BANQUET ADDRESS NATIONAL RIGHT TO LIFE COMMITTEE WASHINGTON, D.C. JUNE 22, 1985 C, EVERETT KOOP. M.D. SURGEON GENERAL ALTHOUGH I AM THREE MONTHS INTO MY FIFTH YEAR IN GOVERNMENT, IT IS THE FIRST TIME I HAVE ADDRESSED THIS ORGANIZATION SINCE LEAVING PHILADELPHIA AND THE PURSUIT OF PEDIATRIC SURGERY. I FEEL MOST FORTUNATE TO HAVE HAD TWO SUCH EXCITING CAREERS, - IN ACADEMIC PEDIATRIC SURGERY AND IN GOVERNMENT. BOTH THESE ERAS HAVE HAD GREAT SIGNIFICANCE FOR YOUR CONCERNS. THAT FIRST ERA BEGAN FOR ME IN MEDICAL SCHOOL IN 1937 AND HAS SINCE CONTINUED ON AS I APPROACH A HALF CENTURY OF INVOLVEMENT IN MEDICINE AND HEALTH. DURING THAT TIME I SAW THE ETHICS AND THE COUNTENANCE OF MEDICAL PRACTICE CHANGE. O THE HIPPOCRATIC TRADITION WITH ITS “EQUALITY OF LIFE ETHIC” CHANGED TO “A QUALITY OF LIFE ETHIC.” O SOCIAL ISSUES BECAME MEDICALIZED. -?2- 0 PHYSICIANS WERE URGED TO SUBVERT THEIR TRADITIONAL ETHICS TO SERVE THE SOCIAL PLANNERS AND SOCIETY. O AND MANY OF THEM DID. O THERE WAS AN EXPLOSION OF TECHNOLOGY WHICH PROPELLED THIS COUNTRY INTO 0 THE BEST HEALTH CARE AVAILABLE IN THE WORLD O INTO DILEMMAS CONCERNING ITS PROVISION, - BOTH REAL AND ARTIFICIAL. THIS WAS THE ERA THAT SAW THE UNNECESSARY DESTRUCTION OF AN UNBORN BABY SHIFT OUT OF THE CRIMINAL CODE TO BECOME THE RIGHT OF EVERY WOMAN AND ABORTION ON DEMAND BECAME THE LAW OF THE LAND, -3- THIS WAS ALSO THE ERA WHEN INFANTICIDE BEGAN TO OCCUR IN HOSPITALS TO ALLEVIATE THE SUFFERING OF PARENTS CALLED UPON 10 RAISE A HANDICAPPED CHILD. AND OF COURSE THIS ERA SAW THE REKINDLING OF THE ZEALOUS WHO SAW EUTHANASIA AS YET ANOTHER MEDICAL SOLUTION TO A SOCIAL PROBLEM. AND THIS WAS THE TIME OF THE TEST TUBE BABY. PROVING ONCE AND FOR ALL THAT LIFE BEGINS AT CONCEPTION, THE SECOND ERA I REFERRED TO. MY TIME IN GOVERNMENT, WHICH COINCIDES WITH THE TENURE OF THIS ADMINISTRATION, HAS SEEN MANY CHANGES CROWDED INTO THE SHORT SPAN OF A FEW YEARS, AS TO ABORTION, I THINK HISTORY WILL SHOW THAT WE MISSED A ONCE IN A LIFETIME CHANCE TO TURN ABORTION AROUND IN 1981 - PRESIDENT REAGAN’S FIRST YEAR - WHEN ALL THE NECESSARY ELEMENTS WERE PRESENT EXCEPT ONE, - CONSENSUS AMONG THE VARIOUS, PRO LIFE ORGANIZATIONS AS TO THE VEHICLE TO USE, IT WAS THE TRAGIC LOSS OF AN OPPORTUNITY. ~4- LACK OF CONSENSUS ON VARIOUS INITIATIVES CONTINUES TO THE DETRIMENT OF YOUR AVOWED CAUSE. OTHER MILESTONES ARE WORTH MENTIONING: O A WOMAN’S RIGHT TO ABORTION HAS ESSENTIALLY BECOME HER RIGHT TO A DEAD BABY. O WRONGFUL BIRTH HAS GAINED SOME CREDENCE AND SUPPORT. O SEVERAL RELIGIOUS DENOMINATIONS HAVE REVERSED A PRO ABORTION STATEMENT, O OTHER DENOMINATIONS HAVE SEEN A GRASS ROOTS MOVEMENT WHICH IS PRO LIFE. O BERNARD NATHANSON'S “THE SILENT SCREAM” HAS .TOUCHED A SENSITIVE SPOT IN A BROAD SEGMENT OF SOCIETY. O I HAVE JUST RETURNED FROM THE ANNUAL MEETING OF THE HOUSE OF DELEGATES OF THE AMERICAN MEDICAL ASSOCIATION AND THERE THE STUDENT SECTION SUBMITTED A RESOLUTION INSTRUCTING THE BOARD OF TRUSTEES TO INVESTIGATE THE CLAIMS OF "THE SILENT SCREAM” AS WELL AS OF OPPOSING VIEWPOINTS, 0 THE EDUCATIONAL PROCESS IS SLOW, - BUT I HAVE YET TO MEET A PRO LIFER TURNED PRO ABORTION. BUT I HAVE MET HUNDREDS OF PEOPLE WHO ARE PRO LIFE WHO WERE ONCE ON THE OTHER SIDE OF THE FENCE, - AND I KNOW THERE ARE THOUSANDS MORE. THIS ERA SAW THE BIRTH OF BABY DOE IN BLOOMINGTON, INDIANA AND OF JANE DOE IN PORT JEFFERSON, NEW YORK, WE SAW OR HEARD ABOUT : THE PRESIDENT’S ANGER ABOUT AND POSITIVE RESPONSE 10 BABY DOE. THE INTERIM FINAL RULE BASED ON SECTION 504 OF THE REHABILITATION ACT OF 1973. WE SAW THIS STRUCK DOWN IN THE COURTS BY JUDGE GESELL, THEN THERE WAS THE NOTICE OF PROPOSED RULEMAKING OF THE SUMMER OF 1983, THE REGULATIONS OF JANUARY 1984, THESE WE SAW STRUCK DOWN IN NEW YORK IN A SUIT BROUGHT BY THE AMERICAN MEDICAL ASSOCIATION IN THE SUMMER OF 1984, O THE RESPONSE OF CONGRESS. Q FIRST IN THE HOUSE 0 THEN AFTER SEEING CARLTON SHERWOOD’S EXPOSE OF HOW 24 SPINA BIFIDA BABIES IN THE OKLAHOMA CHILDREN’S HOSPITAL WERE SELECTED FOR NON TREATMENT AND ALL OF WHOM DIED ih THE O A SENATE