERAL, I CAN TELL

YOU THAT THERE'S BEEN AN IMPORTANT ETHICAL DIMENSION TO EVERY

MEDICAL AND HEALTH PROBLEM THAT WAS PLACED ON MY AGENDA SINCE THE

DAY I TOOK OFFICE, BACK IN 1981,

  TODAY, I WANT TO FOCUS ON THE ETHICAL SIDE OF THE ISSUE OF

AIDS AND I DO SO, BECAUSE VIRTUALLY EVERY ETHICAL QUESTION

THAT HAS ARISEN FROM A WIDE RANGE OF OTHER HEALTH PROBLEMS, HAS

ALSO BEEN RAISED REGARDING THE SINGLE PROBLEM OF AIDS, WERE I TO

GIVE THIS ADDRESS A SUB-TITLE, IT MIGHT BE "THE RELUCTANT

PHYSICIAN,"


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AS YOU KNOW, I'M SURE,a a



*   AIDS IS VIRTUALLY 100 PERCENT FATAL-



*   WE HAVE NO VACCINE AGAINST IT AND NO DRUGS TO CURE

PEOPLE WHO BECOME INFECTED, n a



*   PEOPLE GET AIDS BY DOING THINGS MOST PEOPLE DON'T DO

AND DO NOT APPROVE OF,



*   AND OUR ONLY WEAPON OF ANY CONSEQUENCE AT THIS TIME IS

PUBLIC EDUCATION TO CHANGE SOME RATHER BASIC HUMAN BEHAVIORS

INCLUDING SEXUAL BEHAVIOR,

  AIDS, THEN, HAS ALL THE ELEMENTS OF A MAJOR HUMAN TRAGEDY:

FEAR,,,PREJUDICE, ,,REJECTION,,,AND HOPELESSNESS,


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  LAST YEAR I WROTE AN EDITORIAL IN JAMA ASKING PHYSICIANS TO

TAKE THE LEAD IN THE FIGHT AGAINST AIDS, I DON'T THINK I

UNDERESTIMATED THE RESPONSIBILITIES I WAS LAYING BEFORE THE

MEDICAL COMMUNITY, BUT, IN RETROSPECT, PERHAPS I SHOULD HAVE

SPELLED IT OUT MORE FULLY,

IN THIS "AGE OF AIDS" PHYSICIANS ARE BEING ASKED TO DO

THINGS THEY DON'T LIKE TO DO, FOR EXAMPLE mm,

*   TO CARE FOR YOUNG PATIENTS WHO MAY GET WELL FOR A SHORT

PERIOD OF TIME -- AND THEN DIE


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*

  .TO TREAT A NUMBER OF RARE MALADIES THEY NEVER SAW

BEFORE THAT ARE BUNCHED TOGETHER UNDER THE GLIB LABEL OF

"OPPORTUNISTIC DISEASES"



*

  WE ASK THEM TO TEST FOR HI I J ANTIBODIES AND THEN TO

COUNSEL PATIENTS WHO ARE HI I J, NEGATIVE HOW TO STAY

NEGATIVE ,a, TO COUNSEL PATIENTS WHO ARE HI IX POSITIVE HOW

TO PROTECT OTHFRPEOPLE -- AND HOW TO FACE THE FUTURE ,, m

AND TO COUNSEL THOSE PATIENTS WHO RFFUSE TO BE TESTED

ALTOGETHER,

  ALL THAT IS BAD ENOUGH, BUT WE'RE ALSO ASKING PHYSICIANS TO

TAKE A SEXUAL AND DRUG-USE HISTORY OF APPROPRIATE PATIENTS --

AND IN MANY PRACTICE AREAS THAT MIGHT MEAN MOST PATIENTS,


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  BUT, .AS DRm NEIL SCHRAM OF LOS ANGELES SAYS, "MOST

PHYSICIANS HAVE HAD LITTLE TRAINING FOR THIS, SO A GREAT DEAL OF

NEW INFORMATION AND A GREAT MANY NEW SKILLS MUST BE LEARNED AND

APPLIED,"

