Lecture Vol. 12 # 14A  September 30, 1987 cover
Private Thoughts on Public Issues by C. Everett Koop, MD, ScD
Surgeon General
U.S. Public Health Service
U.S. Department of Health and Human Services
Presented to the Royal Children's Hospital
Glasgow, Scotland
September 30, 1987
Although we speak the same language, there are many cultural differences between the behavior of folks in the United States and folks in the United Kingdom. Within the field of medicine there are gross differences in ethics. For example, the recommendation of the Presidential Commission on Biomedical Ethics concluded that regardless of any deformity or congenital anomaly, every child was entitled to the same degree of expert care aimed at correction of the child defect and survival. In the United Kingdom, it is the excepted practice to starve to death the children who are born with spina bifida; if the family objects to this and takes the patient out from care against advice, they are no longer eligible for care under the National Health Service.
To address a Scottish audience on private thoughts and public issues might at first glance seem to be a very difficult assignment. It was. But, because of the twelve years I had spent on the Council of the British Association of Pediatric Surgeons and the number of friends that I had in medical circles in the UK and because I was an honorary member of the Royal College of Surgeons of London, as well as a fellow of the Royal College of Physicians and Surgeons of Glasgow, and a recipient of an honorary MD from the University of Liverpool, I felt the pros outweighed the cons and willingly plunged into the subject.
It was made clear that I wanted to talk about medicine and public service and personal codes of conduct and how all three might coincide. I said I would do this by recounting several brief stories that centered around children, each which touched a chord in my own soul as a doctor and each one helped to shape the kind of Surgeon General I had become.
I then talked a little bit about the appointment by President Reagan in 1981 and how much I loved every minute of my job, inasmuch as the frustrations far outweighed the satisfactions of achievement. I staked out my position as a person who held views, which other people found to be controversial, that I was an advocate for people who were physically and mentally disabled.
Rhetorical questions were asked about what happened when a person with strong controversial and publicly advertised ideas entered government? I answered those questions to my satisfaction and I hope to that of the audience as well. I then used case histories of Katie Beckett, a respirator-dependent child and how our involvement with her first established waivers to permit ventilator care at home and later a change in the law so that waivers were no longer necessary.
Next, I went into President Reagan's involvement with children who needed liver transplants and got into the history of the Surgeon General and the Public Health Service with the whole process of organ transplantation in America, including the establishment of the American Council on Transplantation. Unlike the happy ending of the Katie Beckett Story, this one has no clear foreseeable happy conclusion.
Then, I got into the "Baby Doe" situation, which certainly was familiar to my pediatric surgical friends in the audience. I looked at this from the medical side of the issue and then the ethical side, I waxed philosophical about the fact that developments of the past twenty years have so greatly expanded the range of curative medicine that this was an instance of simply not being able to abide confronting a case that cannot be cured. Nevertheless, there are things for which we have no cures and the "Baby Does" of this world need something else that is just as valuable as magical medical cure. They need a lot of genuine care. I felt that was an important message. It was a demanding message. We have to work through these questions and answers that are spun out of the depths of our conscious, not out of medical text. I finished up my examples with children under the age of 13 who had AIDS and newborns who came into the world HIV positive. About discrimination, I gave examples that might not have been familiar to a Scottish audience. I closed on a pessimistic note about children with HIV positivity. (This is something that changed with history, but only for affluent patients.)
In spite of the difference of conclusion on these subjects, to the best of my ability to judge, my talk was received well and my cordial relationships with my Scottish colleagues have continued to this day.