BILL #8 FORM OF BABY DOE AMENDMENTS TO THE CHILD ABUSE LEGISLATION REPRESENTING A CONSERVATIVE-LIBERAL AND REPUBLICAN-DEMOCRAT COALITION FOLLOWED. QO THAT BILL BECAME LAW ON OCTOBER 15, 1984. O REGULATIONS WERE PUBLISHED IN APRIL 1985. THE FIRST TWO ATTEMPTS AT REGULATION I PLAYED NO PART IN, EVEN SO. I TOOK THE CRITICISM FOR THE ADMINISTRATION, ACTED AS THE LIGHTENING ROD. BUT I DID HAVE A LOT TO DO WITH THE FINAL RULE OF JANUARY 1984, THEY WERE GOOD REGULATIONS: THEY HAD THE SUPPORT OF THE AMERICAN ACADEMY OF PEDIATRICS AND THE DISABILITY GROUPS. AND THEY WOULD HAVE WORKED HAD THE AMA NOT SUED. THEY WOULD HAVE WORKED BECAUSE THEY WERE DESIGNED 10 SAVE ALMOST EVERY BABY, BUT PERHAPS NOT EVERY ONE. THE CLIMATE WAS NOT RIGHT FOR 100 PERCENT, - AND HAD WE TRIED FOR 100 PERCENT WE WOULD HAVE LOST IT ALL. AND YET, - IN SPITE OF MY RECORD ON BEHALF OF HANDICAPPED NEWBORNS, - EVERY MAJOR PRO LIFE GROUP IN THE UNITED STATES - EXCEPT THIS ONE - CRITICIZED ME AND ACCUSED ME OF SELLING OUT 10 THE OTHER SIDE. THEY WANTED ALL OR NOTHING. ALL WAS NOT POSSIBLE: NOTHING WAS THEREFORE INEVITABLE. -g- THERE IS A MORAL TO THIS WHICH MAY BE APPLICABLE 10 WHAT I HAVE TO SAY LATER ON, BUT HHS HAS APPEALED THIS TO THE SUPREME COURT AND LAST WEEK THE SUPREME COURT ACCEPTED THIS CASE. BABY JANE DOE’S CASE CENTERED AROUND THE GOVERNMENT’S RIGHT TO SEE A HOSPITAL RECORD WHEN A PATIENT’S CIVIL RIGHTS HAVE BEEN REPORTED ABROGATED, WE LOST THAT IN ALL THE NEW YORK COURTS ONE REMARKABLE SPINOFF: NAT HANTOFF OF THE VILLAGE VOICE. A SYNDICATED COLUMNIST, LIBERTARIAN, FORMER VICE PRESIDENT OF THE ACLU, SAW THE ISSUE CLEARLY AND BECAME IN THE PROCESS OF LEARNING A DEFENDER OF THE RIGHTS OF HANDICAPPED NEWBORNS AND EVENTUALLY OF THE UNBORN, I CANNOT PREDICT HOW THE REGULATIONS UNDER CHILD ABUSE LEGISLATION WILL WORK OUT BUT TIME WILL TELL. 1 DO BELIEVE THIS, HOWEVER: IF BY MAGIC YOU COULD PUSH A BUTTON, REMOVE ALL BABY DOE REGULATIONS, BUT NOT THE MEMORY OF -10- THE YOUNGSTER AND THE EVENTS SUBSEQUENT TO HIS DEATH, BABY DOES ARE FAR BETTER OFF FOR THE PRESENT AND THE IMMEDIATE FUTURE THAN THEY HAVE BEEN IN THE YEARS OF MY CONCERN. QO THE PUBLIC IS AWARE. 0 PEDIATRICIANS HAVE NARROWED THEIR ETHICAL DILEMMAS. 1 DON'T THINK THERE IS MUCH YOU SHOULD DO ABOUT BABY DOE EXCEPT TO MONITOR HOW WELL YOUR STATE’S CHILD ABUSE SERVICE AGENCY MANAGES ITS ROLE UNDER THE LAW. BUT THERE ARE SOME CRITICAL THINGS YOU MUST DO ABOUT ABORTION. O YOU MUST FORM A COALITION OF THE PRO LIFE GROUPS. QO YOU MUST CHOOSE AN AGENDA. -jl- Q YOU MUST DECIDE ON THE ONE EFFORT YOU WILL MAKE WITH CONGRESS. O IF ONE GROUP CAN’T REACH CONSENSUS WITH THE OTHERS - DROP IT. O THIS COALITION MUST DECIDE ON STRATEGIC POLICY. O AND YOU MUST DO 1T NOW - IN THIS ADMINISTRATION, WELL MEANING PEOPLE SUCH AS YOU - IN THE PAST FIFTEEN YEARS - HAVE BEEN CAUGHT UNPREPARED BY THE MAJOR ISSUES OF ABORTION AND INFANTICIDE. AND I MIGHT SAY THERE WAS AMPLE WARNING, ON THE ABORTION ISSUE BY MANY INDIVIDUALS ON MANY FRONTS AS WELL AS BY CURRENT EVENTS, ON INFANTICIDE - AT LEAST BY ME. FIRST WHEN J WARNED WHEATON COLLEGE IN A COMMENCEMENT ADDRESS IN 1973 WHICH THEY WERE -12- EMBARRASSED TO PUBLISH BECAUSE I SPOKE CHIEFLY OF ABORTION. BUT MOST NOTABLY WHEN I DELIVERED THE ADDRESS ON RECEIPT OF THE WILLIAM E LADD GOLD MEDAL BEFORE THE AMERICAN ACADEMY OF PEDIATRICS IN 1976, ALTHOUGH THAT ADDRESS WAS PUBLISHED IN THE HUMAN LIFE REVIEW, AS “THE SLIDE TO AUSCHWITZ,” THERE WAS SORT OF A DISBELIEVING DISCLAIMER IN THE SAME ISSUE WRITTEN BY JOSEPH SOBRAN, I FELT LIKE CASSANDRA SHOUTING FROM THE HOUSETOPS - WITH NO ONE LISTENING, a WHEN THE HUMAN LIFE REVIEW REPUBLISHED THE ESSAY TER YEARS LATER THERE WAS NO DISCLAIMER AND THEN IT IS PUBLISHED AS AN AFTERWORD IN RONALD REAGAN'S “ABORTION AND THE CONSCIENCE OF A NATION” IN 1984, YOU GOOD PEOPLE LET ME ADDRESS YOU ON THE SUBJECT UNDER THE TITLE OF “THE SILENT DOMINOE” AT YOUR ANNUAL MEETING IN -]3- CINCINATTI AND BOB DORNAN HAD IT READ INTO THE CONGRESSTONAL RECORD THE NEXT WEEK. I WISH NOW TO ADDRESS YOU ON AN ISSUE