AND I WOULD ADD THAT SUCH SKILLS MUST BE "LEARNED AND

APPLIED" mm, RIGHT NOi$

  WHAT I JUST DISCUSSED CONCERNS, OF COURSE, THE DANGER TO

THE GENERAL PUBLIC BUT SHOULD PHYSICIANS ALSO BE CONCERNED

ABOUT THE POTENTIAL DANGER TO THEMSELVES? YES, THEY SHOULD,


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  WHILE-YOU, AS PRACTICING PHYSICIANS, ARE MANKIND'S FIRST

LINE OF DEFENSE AGAINST AIDS, ETHICALLY YOU SHOULD BE AS

CONCERNED FOR YOUR OWN HEALTH AS YOU ARE FOR THE HEALTH OF YOUR

PATIENTS

  THIS IS NOT AN OVERWHELMING TASK, BY THE WAY. QUITE EARLY

IN THE HISTORY OF THIS EPIDEMIC, THE US, PUBLIC HEALTH SERVICE

PUBLISHED A SET OF COMMON-SENSE SAFETY GUIDELINES FOR ALL HEALTH

PERSONNEL, INCLUDING PHYSICIANS, THE GUIDELINES SUGGEST YOU USE

GLOVES AND BE ESPECIALLY CAREFUL AROUND NEEDLES AND SCALPELS,

WHEN TREATING PATIENTS WITH AIDS


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  I SHOULD ALSO MENTION THE GUIDELINES OF THE AMERICAN

HOSPITAL ASSOCIATION, CONCERNING THE HANDLING OF BODY FLUIDS,

THEY ARE SENSIBLE AND I BELIEVE THEY, TOO, OUGHT TO BE FOLLOWED

AS A GENERAL RULE, NOT JUST IN CASES WHERE SEROPOSITIVITY IS

SUSPECTED,

  I THINK THESE GUIDELINES HAVE WORKED, ALONG WITH THE GOOD

SENSE OF HEALTH PROFESSIONALS EVERYWHERE, OF THE NEARLY 7

MILLION PEOPLE INVOLVED IN HEALTH CARE IN THIS COUNTRY --

PHYSICIANS, DENTISTS, NURSES, LAB TECHNICIANS, EMERGENCY ROOM

PERSONNEL, AND SO ON -- FEWER THAN A DQZEN HAVE BECOME

ACCIDENTALLY INFECTED WITH THE AIDS VIRUS WHILE PROVIDING DIRECT

PAT I ENT CARE,


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AND IN ALMOST EVERY CASE, THE ACCIDENT COULD HAVE BEEN

PREVENTED,

  BUT DESPITE THIS EXTRAORDINARY SAFETY RECORD WE STILL HEAR

-- EVERY DAY -- INSTANCES IN WHICH A PHYSICIAN, DENTIST, NURSE,

AND OTHER HEALTH PROFESSIONAL HAS REFUSED TO TREAT PERSONS WITH

AIDS, ,,OR EVEN TO TREAT PERSONS WHOM THEY SUSPECT OF HAVING

AIDS,

  SUCH CONDUCT HAS NEVER BEEN CONDONED, AND YOU NEED LOOK NO

FARTHER THAN THE HIPPOCRATIC OATH FOR PROOF, ALMOST 2,400 YEARS

AGO, HIPPOCRATES WROTE, 1 m


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QUOTE.,, "I WILL USE TREATMENT TO HELP THE SICK ACCORDING TO

MY ABILITY AND JUDGMENT BUT NEVER WITH A VIEW TO INJURY OR

WRONGDOING.,/',,CLOSE QUOTEm

DENYING TREATMENT TO SOMEONE WHO HAS AIDS Ias TURNING AWAY A

PERSON WHO IS SICK AND DYING aa, THAT IS DOING SOMETHING WRONG,

IT'WAS WRONG 2,400 YEARS AGO,

IT'S WRONG TODAY,

  AND IT WILL CONTINUE TO BE WRONG TOMORROW, WHILE THIS

TERRIBLE EPIDEMIC IS STILL WITH US,


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  FORTUNATELY, THE MAJORITY OF PHYSICIANS AND OTHER HEALTH

PROFESSIONALS HAVE FORTHRIGHTLY RE-STATED THE HIPPOCRATIC

