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ETHICAL IMPERATIVES AND THE NEW PHYSICIAN:

HE VHALLENGE OF IEDIC RACTICE

CoMMENCEMENT ApprEss 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 AT THE COMMENCEMENT EXERCISES OF THE
F. EDWARD HEBERT SCHOOL OF MEDICINE OF THE
UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES
BETHESDA, MARYLAND
May 12, 1988
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(GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.)

I WANT TO THANK THE MEMBERS OF THE CLASS OF 1988 FOR
EXTENDING TO ME THE HONOR OF BEING THEIR SPEAKER AT THESE
COMMENCEMENT EXERCISES,

FOR MORE THAN 40 YEARS, WHEN I WAS ON THE FACULTY OF THE
UNIVERSITY OF PENNSYLVANIA, I HOPED THAT MY COLLEAGUES HAD A GOOD
OPINION OF ME. BUT OVER TIME, MY GREATER CONCERN BY FAR WAS THAT
THE STUDENT BODY HAD A GOOD OPINION OF ME.
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YOUNG PEOPLE ARE TOUGH-MINDED. FORTUNATELY, YOU DON’T YET

SEE THE WORLD AS WE OLDER MEMBERS FREQUENTLY SEE IT: AS ONE
GREAT ZONE OF GRAY, LAVISHLY FURNISHED WITH IDEAS THAT ARE NOT
ONLY “ON THE ONE HAND” BUT ARE ALSO “ON THE OTHER HAND,” TOO.

THE VISION OF YOUTH TENDS TO BE MORE CANDID AND MORE
CLEARCUT. YOUR WORLD SEEMS TO BE DIVIDED INTO CLEARLY MARKED
AREAS OF LIGHT AND SHADOW THROUGH WHICH WE ALL MUST TRAVEL.

SO NATURALLY I WAS VERY PLEASED TO LEARN THAT, IN YOUR
VALUED OPINION, I SOMEHOW MANAGED TO TURN UP IN THAT HALF OF THE
WORLD THAT IS FULL OF LIGHT.
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HOW LONG WILL I BE ALLOWED TO REMAIN THERE? WHO CAN TELL?

THIS COULD BE A TEMPORARY HONOR, YET I VALUE IT ALL THE SAME,

IN ANY CASE, AND AT LEAST FOR NOW, I ENJOY YOUR GOOD
OPINION. AND, AS A REWARD, YOU'VE GIVEN ME ACCESS -- THIS
MORNING, ANYWAY -- TO YOUR EARS ... AND YOUR MINDS ... AND YOUR
HEARTS,

AND TO YOU, THE FAMILIES AND FRIENDS OF THE GRADUATES, I
INVITE YOU ALL TO LISTEN IN ON THE CONVERSATION I’M ABOUT TO HAVE
WITH THE CLASS OF 1988.
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I KNOW YOU’RE VERY PROUD OF TODAY’S GRADUATES -- AS WELL YOU

SHOULD BE -- AND I’M SURE YOU'LL FEEL THIS WAY FOR MANY YEARS 10
COME.

SO I ASK YOU TO EAVESDROP ON WHAT I HAVE TO SAY BECAUSE, IN
A WAY, IT MAY HELP EXPLAIN TO YOU -- TODAY AND IN THE DAYS AHEAD
-- JUST WHY YOUR YOUNG PHYSICIAN IS SO SPECIAL,

THIS TS AN EXTREMELY VALUABLE OPPORTUNITY FOR ME AND I DON’T
WANT TO WASTE IT. THEREFORE, I AM USING THIS OCCASION TO GIVE
THE FIRST OF A CYCLE OF SIX MEDICAL SCHOOL COMMENCEMENT
ADDRESSES, ALL OF WHICH ARE CONCERNED IN SOME WAY WITH THE
“ETHICAL IMPERATIVES” OF MEDICAL PRACTICE.
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THIS CYCLE OF ADDRESSES WILL CONCLUDE IN ONE MONTH AT THE

COMMENCEMENT EXERCISES OF THE UNIVERSITY OF HEALTH SCIENCES -
CHICAGO MEDICAL SCHOOL.

LATER IN THE SUMMER I HOPE TO SEND EACH OF YOU AND MEMBERS
OF THE FACULTY THE FINAL PUBLISHED COLLECTION OF ALL SIX
ADDRESSES. EXCEPT FOR AN ADDED FOOTNOTE HERE AND THERE, THEY
WILL BE EXACTLY AS DELIVERED.