THAT SHOULD NOT CATCH YOU UNAWARE. AN ISSUE THAT YOU HAVE TIME TO PREPARE FOR AND AN ISSUE WHICH YOU SHOULD BE ABLE TO TACKLE BECAUSE OF YOUR EXPERIENCE WITH ABORTION AND BABY DOE, I REFER, OF COURSE. T0 EUTHANASIA, ] WOULD LIKE TO SPEAK TO: O THE CURRENT CLIMATE 0 THE DEMOGRAPHY OF THE NEXT 25 YEARS Q MISTAKES OF THE PAST FROM WHICH YOU CAN PROFIT IN THE FUTURE O A PLAN OF ACTION - j4 - FINALLY, I WILL POSE A SERIES OF QUESTIONS, THE ANSWERS TO WHICH MAY HAVE TO BE CONTRARY TO YOUR BELIEFS. YOUR SENSITIVITIES, AND PERHAPS EVEN YOUR SENSE OF RIGHT AND WRONG IF YOU ARE TO SALVAGE ANY THING FROM WHAT I BELIEVE IS ASSUMING THE PROPORTIONS OF A JUGGERNAUT. I WILL NOT PROPOSE ANSWERS MYSELF BUT RATHER TRY TO INDICATE BY THE QUESTIONS WHERE THIS OBSERVER THINKS THE LINES WILL BE DRAWN, AS TO THE CURRENT CLIMATE: Q EUTHANASIA FORCES ARE ABROAD IN THE LAND AS NEVER BEFORE. OQ EUPHEMISMS CONTINUE TO CONFUSE - AS ALWAYS, -|5- O THE “EUTHANASIA SOCIETY” HAS BECOME “CONCERNED FOR DYING.” O MODEL LIVING WILLS PUBLISHED BY CONCERN FOR DYING HAVE BECOME BROADER AND ADDRESS NUTRITION AND HYDRATION, O MORE NEWS REPORTS ON EUTHANASIA ARE APPEARING THAN ONE SEES ON ABORTION, O THE MEDIA DOES ITS BEST TO ESTABLISH TRENDS. REPORTING ITEMS OF SIGNIFICANT BUT LIMITED IMPORTANCE AS GLOBAL PRACTICE SOON TO BECOME POLICY, O ONE GOVERNOR SUGGESTED THAT THE OLD HAD “A DUTY 10 DIE.” -16- 0 THE FINANCIAL INTERESTS OF THE HEALTHY - WHO SEEM AT TIMES TO CONFUSE THEIR GOOD HEALTH WITH IMMORTALITY - ARE BOUND TO CONFLICT WITH THE FINANCIAL INTERESTS OF THE AGING AND THE INCURABLY ILL. O COOL DETACHMENT RATIONALIZES EUTHANASIA, O A HARRIS POLL SHOWED 85 PERCENT NOW (COMPARED TO 62 PERCENT IN 1973) IN FAVOR OF A TERMINALLY ILL PATIENT’S RIGHT TO INSTRUCT THE DOCTOR TO STOP TRYING TO EXTEND LIFE, AND 61 PERCENT NOW CAS AGAINST 3/7 PERCENT IN 1973) IN FAVOR OF THE PATIENT’S RIGHT 10 ASK THE DOCTOR FOR THE TERMINATION OF HIS LIFE. 0 THIS POINT OF VIEW IS IN VOGUE. THIS MONTH THE WALL STREET JOURNAL’S SENIOR NATIONAL CORRESPONDENT QUERIED THE COUNTRY: “CAN’T WE PUT MY MOTHER TO SLEEP?” -l7 - DOCTORS ARE DISTURBED ABOUT THESE TRENDS, MOST BELIEVE THAT THEIR DECISIONS REGARDING PATIENTS SHOULD NOT HAVE TO BE CONCERNED IN INDIVIDUAL CASES WITH ECONOMICS OF SOCIETY. THE CONSTANT REITERATION OF HEALTH COST CONTAINMENT IS A THREAT TO THE PATIENT AND THE PHYSICIAN IS CAUGHT BETWEEN THE ECONOMIC DEMANDS OF A HEALTHY SOCIETY AND THE NEEDS OF HIS PATIENT, THE PHYSICIAN REPRESENTS - IN A SENSE - HIS PATIENT‘S INTEREST OVER AGAINST THE HEALTHY SOCIETY WHICH MAKES THE LAWS AND SAYS THE COST OF MEDICAL CARE IS TOO HIGH, MANY PHYSICIANS FEEL THEY ARE THE ADVOCATES, THE DEFENDERS FOR THEIR PATIENTS, - AGAINST SOCIETY - JUST AS A LAWYER DEFENDS HIS ACCUSED CLIENT AGAINST SOCIETY. I SPOKE EARLIER ABOUT THE MEDICALIZATION OF SOCIAL PROBLEMS, THE MEDICAL PROFESSION IS CALLED UPON TODAY NOT ONLY - 18 - TO PROVIDE TRADITIONAL MEDICAL CARE BUT SOCIETY EXPECTS THE MEDICAL ESTABLISHMENT TO ADDRESS VIOLENCE IN FAMILIES, DIVORCE, DRUNK DRIVING, AND IN SOME CASES, POVERTY. THE FORCES WHICH BROUGHT ABORTION ON DEMAND TO BE THE LAW OF THIS LAND WERE SOCIAL FORCES, - YET THE MEDICAL PROFESSION RESPONDED TO THESE PRESSURES AND STILL DOES. IN SIMILAR FASHION, THE PRESSURES THAT BROUGHT INFANTICIDE TO WHERE IT WAS IN THE LATE 70’S AND EARLY 80’S WERE ALSO SOCIAL. YET MANY WHO CARED FOR NEWBORNS RESPONDED. THAT RESPONSE HAS DWINDLED AND THE FUTURE IS HOPEFUL, BUT UNCERTAIN. THE MANAGEMENT OF THE TERMINALLY OR INCURABLY ILL IS A MEDICAL PROBLEM WITH SOCIAL IMPLICATIONS. DOCTORS ARE MORE CONCERNED ABOUT THESE TRENDS THAN YOUR EXPERIENCE WITH THEM IN REFERENCE TO ABORTION OR INFANTICIDE MIGHT HAVE LED YOU TO BELIEVE. THE MANAGEMENT OF THE AGED IS - EXCEPT FOR THEIR INTERCURRENT ILLNESSES - NOT A MEDICAL PROBLEM - BUT IT IS RAPIDLY BECOMING MEDICALIZED. - 19 - I HAVE ADDRESSED THIS AUDIENCE BEFORE ON THE HAZARDS TO BE EXPECTED WHEN MAJOR CONCEPTS, TRENDS, OR PRACTICES MEET AT THE CROSSROADS, THE BEST EXAMPLE FOR YOU IS THE MEETING OF THE CORRUPTION