PRINCIPLE IN CONTEMPORARY TERMS

  THE REFUSAL TO TREAT AIDS PATIENTS IS UNACCEPTABLE PROFES-

SIONAL BEHAVIOR, SAY THE AMERICAN MEDICAL ASSOCIATION, THE

AMERICAN COLLEGE OF PHYSICIANS, THE AMERICAN NURSES ASSOCIATION,

THE AMERICAN DENTAL ASSOCIATION, AND MANY OTHERS,

  AND, OF COURSE, I HAVE SAID IT OVER AND OVER AGAIN IN THE

PAST 2 YEARS, IN THE MEDIA -- NEWSPAPERS, RADIO, AND TX -- AND

FROM DOZENS OF PLATFORMS SUCH AS THIS,


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  I DONfT WANT TO OVER-STATE THE CASE, SO I WILL GLADLY

ACKNOWLEDGE THAT NATIONWIDE THE GREAT MAJORITY OF OUR COLLEAGUES,

WHEN ASKED, HAVE INDEED PROVIDED -- AND WILL CERTAINLY CONTINUE

TO PROVIDE -- QUALITY, COMPASSIONATE CARE TO PERSONS WITH AIDS,

  BUT THE ETHICAL CONDUCT OF THE MAJORITY SHOULD NOT IN ANY

WAY SHIELD THE UN-PROFESSIONAL AND UNETHICAL CONDUCT OF A FEARFUL

AND IRRATIONAL MINORITY ama CONDUCT THAT THREATENS TO REND THE

VERY FABRIC OF HEALTH CARE IN THIS COUNTRY,

  IF SUCH DISCRIMINATORY CONDUCT IS PERMITTED WITH REGARD TO

AIDS, THEN WHAT WILL BE THE NFXT EXCEPTED CONDITION .,a OR CLASS

OF PAT I ENT?


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  BUT AGAIN, I WOULD EMPHASIZE THAT PHYSICIANS SHOULD NOT BE

UNNECESSARILY EXPOSED TO RISK, BECAUSE OF THEIR ETHIC& CONDUCT,

I'VE ALREADY MENTIONED THE P,H,S, GUIDELINES, BUT I THINK

WE NEED TO LOOK AT PATIENT TESTING AS WELL,

I BELIEVE THAT ROUTINE TESTING OF ALL PATIENTS IS

UNNECESSARY AND PRESENTS A GREATER BURDEN TO INSTITUTIONS THAN

THE OCCASIONAL AIDS PATIENT DOES,

  HOWEVER, TESTING PATIENTS ON A CASE-BY-CASE BASIS MAKES

SENSE,


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IF A HOSPITAL ADMITS A PATIENT WHO PRESENTS THE MARKS AND

                                                                           '

SYMPTOMS OF AN INTRAVENOUS DRUG ADDICT -- AND IF THE INSTITUTION

IS IN AN AREA WHERE, IN FACT, AIDS HAS BEEN REPORTED -- THEN I

THINK THE INSTITUTION HAS AN OBLIGATION TO ITS STAFF TO DO A

ROUTINE BLOOD TEST FOR AIDS ON THAT NEW ARRIVAL,

  I THINK THE SAME SHOULD BE SAID FOR A HOMOSEXUAL PATIENT

WITH A HISTORY OF SEXUAL PROMISCUITY AND/OR SEXUALLY TRANSMITTED

DISEASE AND FOR A HETEROSEXUAL PATIENT WITH A HISTORY OF MULTIPLE

SEX PARTNERS


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  OF COURSE, SUCH A POLICY MEANS STRONG INTERNAL CONTROLS OVER

TEST RESULTS AND A RESTRICTED CIRCLE OF PERSONNEL WHO HAVE A

"NEED TO KNOW" THOSE TEST RESULTS

  HOSPITALS ALREADY HAVE SUCH CONTROL SYSTEMS IN PLACE, ARE

THEY PERFECT? NO, THEY'RE NOT, I'VE BEEN IN MEDICINE FOR

ALMOST A HALF CENTURY AND I HAVEN'T SEEN PERFECTION YET, WHY

SHOULD IT SUDDENLY APPEAR NOW?