I WANT TO DO THIS BECAUSE, FOR ONE THING, THE TERM “ETHICS”
IS NOW THE BUZZ-WORD THROUGHOUT OUR SOCIETY. IT’S IN FASHION
NOT ONLY AMONG PHYSICIANS BUT ALSO AMONG LAWYERS AND EDUCATORS
AND BUSINESS PEOPLE AS WELL.
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UNFORTUNATELY, BUZZ-WORDS GO QUT OF FASHION, TOO. THERE-

FORE, I WANT TO TALK ABOUT IT DURING THIS COMMENCEMENT SEASON IN
THE HOPE THAT I MIGHT CONVINCE YOU TO KEEP ETHICS “IN FASHION”
THROUGHOUT YOUR MEDICAL CAREERS.

BUT WHY SHOULD ETHICS BE ON EVERYONE'S MIND THESE DAYS?

AS MANY REASONS HAVE BEEN ADVANCED AS THERE ARE THEORISTS.

BUT I LEAN TOWARD A THEORY THAT HAS AN ADDITIONAL MESSAGE FOR THE
PHYSICIAN,
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THIS THEORY SAYS THAT ETHICS HAS SUDDENLY TAKEN ON GREAT

IMPORTANCE BECAUSE WE -- AS A PEOPLE -- ARE WAKING UP TO THE FACT
THAT OUR EXTRAORDINARY NEW TECHNOLOGIES HELP US GET THINGS DONE
.++ BUT TECHNOLOGY DOESN'T HELP US DECIDE WHETHER THOSE THINGS
SHOULD BE DONE IN THE FIRST PLACE OR EVEN THE BEST WAY 10 DO

 

THEM,

IN OTHER WORDS, DESPITE ALL THE NEW ELECTRONICS AND ALL THE
OPTICS ... THE COMPUTER PROGRAMS AND THE WONDER DRUGS ... THE
BASIC DECISION TO ACT -- OR NOT TO ACT -- IS STILL OURS ... AND
IT’S A DECISION GUIDED MORE BY ONE’S OWN PERSONAL SYSTEM OF
ETHICS AND LESS BY TECHNICAL KNOWLEDGE AND EXPERTISE.
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I KNOW OF NO MEDICAL FACULTY TODAY THAT DOES NOT HAVE AT

LEAST A PART-TIME ETHICIST TO TEACH STUDENTS AND ADVISE
COLLEAGUES. OF COURSE, IT WASN’T ALWAYS THIS WAY. IN MY OWN
EXPERIENCE AS A MEDICAL STUDENT, A HALF CENTURY AGO, I HAD NO
COURSE IN ETHICS. NONE WAS GIVEN,

BUT I HAD NO TROUBLE RECOGNIZING THE FACT THAT ALL MY
TEACHERS HAD THEIR OWN PERSONAL SYSTEMS OF ETHICS THAT IMPELLED
THEM TO DO WHAT THEY THOUGHT WAS “RIGHT,”
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GRANTED, IT WAS A VERY SUBJECTIVE AND INTUITIVE APPROACH TO

ETHICS. AND, IN CERTAIN RESPECTS, RATHER INEFFICIENT, ALSO.

FOR EXAMPLE, I HAD COMPLETED MY INTERNSHIP, MY RESIDENCY IN
GENERAL SURGERY, AND MY FELLOWSHIP IN PEDIATRIC SURGERY BEFORE |
SERIOUSLY RAISED THE QUESTION FOR MYSELF, “JUST WHY DID I PICK A
LIFE OF MEDICINE?”

AND MY ANSWER TO THAT QUESTION MORE OR LESS DEFINED MY
PROFESSIONAL CAREER FROM THEN ON,

T CONCLUDED THAT I CHOSE MEDICINE BECAUSE I WANTED TO SAVE
LIVES ... AND I ALSO WANTED TO ALLEVIATE SUFFERING,
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BUT ALMOST FROM THE BEGINNING, I RECOGNIZED THAT THESE TWO

OBJECTIVES WERE OFTEN IN TENSION ... THAT I COULD NOT ALWAYS
ACHTEVE BOTH OBJECTIVES AT THE SAME TIME ~~ FOR THE SAME PATIENT,

AND 1 ALSO KNEW THAT, FROM TIME TO TIME, I MIGHT HAVE TO
CHOOSE ONE OF THESE OBJECTIVES AS MORE APPROPRIATE FOR A GIVEN
PATIENT WITH A GIVEN CONDITION,