OF MEDICINE WITH THE CORRUPTION OF LAW IN GERMANY OUT OF WHICH WAS BORN THE HOLACAUST, TWO OTHER FORCES ARE NOW AT THE CROSSROADS: THE DECLINE OF MEDICAL ETHICS AND THE PUSH FOR HEALTH COST CONTAINMENT. THE CRISIS IS HERE. HOW IT WORKS OUT REMAINS TO BE SEEN, ONE BRIGHT SPOT: MORE PHYSICIANS ARE CONCERNED - IN MY ESTIMATION - ABOUT THE RATIONING OF MEDICAL CARE THAN WERE CONCERNED ABOUT ABORTION OR INFANTICIDE, THESE MEN AND WOMEN WILL BE YOUR ALLIES. SEE TO IT THAT THEY ALSO BECOME YOUR FRIENDS. EVEN SO, REMEMBER WHEN BABY DOE HIT THE FRONT PAGES IN 1982 THE EDITORIAL RESPONSE WAS ONE OF HORROR. BUT THERE WAS A GRADUAL SHIFT FROM OUTRAGE TO TOLERANCE: FROM TOLERANCE 10 ESPOUSAL OF WITHHOLDING FOOD AND FLUIDS FROM HANDICAPPED NEWBORNS. - 20 - WHERE DID THE EDUCATIONAL PROCESS FAIL? HOW CAN YOU AVOID A SIMILAR SCENARIO WITH EUTHANASIA? IN REFERENCE TO THE CLIMATE } SPOKE ABOUT THERE IS GOOD AND BAD NEWS - ALL FOUND IN THE SAME NUMBER OF THE SAME JOURNAL, THE ARCHIVES OF INTERNAL MEDICINE. THE JANUARY 1985 ISSUE OF THAT JOURNAL CARRIED THREE ARTICLES UNDER THE RUBRIC “CLINICAL ETHICS.” THE THIRD OF THESE IS THE GOOD NEWS. BY MARK SEIGLER. M.D, OF THE UNIVERSITY OF CHICAGO AND ALLAN J. WEISBARD, J.D. OF THE CARDOZA SCHOOL OF LAW, YESHIVA UNIVERSITY. THE TITLE OF THEIR PAPER SAYS IT ALL: “AGAINST THE EMERGING STREAM.” IT IS, I THINK, THE FIRST INDICATION WITHIN THE FRATERNITY OF ORGANIZED MEDICINE THAT SENSES SOMETHING HAS GONE AWRY IN MEDICAL ETHICS, THEY APPARENTLY WERE WRITING TO OFFSET THE BAD NEWS IN THE SAME ISSUE OF THE JOURNAL IN TWO OTHER PAPERS THAT REVIEWED CURRENT LEGAL AND CLINICAL THINKING ON THE WITHDRAWING OF FLUIDS AND NUTRITIONAL SUPPORT FROM TERMINALLY ILL OR PERMANENTLY UNCONSCIOUS PATIENTS, -2] - ALL OF THESE PAPERS WERE WRITTEN BEFORE THE NEW JERSEY SUPREME COURT OVERTURNED THE APPEALS COURT DECISION IN THE MATTER OF CLAIRE CONROY. THE OTHER TWO PAPERS CITED WERE MILD COMPARED TO ANOTHER THAT WAS REFERENCED IN THE THOUGHTFUL PAPER BY SEIGLER AND WEISBARD, THIS WAS A PAPER PUBLISHED BY WANZER, ADELSTEIN, AND CRANFORD IN THE NEW ENGLAND JOURNAL OF MEDICINE LAST YEAR. AS QUOTED BY SEIGLER AND WEISBARD THIS PAPER ADVOCATED: “THE WITHHOLDING OF PARENTERAL FLUIDS AND NUTRITIONAL SUPPORT FROM SEVERELY AND IRREVERSIBLY DEMENTED PATIENTS AND PERHAPS AT TIMES FROM ELDERLY PATIENTS WITH PERMANENT MILD IMPAIRMENT OF COMPETENCE” (A GROUP THE AUTHORS REFER TO AS THE “PLEASANTLY SENILE”). SO MUCH FOR THE CLIMATE. NOW FOR DEMOGRAPHY. IN 1985 THERE ARE 28.7 MILLION CITIZENS OVER THE AGE OF 65 AND 12 MILLION OVER 75. THOSE FIGURES IN THE YEAR 2000 JUMP TO 35 MILLION AND 17 MILLION, AND IN 2050 10 6/7 -22 - MILLION AND 37 MILLION, NO NATION HAS EVER BEEN CALLED UPON T0 DEAL WITH THIS MANY ELDERLY PEOPLE EITHER IN ABSOLUTE NUMBERS OR IN PROPORTION TO THE YOUNGER PEOPLE IN THE POPULATION, THE FIGURES I HAVE GIVEN YOU WOULD BE BAD ENOUGH BUT THAT’S ONLY PART OF THE STORY. IN THE EARLY YEARS OF THE NEXT CENTURY THAT LARGE GROUP OF PEOPLE WE REFERRED TO AFTER WORLD WAR II AS THE BABY BOOM WILL BE HAVING THEIR GRANDCHILDREN, SO IN ADDITION TO THE LARGE NUMBER OF THE ELDERLY THERE WILL BE A LARGE NUMBER OF CHILDREN. NOT BECAUSE OF THE HIGH FERTILITY OF THEIR PARENTS, BUT BECAUSE OF SHEER NUMBERS REPRODUCING. IT WOULD BE BAD ENOUGH IF WE HAD NOT GONE TO SMALLER FAMILIES AND IF WE HAD NOT LOST AN ENORMOUS NUMBER OF PEOPLE WHO DIED THROUGH ABORTION WHO WOULD BE WAGE EARNERS AND TAX PAYERS IN THE EARLY NEXT CENTURY. - 23 - ONE WAY TO LOOK AT THE FUTURE IS TO COMPARE RATIOS NOW AND THEN BETWEEN RETIRED WORKERS, DISABLED WORKERS, SPOUSES. CHILDREN, AND SURVIVOR BENEFICIARIES ON THE ONE HAND AND WORKERS ON THE OTHER. THIS RATIO DECLINED FROM 5.1 IN 1960 TO 3.3 IN 1984, IT IS EXPECTED TO REACH 2.0 BY THE MIDDLE OF THE NEXT CENTURY AS THE NUMBER OF BENEFICIARIES INCREASES MORE RAPIDLY THAN THE NUMBER OF COVERED WORKERS. THE NUMBERS OF THE ELDERLY ARE MIND BOGGLING. LET’S JUST LOOK AHEAD TO THE YEAR 2000 WHEN THERE WILL BE MORE THAN 53 MILLION PEOPLE OVER THE AGE OF 65. THERE IS