   BUT THAT ARGUMENT IS NOT GOOD ENOUGH TO PREVENT AN

INSTITUTION FROM ESTABLISHING A POLICY OF RESTRAINED PATIENT

TESTING FOR THE PRESENCE OF AIDS ANTIBODIES,


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I THINK THAT PEOPLE WHO CANNOT CONTROL THEIR OWN HIGH-RISK

BEHAVIOR SHOULD NOT EXPECT -- NOR SHOULD THEY GET -- A "FREE

RIDE" FROM THE HEALTH CARE SYSTEM,

  THERE ARE PENALTIES FOR HIGH-RISK BEHAVIOR, ONE OF THEM IS

THE POSSIBILITY OF DYING OF AIDS,
          ANOTHER IS THE POSSIBILITY

THAT YOU WILL BE JFSTU FOR AIDS, AS A PRIOR CONDITION TO

RECEIVING MEDICAL CARE,

  IN ANY CASE, I DON'T BELIEVE THE ETHICAL QUESTIONS

SURROUNDING THE AIDS ISSUE ARE QUESTIONS FOR HEALTH PERSONNEL

ONLY,  SOCIETY JN GFNERAI. OUGHT TO BE HELD TO A STRONG ETHICAL

STANDARD,


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   NEITHER MEDICAL PERSONNEL NOR ANYONE ELSE SHOULD BE PLACED

AT ANY UNNECESSARY OR PREVENTABLE RISK, IF THEY OTHERWISE ACT IN

AN ETHICAL MANNER,

  CONVERSELY, IF MEDICAL PERSONNEL OR ANYONE ELSE CAN'T ABIDE

BY A COMMON, COMMUNITY STANDARD, THEN THEY MUST BE PREPARED TO

PAY A PRICE, AND IT COULD BE A VERY HIGH PRICE,

   IF A PHYSICIAN OR OTHER HEALTH WORKER BECOMES SEROPOSITIVE

OR HAS AIDS, I BELIEVE THAT PERSON IS OBLIGED TO REPORT SUCH

INFORMATION TO HIS OR HER SUPERVISOR, FROM THAT POINT ON, I

SUGGEST THAT A LOCAL COMMITTEE OF PEERS OUGHT TO DECIDE WHAT THE

INFECTED PERSON CAN AND CANNOT DO IN HEALTH CARE,


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AND I-MIGHT ADD THAT THE LONGER THE HEALTH PROFESSION DELAYS

ESTABLISHING ETHICAL PROCEDURES COVERING ITS OWN PEOPLE WITH

AIDS, THE SOONER WILL THE PUBLIC LOSE PATIENCE AND TURN TO THE

COURTS FOR RELIEF,  AND THE COURTS WILL -- ONCE AGAIN -- HAVE TO

STEP IN AND TELL MEDICINE WHAT TO DOa

  AND FINALLY a a, WHAT ABOUT THE COST OF HEALTH CARE FOR

PEOPLE WITH AIDS? WHAT IS THE ETHICAL IMPERATIVE IN JHIS ISSUE?

  YOU KNOW, OF COURSE, THAT THE AMERICAN TAXPAYER WILLINGLY

SUPPORTS MATERNAL AND CHILD HEALTH PROGRAMS, FOR EXAMPLE, AND

DIABETES CONTROL AND HYPERTENSION SCREENING PROGRAMS, AND SO ON,


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RELATED PHYSICIAN SERVICES, NURSING CARE, LABORATORY FEES

I I t MOST OF THOSE ARE ALSO PAID OUT OF GENERAL TAX REVENUES,

  TAXPAYERS ALSO SUPPORT PROGRAMS FOR ALCOHOLICS, DRUG

ADDICTS, AND PERSONS WITH SYPHILIS, YOU MIGHT ONE DAY PROVIDE

THOSE SERVICES, OR -- TRAGICALLY -- YOU MIGHT ONE DAY NEED THEM

YOURSELF,

  IN ANY CASE, THOSE ARE PROGRAMS THAT ARE GEARED TO BRING --

OR TO BRING BACK -- MEN, WOMEN, AND CHILDREN TO A STATE OF GOOD

HEALTH,


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  WE ullf THOSE PROGRAMS, THEY SERVE IMPORTANT PURPOSES AND

THEY AREN'T VERY EXPENSIVE EITHER,

  THE AIDS PROGRAM OUGHT TO BE IN THIS CATEGORY, TOO, BUT IT

REALLY ISN'T, AFTER CONSUMING TENS OF THOUSANDS OF DOLLARS WORTH

OF MEDICAL CARE AND SOCIAL SERVICES a,, THE AIDS PATIENT IS NOT

CURED, THE PATIENT DIES,

AS I MENTIONED EARLIER, AND AS YOU KNOW FULL WELL, I'M SURE,

THIS DISEASE IS VIRTUALLY 100 PERCENT FATAL,


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NOW, THE AIDS CASE-LOAD IS CLIMBING, AND SO ARE THE COSTS,

THE CARE REQUIRED FOR AN AIDS PATIENT IS BOTH TECHNOLOGY- AND

LABOR-INTENSIVE, HENCE, THE AVERAGE COST OF CARE FOR Ox AIDS

PATIENT FOR ONE YEAR IS $20,000, ACCORDING TO FIGURES RECENTLY

PUBLISHED IN JAMAm

  IN 1991, WE ANTICIPATE LOGGING IN 74,000 w AIDS PATIENTS

THE TOTAL COST OF PATIENT CARE THAT YEAR COULD BE AT LEAST $415

BILLION aam OR AS MUCH AS $8 BILLION, IF YOU TAKE INCLUDE THE

COST OF LOST PRODUCTIVITY AND SO ON.