T SHOULD WARN YOU THAT BEING AWARE OF MY OWN ETHICAL SYSTEM
OF PROFESSIONAL BEHAVIOR DID NOT NECESSARILY MAKE LIFE ANY EASTER
FOR ME.
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BUT IT DID CLARIFY A GREAT MANY THINGS AND AT LEAST MADE IT

POSSIBLE FOR ME TO ACT ... AND TO DO SO WITH REASONABLE
CONSISTENCY,

MY EXPERIENCE AND THE SIMILAR EXPERIENCES OF TEACHERS AND
COLLEAGUES OF MY GENERATION WERE A FAR CRY FROM THE CONSENSUS-
SEEKING APPROACH TO MEDICAL ETHICS THAT OUR PROFESSION SEEMS
COMMITTED TO TODAY,

] SUPPOSE IN A VOCATION AS COMPLEX AS CONTEMPORARY MEDICINE,
IN WHICH A VERY HIGH PREMIUM IS PAID TO ACCOUNTABILITY, IT IS
ONLY NATURAL THAT THE MEDICAL PROFESSION ITSELF ARRIVE AT ITS OWN
ETHICAL SYSTEM OUT OF A BROAD, CONSENSUS-BUILDING PROCESS.
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I KNOW THAT’S THE CASE AND I RESPECT THE MEN AND WOMEN

ENGAGED IN THAT PROCESS ON MY BEHALF. YET, I MUST CONFESS TO YOU
THAT I HAVE A BIAS THAT FAVORS THE OLDER AND MORE PERSONAL
SYSTEM,

HOWEVER FAULTY IT MAY SOMETIMES BE, AT LEAST IT IS AN
ETHICAL SYSTEM THAT REFLECTS ONE'S OWN IDEAS ABOUT LIFE, THE
HUMAN BODY AND MIND, HUMAN RELATIONSHIPS, SUFFERING, AND DEATH --
IDEAS THAT EMERGE OUT OF A MIX OF INFLUENCES FROM FAMILY, FROM
TEACHERS AND OTHER ROLE MODELS, FROM SCHOOL, COMMUNITY, RELIGION
OR LACK OF IT, AND FROM ONE’S OWN PERSONALITY.
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SIMPLY STATED, I BELIEVE YOU PRACTICE MEDICINE THE SAME WAY

YOU PRACTICE LIFE. IF YOU ARE INHERENTLY A SENSITIVE, COMPAS-
SIONATE, AND COMMUNICATIVE PERSON, YOU WILL BE A SENSITIVE, COM-
PASSIONATE, AND COMMUNICATIVE DOCTOR. AND CERTAINLY THE
CONVERSE IS ALSO TRUE.

IF THAT'S THE CASE -- IF ETHICS IS REALLY THAT INTUITIVE --
WHY DO WE NEED THE FORMALITY OF ETHICS STUDIES AND ETHICS
DISCUSS TONS?

FOR ME, THE ANSWER IS THAT AN UNDERSTANDING OF ETHICS
ALLOWS YOU TO STRENGTHEN YOUR OWN PRINCIPLES AND IMPULSES
THROUGH ACTUAL DAILY PRACTICE ... PUTTING ETHICS TO WORK, AS IT
WERE,
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IT ALSO ENABLES YOU AND YOUR PATIENTS AND YOUR COLLEAGUES

TO EVALUATE YOUR PERFORMANCE -- FUTURE AS WELL AS PAST -- ON SOME
BASIS OTHER THAN WHIM OR PREJUDICE.

CONSENSUS ETHICS HAS MUCH TO RECOMMEND IT IN A DEMOCRATIC
SOCIETY, OF COURSE. AND IT CERTAINLY HAS A PLACE IN A PROFESSION
WITH NEARLY A HALF-MILLION PRACTICING MEMBERS.

BUT I MUST ALSO WONDER: CAN AN ACT EVER BE “ETHICAL,” IF A
MAJORITY OF PEOPLE OPPOSE IT? SIMILARLY, IS AN ACTION ALWAYS
“ETHICAL,” IF A MAJORITY OF THE PEOPLE SUPPORT IT?
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HOWEVER RATIONAL AND COGENT AND COMPASSIONATE AND RELEVANT A

CONSENSUS ON ETHICS MAY BE, AND HOWEVER LOYALLY AND FERVENTLY YOU
SUBSCRIBE TO IT, REST ASSURED THAT THE MOST IMPORTANT MEDICAL
DECISIONS YOU WILL MAKE DURING YOUR ENTIRE CAREER WILL BE
DECISIONS THAT SPRING FROM YOUR OWN PERSONAL VISION OF THE ETHICS
OF MODERN MEDICAL PRACTICE ... AGAIN, A VISION BASED ON THOSE
INFLUENCES OF FAMILY, ROLE MODELS, SCHOOL, COMMUNITY, AND SO ON,