NO WAY OF TELLING HOW MANY OF THESE WILL HAVE AN ABRUPT TERMINATION OF LIFE DUE 10 STROKE OR HEART DISEASE. HOW MANY WILL HAVE A LINGERING TERMINAL ILLNESS, OR HOW MANY WILL HAVE A PROTRACTED CHRONIC ILLNESS FOR EVEN YEARS BEFORE DEATH COMES, BUT THE ONE INEVITABLE THING IS THAT DEATH WILL COME TO EACH OF THOSE 53 MILLION AND EACH OF THOSE LIVES IS A POTENTIAL CHALLENGE TO THOSE WHO ARE OPPOSED 10 EUTHANASIA BY ANY EUPHEMISM. - 24 - COMPARE THE NUMBERS TO THE ISSUES WE HAVE DEALT WITH IN THE PAST, BETWEEN 17 AND 20 MILLION ABORTIONS IS A STAGGERING FIGURE BUT IT CANNOT COMPARE TO THE POTENTIAL NUMBER OF SO CALLED ETHICAL DECISIONS AROUND THE TERMINAL ILLNESS OF THE AGED. ONE OF THE MOST ELUSIVE FIGURES IN HISTORY IS THE NUMBER OF BABY DOES THAT WERE DENIED LIFE BY SOMEONE ELSE'S CHOICE. THE NUMBERS HAVE RANGED FROM 1500 TO 5000 A YEAR, I SUSPECT THE LOWER FIGURE IS CLOSER TO ACTUALITY, BUT FOR EVERY BABY DOE THERE COULD BE 15 TO 20,000 GRANNY DOES. I PUT IT IN FEMALE TERMS BECAUSE OF THE LONGER LIFE EXPECTANCY OF THAT SEX, 1 SAID A FEW MOMENTS AGO I WOULD TALK TO YOU ABOUT MISTAKES OF THE PAST, PLEASE DON’T TAKE THIS TO MEAN THAT I AM SITTING IN JUDGMENT ON WHAT HAS BEEN ACCOMPLISHED BY THIS COMMITTEE OR BY THE PRO LIFE WORLD IN GENERAL. HOWEVER, AS A FAIRLY ASTUTE OBSERVER OF THE PASSING SCENE IN THIS PARTICULAR FIELD, THERE ARE SOME THINGS THAT YOU MUST RECOGNIZE AS WELL AS I. CALL THEM WHATEVER YOU LIKE BUT HERE THEY ARE: - 25 - QO LACK OF UNIFIED EFFORT BY THE PRO LIFE MOVEMENT. QO LACK OF AN AGENDA OR A STRATEGIC POLICY. 0 LACK OF CONSENSUS AS TO THE MANNER IN WHICH WHAT AGENDA YOU DID HAVE WAS ADDRESSED. AT TIMES IN THE PAST SEVERAL YEARS IT HAS SEEMED THAT SOME SEGMENTS OF THE PRO LIFE MOVEMENT SPENT MORE TIME ON THE TREES THAN ON THE FOREST. ARGUMENTS OVER THE WORDING OF A SENTENCE TOOK MORE TIME THAN THE MINIMAL SUBSTANTIVE BENEFIT TO BE DERIVED. AND FINALLY, PERHAPS THE HARDEST THING TO TALK ABOUT IS THE ALL OR NOTHING PRINCIPLE. I SAID THAT THE EXPERIENCE WITH THE BABY DOE REGULATIONS COULD PROVIDE A MORAL. IF IN THE BLACK AND WHITE WORLD OF ABORTION AS WE SEE IT THERE ARE THOSE WHO WANT ALL OR NOTHING I CAN UNDERSTAND THAT FULL WELL BUT 1 MUST ACKNOWLEDGE THAT IT GRIEVES ME TO THINK OF THE MILLIONS OF UNBORN - 26 - LIVES THAT MIGHT HAVE BEEN SAVED HAD A TOTAL 100 PERCENT VICTORY NOT BEEN THE GOAL. Ste WHEN YOU SAY YOUR EFFORTS TURNED BACK YEAR AFTER YEAR WITH THE BABY DOE REGULATIONS, I CAN SEE THE PUREST POINT OF VIEW THAT THE NUMBERS ARE SO SMALL THAT WE SHOULD NOT GIVE AN INCH IN COMPROMISE. BUT WHEN IT COMES TO THE SHEER NUMBERS OF THE ELDERLY AS | HAVE OUTLINED THEM, MANY OF THE ISSUES ARE NOT AS BLACK AND WHITE AS THEY ARE WITH ABORTION, AND THE ECONOMICS WILL NOT ONLY BE AS I OUTLINED THEM IN MY DISCUSSION OF THE CURRENT CLIMATE BUT MUCH MORE, - I THINK THAT THE ALL OR NOTHING PRINCIPLE 1S OUT OF THE QUESTION, THINK OF WHAT I HAVE BEEN SAYING FROM THE POINT OF VIEW OF THE TODDLER OF TODAY WHO IN THE EARLY YEARS OF THE NEXT CENTURY WILL BE A WAGE EARNER, A TAX PAYER, A SPOUSE AND A PARENT. WHETHER HE IS AN ORDINARY CITIZEN OR A MOVER AND SHAKER OF SOCIETY HE HAS TO FACE THE PROVISION OF HEALTH AND HUMAN SERVICES - 27 - TO THE AGED POPULATION THAT I OUTLINED BUT HE ALSO HAS 10 RECOGNIZE THAT THAT WILL BE THE ERA OF THE BIRTH OF THE GRANDCHILDREN OF WHAT WE CALL THE BABY BOOM OF WORLD WAR II. IN OTHER WORDS WHETHER HE LOOKS FORWARD TO OLD AGE OR BACKWARD TOWARD INFANCY, THE NUMBERS - THE SHEER NUMBERS - OF THOSE REQUIRING SERVICES ARE STAGGERING, AS FAR AS PLANNING FOR THE FUTURE IS CONCERNED I THINK IT IS PERFECTLY FAIR TO SAY THAT WE HAVE TO MOVE FROM A POSTURE OF CRISIS MANAGEMENT TO A GRAND PLAN, AS REALISTIC AS I CAN BE ABOUT THE DIFFICULTY OF BRINGING ABOUT A COALITION AMONG PRO LIFE GROUPS WITH ESSENTIALLY THE SAME GOAL, I HAVE TO ACKNOWLEDGE THAT WITHOUT THE FORMATION OF SUCH A COALITION I DON’T THINK WE WILL EVER MAKE IT. AS MUCH AS I ADMIRE THE TREMENDOUS ZEAL. PRODUCTIVITY. AND SELF SACRIFICE OF MEN LIKE JOE STANTON AND JERRY SHEN - GOD