WILL THE AMERICAN PEOPLE CONTINUE TO SUPPORT HIGH-COST

PATIENT CARE FOR PEOPLE WITH AIDS?


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WILL YOU BE WILLING TO SUPPLY SUCH CARE -- RFGARDLFSS OF THE

WAY YOU'RE REIMBURSED?

WILL THE GENERAL PUBLIC ASK FOR RELIEF? WILL THEY ASK THAT

CORNERS BE CUT?

WILL THEY DEMAND A CHEAPER KIND OF "SECOND-CLASS CARE" FOR

AIDS PATIENTS?

AND IF THEY DO, WILL YOU GO ALONG WITH THAT? OR NOT?


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   I URGE YOU TO WORK OUT IN YOUR OWN MINDS JUST WHAT YOUR

RESPONSE TO. THESE ETHICAL ISSUES MIGHT BE, AS THEY ARISE IN YOUR

PROFESSIONAL LIVES BECAUSE THEY SURELY Wu ARISE m,, AND IN

SOME HIGHLY PUBLICIZED WAY, TOO, I FEEL SURE,

   THAT HASN'T HAPPENED YET, BUT I'M POSITIVE THAT THE DISEASE

OF AIDS WILL SOON HAVE ITS OWN PATIENT am, SOMEONE LIKE "BABY

DOE" OR KAREN ANN QUINLAN a mm A PERSON -- AT ONCE BOTH REAL AND

SYMBOLIC -- WHO WILL SUDDENLY SYNTHESIZE ALL THE VARIOUS ARGU-

MENTS, PRO AND CON, ABOUT THE COSTS OF CARE FOR AIDS PATIENTS,


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  LAWYERS AND JUDGES AND C,P.A,'s AND ALL MANNER OF PEOPLE

WILL TAKE TO THE PUBLIC PLATFORM TO ARGUE THE ETHICAL QUESTIONS

RAISED BY THE CASE, AND THEY COULD ALL BUT DROWN OUT THE VOICE

OF MEDICINE ,,t YOUR VOICE, I MIGHT ADD,

  THAT'S WHY I FEEL IT IS ESSENTIAL FOR EACH OF YOU TO LOOK AT

THESE MATTERS NOW -- BEFORE THEY HIT THE STREETS AND THE EVENING

NEWS -- AND BEFORE YOU YOURSELF ARE GOADED INTO MAKING A HASTY

AND UNETHICAL RESPONSE TO THE QUESTIONS RAISED,

I'D LIKE TO SURPRISE YOU AND COME UP WITH SOME HARD AND FAST

ANSWERS TO THE QUESTIONS I'VE RAISED TODAY.


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BUT I- DON'T HAVE THEM, NO ONE HAS,

  YET, u OF US SHOULD BE DEEPLY CONCERNED ABOUT THE ANSWERS

THAT WILL BE EVOLVING OVER THE YEARS AHEAD mm1 AND WE SHOULD BE

DEEPLY ENGAGED IN JHAT PROCESS AS WELL,

  MANY YEARS AGO, THE AMERICAN PHILOSOPHER, ALFRED NORTH

WHITEHEAD, WARNED US ABOUT THE FOLLY OF SEEKING QUICK-AND-EASY

ANSWERS TO THE KINDS OF QUESTIONS I'VE RAISED,


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HE SAID IT THIS WAY:

"WE MUST NOT EXPECT SIMPLE ANSWERS TO FAR-REACHING

QUESTIONS, HOWEVER FAR OUR GAZE, THERE ARE ALWAYS HEIGHTS

BEYOND, WHICH BLOCK OUR VISION,"

  MY PLEA TO EACH OF YOU TODAY IS SIMPLY THIS: KEEP PROBING,

KEEP CLIMBING, AND KEEP YOUR VISION AS CLEAR AS CAN BE THROUGHOUT

YOUR CAREER IN MEDICINE,

  ONCE AGAIN, THANK YOU FOR YOUR INVITATION TO SPEAK HERE ON

YOUR "CLASS DAY,"

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