THERE IS YET ANOTHER ASPECT THAT IS EVEN MORE DIFFICULT TO
ASSESS: AND THAT IS, YOUR RELATIONSHIP AND RAPPORT WITH YOUR
PATIENT, YOUR SUBCONSCIOUS ESTIMATE OF THAT PERSON, AND THE LEVEL
OF TRUST YOU INVEST IN EACH OTHER,
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FOR EXAMPLE, THE COMPUTER PROGRAM HAS NOT YET BEEN WRITTEN

-- AND 1 BELIEVE WILL NEVER BE WRITTEN -- THAT CAN MAKE ... FOR
YOU ... THE LIFE-OR-DEATH DECISION TO START A COURSE OF THERAPY
THAT HAS ONLY AN OUTSIDE CHANCE OF SUCCESS ... OR TO STOP A
COURSE OF THERAPY THAT APPEARS TO BE USELESS.

YOU MAY RECALL THAT WAS THE HEART OF THE PROBLEM FACING THE
EMERGENCY ROOM PHYSICIAN WHO FIRST SAW KAREN ANN QUINLAN,

THAT PHYSICIAN COULD HAVE SAID, “I'VE SEEN ENOUGH OF THESE
CASES INVOLVING DRUGS AND ALCOHOL. I KNOW WE'LL NEVER WIN THIS
ONE. THEREFORE, TO SAVE EVERYONE A LOT OF UNNECESSARY GRIEF, |
WILL NOT PUT THIS YOUNG WOMAN ON A VENTILATOR.”
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IF THE PHYSICIAN HAD SAID THAT, I DOUBT THAT THERE WOULD

HAVE BEEN MUCH CRITICISM, WHETHER OR NOT KAREN QUINLAN CONTINUED
TO LIVE. OF COURSE, THAT‘’S 20-20 HINDSIGHT AND I MAY BE MIS-
READING THE SITUATION.

BUT MISS QUINLAN HAD ALREADY GONE INTO AN IRREVERSIBLE COMA
AND SO I THINK THAT A DECISION TO TAKE NO FURTHER ACTION WOULD
HAVE BEEN ACCEPTED BY ALL CONCERNED,

HOWEVER, THE DECISION TO GO AHEAD AND PUT MISS QUINLAN ON A
VENTILATOR WAS ITSELF -- AT LEAST, IN THAT ERA ~~ AS IRREVERSIBLE
AS HER CONDITION. IT TOOK AN EXTRAORDINARY AMOUNT OF DEBATE,
COURT ACTION, AND PUBLIC APPEALS BY HER PARENTS TO LEGALLY DETACH
THE VENTILATOR,
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THE MOST EXPERT OPINIONS IN THE COUNTRY TESTIFIED THAT

REMOVAL OF THE LIFE-SUPPORT SYSTEM WOULD ALMOST IMMEDIATELY LEAD
TO HER DEATH,

BUT KAREN QUINLAN DID NOT CONVENIENTLY DIE. INSTEAD, SHE
CONTINUED LIVING FOR SEVERAL MORE YEARS,

THE SAME TECHNOLOGY AWAITS THE NEXT UNFORTUNATE KAREN
QUINLAN. AND A PHYSICIAN -- POSSIBLY ONE OF YOU -- TOGETHER WITH
THE PARENTS OR SPOUSE OF THAT PATIENT WILL HAVE TO DECIDE WHAT TO
DO NEXT,
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AT THAT TIME I’M SURE THE QUINLAN CASE WILL WEIGH HEAVILY ON

YOUR MINDS. BUT NO TWO CASES ARE EVER EXACTLY ALIKE, AS YOU’VE
LEARNED BY NOW,

HENCE, I PREDICT THAT, AS TIME GOES ON, YOU WILL RELY LESS
UPON PRECEDENT AND TECHNOLOGY AND MUCH MORE UPON THE BUILDING-
BLOCKS THAT HAVE FORMED YOUR ESSENTIAL CHARACTER -- THE
INFLUENCES OF FAMILY AND COMMUNITY.