BLESS THEM - WILL THEY BE THE ONES TO STEP INTO THE NEXT CLAIRE CONROY CASE OR THE NEXT BROPHY CASE OR WILL THERE BE A STABLE OF EXPERT - 28 - WITNESSES THAT CAN BE DRAWN UPON TO REPRESENT YOUR SIDE OF THE ARGUMENT. ALTHOUGH ABORTION ON DEMAND BECAME LEGAL IN 1973, IT WAS NOT UNTIL 1984 THAT THE NUMBER OF CRISIS PREGNANCY CENTERS EQUALLED THE NUMBER OF ABORTION CLINICS, WE DO NOT HAVE THE LUXURY OF THOSE YEARS AS WE FACE THE PROBLEMS OF EUTHANASIA, WE NOT ONLY NEED A COALITION, AN AGENDA, A STRATEGIC POLICY, AND A PLAN, BUT WE MUST MARSHAL OUR FORCES 10 PROVIDE SOPHISTICATED, INNOVATIVE APPROACHES TO THE FUTURE. IN THE PRO LIFE MOVEMENT I THINK INDIVIDUALS ARE LOOKED UPON EITHER AS ALLIES OR ENEMIES. THERE IS AT LEAST ONE OTHER CLASS OF INDIVIDUAL WITH WHOM YOU CAN WORK AND THAT IS A CO- BELLIGERANT, 1 MENTIONED EARLIER ABOUT THE SINCERE CONCERN THAT MOST PHYSICIANS FEEL ABOUT THE CHANGE IN THE PRACTICE OF MEDICINE WHICH DEPRIVES THEM OF THEIR FREEDOM TO PRACTICE WHAT THEY - 29 - CONSIDER TO BE ETHICAL MEDICINE. YOU SHOULD BE MONITORING THEIR MEETINGS, LEARNING OF THEIR CONCERNS, TALKING WITH THEM ABOUT YOURS, AND ALTHOUGH YOU MIGHT NOT AGREE SO COMPLETELY WITH VARIOUS SEGMENTS OF THE MEDICAL PROFESSION THAT YOU WOULD CALL THOSE SEGMENTS ALLIES, YOU WILL FIND CO-BELLIGERANTS ON SPECIFIC ISSUES THAT WILL FIGHT WITH YOU TO ACHIEVE THE ENDS THAT YOU BOTH SEEK. I MENTIONED BEING INNOVATIVE A SHORT WHILE AGO. 1 THINK THAT MEANS SUCH AN OUTLANDISH SUGGESTION AS BEGINNING A DIALOGUE WITH GROUPS WHO SHARE AT LEAST SOME OF THE CONCERNS THAT YOU SHARE, THE GROUPS THAT COME FIRST TO MIND ARE ORGANIZATIONS CATERING TO THE NEEDS OF THE RETIRED SUCH AS THE AMERICAN ASSOCIATION OF RETIRED CITIZENS. THEN I THINK OF THE VARIOUS GERIATRIC SOCIETIES BASED IN MEDICINE AND HEALTH, THERE ARE VARIOUS SOCIETIES OF INTERWAL MEDICINE AND FINALLY THE AMA WHICH DOES SPEAK FOR ABOUT 50 PERCENT OF THE PHYSICIANS IN AMERICA AND IS THE LARGEST ORGANIZED GROUP WITHIN THE ESTABLISHMENT OF MEDICINE. -30- OTHER GROUPS ARE ALREADY AT WORK SUCH AS THE SOCIETY OF LAW AND MEDICINE MAKING ITSELF AVAILABLE AS A RESOURCE, SUGGESTING WAYS AND MEANS OF ESTABLISHING ETHICAL COMMITTEES FOR HOSPITALS AND NURSING HOMES, AND MOVING TOWARD THE POINT WHERE THEIR POSITION, WHATEVER IT MIGHT BE, IS CONSIDERED THE ETHICAL POSITION. YOU HAVE NOT ONLY AN OBLIGATION, BUT A RIGHT TO DO THE SAME. I SEE THE YEARS AHEAD IN REFERENCE TO EUTHANASIA PERHAPS IN MILITARY TERMS, THERE IS UNDOUBTEDLY GOING TO BE A WAR AND ONE SIDE IS GOING TO WIN. EVERY BATTLE IN THAT WAR WILL HAVE A VICTOR BUT A GOOD MILITARY STRATEGIST MIGHT VARY HIS TACTICS ALL THE WAY FROM AGRESSIVE ADVANCE TO TEMPORARY WITHDRAWAL OR IN SOME CASES EVEN RETREAT IN AN EFFORT TO WIN THE WAR FINALLY, WHEN I WAS IN MEDICAL SCHOOL PEOPLE HARDLY KNEW WHAT A MEDICAL ETHICIST WAS. NOW MEDICAL SCHOOLS HAVE STAFFS OF MEDICAL ETHICISTS AS DO HOSPITALS AND OTHER MEDICAL AND HEALTH GROUPS. I DON’T KNOW WHAT IT TAKES TO BE AN ETHICIST AND J SEE - 3] - PEOPLE WHO GIVE THEMSELVES THAT TITLE WHO HOLD TOTALLY OPPOSING POINTS OF VIEW. I THINK WE HAVE TOO MANY ETHICISTS AND NOT ENOUGH PEOPLE WHO KNOW THE DIFFERENCE BETWEEN RIGHT AND WRONG. IN AS MUCH AS YOU ARE GOING TO PLAY THE GAME, WHY NOT DEVELOP A GROUP OF ETHICISTS TO REPRESENT YOU, AND YOU COULD ACTUALLY DO IT WITH PEOPLE WHO HAVE IMPECCABLE CREDENTIALS. I KNOW MANY OF YOU HAVE LOOKED FORWARD TO THE PROBLEMS I NOW SPEAK OF. YOU REALIZE AS WELL AS I DO THAT SINCE WE HAVE HAD GOVERNMENT ENTITLEMENTS NOT ONLY HAVE FAMILIES ABROGATED SOME OF THEIR RESPONSIBILITIES BUT SO HAVE CHURCHES, CIVIC GROUPS AND THE COMMUNITY. JUST AS WE DIDN’T BEGIN TO MAKE ANY INROADS AGAINST ABORTION CLINICS UNTIL WE HAD CRISES PREGNANCY CENTERS, SO IT IS WITH EUTHANASIA AND ALTERNATIVES. YOU HAVE TO AROUSE THE FAMILIAL OBLIGATION TOWARD THE ELDERLY IN FAMILIES, IF THE ELDERLY ARE NOT GOING 10 BE ABANDONED WE WILL HAVE TO LOOK TO EXTENDED FAMILIES IN MANY INSTANCES. AND FINALLY, CHURCHES, CIVIC GROUPS, AND COMMUNITY - 32 - EFFORT CAN ALL WORK INDIVIDUALLY