September 20, 1967

Dr. Orville G. Brim, Jr.
Russell Sage Foundation
230 Park Avenue

New York, New York 10017

Dear Bert:

A couple of glimpses on the question of termination of care that
came through during a visit I made to the University of Washington
Medical School in Seattle last week.

1. A Dr. Lawes, having some connection with the A.M.A., told
me that the A.M.A. was sponsoring a study of physycian's reactions
to death that would certainly overlap the concerns of our study.

2. A specific circumstance that seems to come up recurrently
is the chronic alcdhelic with advanced cirrhosis of the liver and
uncontrolled bleeding from the esophageal veins. These people can
be kept alive and conscious essentially indefinitely, provided that
enormous quantities of blood sre made continuously available. But
it is Just not to be had. The surgeons have their own standards for
deciding whether or not to operate and often by simply refusing to
accept such cases for heroic surgery, they passa the buck back to the
internists. There is obviously a considerable element of moral and .
social class discrimination in these proceedings, it being impossible
to mobilize all of the potential resources of the community for a
skid-row bum.

3. I was kicking these general subjects around with a rather
bright group of young house officers. There is considerable skepticism
about getting reliable information from doctors in private practice as
compared with those connected with academic institutions, but I don't
think thet this should stop us and anyhow we certainly ought to consider
a pilot run. One of the more creative suggestions is a matter of
medical operations research rather than sociological -- to try to
get scales of estimated cost benefit ratios from actual experience
with heroic life-saving measures.

Wiy gy
Dr. Orville G. Brim, Jr. 2 September 20, 1967

Another suggestion was to solicit more detailed documentation
for examples of exceptional recoveries after the apparent deterioration
of the usual vital signs. For example, one internist or neurologist
Claimed that he had heard of a patient having been revived after a
prolonged flat EEG and to the extent that such antidotes are not
thoroughly clarified they do pose an enormous burden on later
practice.

Sincerely yours,

Joshua Lederberg,
Professor of Genetics

JL:as