OUT OF SUCH RICHNESS IN YOUR OWN BIOGRAPHY YOU WILL FIND THE
COURSE OF ACTION THAT WILL BE ETHICALLY JUST AND MORALLY CORRECT,
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ARE YOU PREPARED TO DO THAT? AND IF SO... WHAT WILL BE THE

DIRECTION YOU WILL PURSUE AND HOW WOULD IT REFLECT THE WAY YOU
RELATE TO YOUR PATIENTS IN GENERAL?

DO YOU, FOR EXAMPLE, SEE YOURSELF AS A KIND OF “PARENT
FIGURE,” KNOWING WHAT’S BEST FOR YOUR PATIENTS AND REQUIRING THEM
TO FOLLOW YOUR DIRECTIONS? OR, AT A MINIMUM, DO YOU ASSUME
THAT YOUR PATIENTS WILL SIMPLY DO WHAT YOU SAY WITHOUT ANY
QUESTION OR ARGUMENT.

OR DO YOU SEE THEM MORE AS PARTNERS IN THE PROCESS OF
DIAGNOSIS AND TREATMENT, PLAYING A ROLE THAT ALLOWS THEM TO MAKE
CERTAIN DECISIONS ON THEIR OWN?
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THESE QUESTIONS HAVE AN ACADEMIC RING TO THEM, I KNOW. THEY

SOUND LIKE THE KIND OF THING YOU'LL BE LEAVING BEHIND, AS YOU
WALK OUT OF THE KENNEDY CENTER THIS MORNING.

BUT QUESTIONS LIKE THESE WILL REMAIN WITH YOU THROUGHOUT
YOUR PROFESSIONAL LIFE. AND -- WHETHER YOU DO SO CONSCIOUSLY OR
NOT -- YOU WILL PROVIDE ANSWERS MERELY BY GOING ABOUT YOUR DAILY
TASKS,

FOR THE OVERALL ETHICAL CONDUCT OF MEDICINE TODAY -- AS YOU
AND I AND THE REST OF THE WORLD PERCEIVE IT -- IS AN AMALGAM OF
THE DAY-TO-DAY CONDUCT OF A HALF-MILLION LICENSED AND PRACTICING
AMERICAN PHYSICIANS,
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IT IS, YOU MIGHT SAY, A “PERCEIVED CONSENSUS” RATHER THAN A

"PREPARED CONSENSUS. ”

MANY OF YOU MAY NOT WISH TO HAVE THAT KIND OF INFLUENCE ON
THE CONDUCT OF YOUR PROFESSION ... BUT IT’S NOT FOR YOU TO
CHOOSE.

HENCE, I URGE YOU TO TAKE THIS ISSUE VERY SERIOUSLY,
BECAUSE -- LIKE IT OR NOT -- THE WAY YOU DELIVER MEDICAL AND
HEALTH CARE OVER YOUR LIFETIME WILL INFLUENCE THE ENTIRE
PROFESSTON’S APPROACH TO ETHICAL CONDUCT AND WILL SURELY AFFECT
THE GENERAL PUBLIC’S PERCEPTION OF HOW WELL MEDICINE IS BEING
PRACTICED.
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YES, YOU MIGHT PREFER THAT THE ISSUE WOULD SIMPLY GO AWAY

eos THAT IT RETURN SAFELY WITHIN THE HALLS OF U.S.U.H,.S. AND TO

MEDICAL SCHOOLS GENERALLY. BUT I’M AFRAID MEDICAL ETHICS IS NOT
PURELY AN ACADEMIC MATTER.

IN FACT, I BELIEVE THAT MEDICAL ETHICS IS ... AND WILL
CONTINUE TO BE ... A CENTRAL CONCERN FOR ALL PHYSICIANS, WHETHER
IN PRIVATE OR GROUP PRACTICE ... IN CIVILTAN OR MILITARY SERVICE

» IN STOREFRONT CLINICS OR IN REGIONAL MEDICAL CENTERS.
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THE ISSUE IS HERE .. AND, MY FRIENDS, IT IS OURS.

AND NOW, LET ME CONGRATULATE YOU ALL FOR COMPLETING YOUR
STUDIES HERE AT THE HEBERT SCHOOL OF MEDICINE AND FOR CHOOSING 10
WORK FOR LIFE ... AS YOUR LIFE’S WORK.

HONESTLY, I ENVY YOU TODAY. I ENVY YOUR ENTHUSIASM ...
YOUR OPTIMISM ... YOUR VIGOR ... AND YOUR OPPORTUNITY. MAY GOD
GRANT THAT YOU USE THEM ALL TO MAKE A WELCOME DIFFERENCE.

THANK YOU.
HHH # #