OR TOGETHER TO PROVIDE RESOURCES FOR THE ELDERLY THAT WILL LIFT THEM OUT OF THOSE AREAS WHERE DECISIONS ARE LIKELY TO BE MADE AGAINST THEN, WE HAVE TO FIND THE PEOPLE...WE HAVE TO FIND THE RESOURCES...AND WE HAVE TO FIND WAYS TO FIGHT DISEASE. DISABILITY, AND DISTRESS, AND WE HAVE TO KEEP ON FIGHTING UNTIL WE WIN, HERE ARE SOME OF THE QUESTIONS I THINK YOU WILL HAVE TO ANSWER IN DAYS AHEAD, I THINK MOST OF YOU AND I WOULD ANSWER THEM IN THE SAME WAY AT THIS PARTICULAR JUNCTURE. I AM NOT CERTAIN THAT WITH THE PASSAGE OF TIME, THE REALIZATION OF THE ENORMITY OF THE PROBLEM, AND THE FINAL UNDERSTANDING OF WHAT IT TAKES TO WIN THE WAR, YOU MIGHT EVEN HAVE TO REVERSE AN OPINION HERE AND THERE. IN MANY OF THE ETHICAL STATEMENTS OR DEBATES OF RECENT YEARS ONE ISSUE SEEMS TO FIND CONSENSUS AND THAT IS THAT THERE IS A DIFFERENCE BETWEEN GIVING A PATIENT ALL THE LIFE TO WHICH HE OR - 33 - SHE IS ENTITLED AS COMPARED TO MERELY PROLONGING THE ACT OF DYING. IT SOUNDS SIMPLE AT FIRST AND IT IS FOR MOST PHYSICIANS WHO FIND AN ETHICAL ACCOMMODATION IN THE MANAGEMENT OF THEIR PATIENTS OF WHICH YOU AND I WOULD APPROVE. BUT FOR SOME, THE MATTER BECOMES QUITE SUBJECTIVE AND ALL SORTS OF VARIATIONS ON THE THEME ARE INTRODUCED AROUND BUZZ WORDS SUCH AS “FUTILE.” “INHUMANE,” AND OUR OLD FRIEND “DEATH WITH DIGNITY” AS WELL AS THE INTERPRETATION OF THE WORD “IMMINENT” WHEN APPLIED TO DEATH. THE QUESTIONS WITHOUT ANSWERS THAT I AM ABOUT 10 POSE, BECAUSE OF THE TOPICS MENTIONED, AS WELL AS THE WORDING THEREOF IN SOME INSTANCES, ARE ALREADY UNDER DEBATE ON THE ETHICS OF ACTUAL SITUATIONS WHILE OTHERS ARE FREQUENTLY MENTIONED AS INEVITABLE DILEMMAS DOWN THE ROAD. HERE ARE SOME QUESTIONS: O IS THERE A DIFFERENCE BETWEEN NOT STARTNG A- MEDICATION, A TREATMENT REGIMEN, A LIFE SUPPORT SYSTEM ETC. AND STOPPING IT? - 34 - IS LIFE LESS PRECIOUS BECAUSE IT ALMOST OVER INSTEAD OF JUST BEGINNING? DOES A PATIENT HAVE THE RIGHT TO REFUSE TREATMENT OF ANY KIND? HOW CAN YOU SEPARATE THE INTERESTS OF THE TERMINAL OR CHRONICALLY ILL PATIENT FROM THE INTERESTS OF THE FAMILY SOON TO BE HEIRS? DOES A PARENT HAVE THE RIGHT TO REFUSE TREATMENT FOR A MINOR CHILD? 1S THERE A DIFFERENCE BETWEEN LIFE SAVING SURGERY IN A NEWBORN, REHABILIATION SURGERY FOR DEFORMITY. AND CHEMOTHERAPY FOR CANCER? - 35 - DO RELIGIOUS BELIEFS ALTER THE ANSWERS TO THE PREVIOUS TWO QUESTIONS? DO WE ALL MEAN THE SAME THING WHEN WE SPEAK OF BRAIN DEATH? IS NUTRITION AND/OR HYDRATION A TREATMENT? IN THE TERMINAL PATIENT, CAN IT BE ETHICAL TO WITHHOLD TREATMENT, SAY FOR AN INTERCURRENT INFECTION - WHEN THE SUCCESSFUL TREATMENT OF THAT INFECTION WILL PROLONG THE LIFE THE OF THE PATIENT WITHOUT SIGNIFICANTLY ALTERING THE OUTCOME OF THE DISEASE PROCESS LEADING TO DEATH? REGARDLESS OF YOUR ANSWER TO THAT QUESTION. CAN THAT ANSWER BE APPLIED TO AN AGED PATIENT. NOT TERMINAL. WHO IS SENILE, OR DEMENTED. OR WITH A POOR QUALITY OF - 36 - LIFE FOR ANY NUMBER OF REASONS, OR CANTANKEROUS, OR A NUISANCE, OR AN EXCESSIVE USER OF NURSING TIME, OR ABANDONED BY KNOWN FAMILY, OR WITHOUT FAMILY, - OR ANY COMBINATION OF THE ABOVE OR ALL OF THE ABOVE? SHOULD ANY OF THE PREVIOUS QUESTIONS BE ANSWERED DIFFERENTLY FOR THE RICH, THE WELL OFF. THOSE THAT JUST ABOUT MAKE IT, OR THE TRULY POOR? SHOULD THERE BE A LIMIT TO THE PERCENTAGE OF THE GROSS NATIONAL PRODUCT THAT IS A CEILING FOR HEALTH EXPENDITURES FROM ALL SOURCES? SAME QUESTION FOR THE GOVERNMENT SHARE? SHOULD MEDICAL AND HEALTH DECISIONS BY PHYSICIANS IN GENERAL BE FREE OF ECONOMICAL RESTRAINT? - 37 - IF RESTRAINT IS DEEMED NECESSARY WHO MAKES THE DECISION GENERICALLY. INDIVIDUALLY. AND HOW? COULD A TREATMENT REGIMEN BE ETHICALLY TERMINATED AFTER "X” PERIOD OF TIME OR AFTER THE EXPENDITURE OF “y" DOLLARS - IF THE RESULT WERE SIGNIFICANTLY LESS THAN THE ANTICIPATED AND DECLARED EXPECTATION? IF WE ARE TO ALLOCATE LIMITED RESOURCES IN TREATMENT OF THE ELDERLY, SHOULD THEY COMPETE ONLY WITH THEMSELVES, OR WITH OTHER GROUPS SUCH AS CHILDREN? SHOULD SOCIETY WEIGH THE BENEFIT VERSUS COST OF TREATING TERMINAL ILLNESS, IMPLANTING AN ARTIFICIAL HEART, OR IMMUNIZING CHILDREN? IF THE ELDERLY MUST COMPETE FOR FUNDS, DO THEY DO IT IN HEALTH WITH A CAP OR IS COMPETITION LEGITIMATE - 38 - WITH AGRICULTURE. TRANSPORTATION, DEFENSE, OR SPACE FOR DOLLARS? IS THE DECISION PROCESS IN LIFE OR DEATH MATTERS ENHANCED BY THE USE OF A PATIENT CARE REVIEW COMMITTEE OR BY A BIOETHICAL COMMITTEE? WHO SHOULD PARTICIPATE? ARE SUCH COMMITTEES MERELY ADVISORY OR MORE? 1S SUICIDE EVER AN OPTION FOR A TERMINAL PATIENT? IF IT IS, ARE THERE LEGITIMATE REASONS? RELIEF OF PAIN, DESPAIR. MONEY? COULD PATIENTS WITH SUICIDAL INTENT EVER BE ASSISTED? COULD THIS BE CARE WHILE REFUSING NUTRITION AND FLUIDS, OR MEDICATION? COULD SUCH ASSISTANCE EVER BE ACTIVE? - 39 - 0 IF ONE CLASS OF CITIZEN, THE AGED FOR EXAMPLE, IS UNWILLINGLY AND PERHAPS UNWITTINGLY SUBJECT 10 FINANCIAL CONSTRAINT IN HEALTH CARE, HOW SHOULD SOCIETY, GOVERNMENT, AND THE MEDIA REACT TO THE PUBLIC HEALTH PROBLEM OF 340,000 PEOPLE WHO DIE PREMATURELY EACH YEAR BECAUSE THEY WILLINGLY AND WITTINGLY SMOKE AND COST THE COUNTRY $40 BILLION? OBVIOUSLY YOU OR I COULD POSE AN ADDITIONAL FIFTY QUESTIONS AND WE PROBABLY WOULD NOT DUPLICATE EACH OTHERS. RECENTLY I WAS IN A WESTERN CITY LOOKING UP AT THE AUDIENCE IN THE BALCONY WHEN MY PICTURE WAS TAKEN IN PROFILE. IT WAS PUBLISHED THE FOLLOWING DAY IN THE NEWSPAPER WITH THE CAPTION: "QOKS LIKE LINCOLN, SOUNDS LIKE MOSES.” 1 DO HAVE A BEARD BUT | HAVE NEVER CLAIMED TO BE A PROPHET. NEVERTHELESS, THE SO CALLED PROPHECIES I HAVE MADE IN REFERENCE TO MANY OF THE LIFE ISSUES - 40 - HAVE RATHER REMARKABLY COME TO PASS. NOTHING WOULD PLEASE ME MORE THAN TO BE TOTALLY WRONG IN MY PROPHECY IN THE KINDS OF QUESTIONS I HAVE POSED AND THAT YOU WILL HAVE TO ANSWER IN DAYS AHEAD, I WOULD REMIND YOU THAT WHEN A DECISION IS MADE THAT SEEMS TO BE ETHICAL AND MORAL IT DOES NOT FOLLOW NECESSARILY THAT SUBSEQUENT DECISIONS WILL ALSO BE ETHICAL AND MORAL. WHEN A DECISION IS MADE WITH ETHICAL AND MORAL IMPLICATIONS ONE HAS TO ASK VERY CAREFULLY WHAT IS THE STEP LIKELY TO BE. THERE ARE MANY WHO RECOGNIZE THE SLIPPERY SLOPE OF EUTHANASIA BUT WHO CLAIM THAT THE SLOPE CAN BE DESCENDED IF ONE MOVES CAREFULLY. 1 SEE MANY WHO HAVE LOST THEIR FOOTING ON THIS SLOPE AND SOME OF THESE ARE THE MOST OFTEN QUOTED ETHICISTS OF THE DAY. THEY STILL SHOUT BACK TO US FROM THE VALLEY AND TELL US THAT THE SLOPE IS NOT THAT SLIPPERY. BECAUSE OF THE MANY THINGS I HAVE SAID THIS EVENING, I TRULY BELIEVE IT WILL NOT BE POSSIBLE ALWAYS TO STAND ON THE BRINK OF - 4] - THIS SLOPE, SOME DESCENT WILL BE NECESSARY AND IT IS UP TO YOU TO CARVE THE FOOTHOLDS, MAKE DECISIONS, AND IN THE INEVITABLE CLASH OF SHEER NUMBERS, ECONOMICS, AND IN OPPOSING ETHICAL VIEWPOINTS, TAKE NO STEP WITHOUT CONSIDERING WHERE THE NEXT STEP IS LIKELY TO LEAD. EACH ONE OF US IS CAPABLE NOT ONLY OF EXPERIENCING - BUT ALSO RISING ABOVE - THE CONDITIONS OF DAILY LIFE AS THEY ARE EXPLAINED TO US BY GERIATRICIANS AND LAWYERS AND CERTIFIED PUBLIC ACCOUNTANTS, THE WORLD CAN BE BETTER FOR US AND FOR EVERY OLD PERSON THAT LIVES IN IT, WE HAVE TO REJECT THE DISPOSABLE MENTALITY OF OUR HEALTHY POPULATION TOWARD THE AGED AND CHOOSE THE LIFE GIVING OPTION, I FERVERENTLY HOPE THAT WE DO, OUR LIVES - MINE AS A HEALTH PROFESSIONAL, AND MOST OF YOU AS CONCERNED CITIZENS AND VOLUNTEERS - AS WELL AS THE LIVES OF THE ELDERLY AND THE DISABLED ARE REMARKABLY SHAPED BY THE CARE WE GIVE THOSE THAT ARE HANDICAPPED BY AGE, ILLNESS. OR DISABILITY. - 42 - I] THINK MY 44 YEARS OF HANDS ON EXPERIENCE IN MEDICINE HAS CONVINCED ME THAT ALL ASPECTS OF MEDICAL ETHICS ARE DWARFED BY THIS QUESTION: “HOW OUGHT WE TO CARE FOR THOSE WHO CANNOT IN ONE WAY OR IN EVERY WAY CARE FOR THEMSELVES?” WHEN WE SETTLE THAT QUESTION THEN WE CAN TURN TO THE OTHERS, FINANCES, RESOURCES, COMMITTEES AND SO ON, NO ONE SAID IT WOULD BE EASY. I’M NOT EVEN SAYING IT CAN BE OBJECTIVE. WHAT I AM SAYING IS THAT THE QUALITY OF LIFE WE TALK SO MUCH ABOUT IS NO WHERE AS IMPORTANT AS IN THE REFLECTION THESE DECISIONS MAKE IN THE QUALITY OF OUR OWN LIVES.