ORIGINAL

ETHICAL JMPERATIVES AND THE NEW PHYSICIAN:

YSICIAN= TENT RELATIONSHIP

COMMENCEMENT ADDRESS 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 SESQUICENTENNIAL COMMENCEMENT EXERCISES OF
ALBANY MEDICAL COLLEGE
SARATOGA SPRINGS, NEW YorK
May 26, 1988
1
(GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.)

I WANT TO THANK THE MEMBERS OF THE COMMENCEMENT COMMITTEE
FOR EXTENDING TO ME THE HONOR OF BEING YOUR SPEAKER THIS
AFTERNOON,

THIS IS A VERY SPECIAL OCCASION FOR MANY GOOD REASONS,
IT’S THE 150TH ANNIVERSARY OF YOUR SCHOOL, FOR ONE THING.
2
IN A SOCIETY THAT HAS RAISED THE ANNUAL STYLE-CHANGE TO AN

ART FORM -- A SOCIETY THAT DUMPS IN ONE WEEK IN SOLID WASTE THE
EQUIVALENT TONNAGE OF WHAT MOST OTHER COUNTRIES TAKE ALL YEAR TO
PRODUCE -- IN SUCH A SOCIETY WE MUST BE IMPRESSED BY ANYTHING
THAT STILL WORKS .., AND WORKS VERY WELL ... AFTER 150 YEARS.

THIS IS ALSO A SPECIAL OCCASION NOT ONLY FOR YOU GRADUATES,
BUT ALSO FOR YOUR FAMILIES AND FRIENDS. THEY INVESTED A GREAT
DEAL OF HOPE IN YOU AND, I WOULD GUESS, MUCH PRAYER AND SOME
FINANCIAL SACRIFICE AS WELL, AS YOU TRAVELED THE ROAD THAT LED
YOU HERE TODAY.
3
SO THIS IS A SPECIAL DAY ... AND A MAGICAL DAY. RIGHT AT

THIS MOMENT, IT STILL FEELS LIKE THE LAST DAY OF YOUR MEDICAL
SCHOOL EXPERIENCE,

BUT BEFORE MANY MORE TICKS OF THE CLOCK, THIS DAY WILL ONCE
AGAIN BE AN OPENING DAY ... THE ELRST DAY OF THE NEXT STAGE IN
YOUR VOCATION OF MEDICINE,

AND I USE THE TERM “VOCATION” ADVISEDLY, BECAUSE OF ITS ROOT
TERM OF “CALLING.”
4
THE PRACTICE OF MEDICINE IS AN ACTIVITY WITH A FIRM MORAL

BASE, AND IN THAT SENSE IT IS A “CALLING.” IT IS CONCERNED WITH
THE HERE AND NOW ... YET IT ALSO PRESENTS YOU WITH THE
OPPORTUNITY AS WELL AS THE NEED TO CONNECT UP WITH EVENTS ... AND
IDEAS .., AND ISSUES THAT TRANSCEND ONE'S DAY-TO-DAY MEDICAL
PRACTICE.

THEREFORE, I WANT TO SPEND MY FEW MOMENTS WITH YOU TODAY
LOOKING AT ONE OF THOSE TRANSCENDENT ISSSUES IN MEDICAL PRACTICE
AND SHARING WITH YOU MY PERCEPTIONS OF WHAT IT HAS MEANT TO ME
.1. AND IN SO DOING, MAYBE I CAN STIMULATE YOU TO RE-THINK WHAT
IT MEANS TO YOU, ALSO. |
5
THIS ADDRESS, BY THE WAY, IS THE SECOND IN A CYCLE OF SIX

MEDICAL SCHOOL COMMENCEMENT ADDRESSES I’M PRESENTING THIS SPRING.
THEY ALL FOCUS UPON THIS ONE TOPIC: “ETHICAL IMPERATIVES AND THE
NEW PHYSICIAN.”

THE CYCLE WILL CONCLUDE IN THREE WEEKS IN CHICAGO, AFTER
WHICH I HOPE TO SEND EACH MEMBER OF THE CLASS OF 1988 A COPY OF
THE PUBLISHED COLLECTION OF ALL SIX ADDRESSES,

MY REMARKS TODAY, HOWEVER, DEAL PARTICULARLY WITH THE
ETHICAL IMPERATIVES THAT CONFRONT THE NEW PHYSICIAN IN WHAT IS
COMMONLY KNOWN AS THE “DOCTOR-PATIENT RELATIONSHIP.”
6
AS YOU MAY HAVE GUESSED BY NOW, I AM A PHYSICIAN AND A

SURGEON WHO WAS TRAINED BEFORE THE DISCOVERY AND DEVELOPMENT OF
ANTIBIOTICS AND ALL THOSE PLASTIC GADGETS WITHOUT WHICH ONE
CANNOT PRACTICE MEDICINE TODAY,

] HAVE SEEN IN MY OWN LIFETIME A PROFOUND CHANGE IN THE
SCIENCE THAT FORMS THE BASE OF MY “CALLING” AND -- LIKE ALL MY
COLLEAGUES -- I’VE TRIED HARD TO KEEP UP WITH IT,

BUT THE MOST IMPRESSIVE CHANGE HAS NOT OCCURRED IN
PHARMACEUTICALS OR DIAGNOSTICS OR SURGERY. RATHER, IT HAS TAKEN
PLACE IN THAT OFTEN METAPHYSICAL EXPERIENCE WE CALL THE "DOCTOR-
PATIENT RELATIONSHIP.”
7
IT’S BEEN FASCINATING TO WATCH AND TO HAVE BEEN A PART OF

IT. BUT IT HAS ALSO BEEN EXTREMELY CHALLENGING ... PARTICULARLY
TO THAT ETHICAL FRAMEWORK WITHIN WHICH EACH PHYSICIAN PRACTICES.

THE MOST OBVIOUS CHANGE HAS BEEN THE DECLINE AND VIRTUAL
DISAPPEARANCE OF MEDICAL PATERNALISM -- THE ETHIC THAT SAYS, “THE
PHYSICIAN-FATHER KNOWS BEST.”

BUT IT APPEARS, FROM THE WEIGHT OF BOTH POPULAR AND
PROFESSIONAL OPINION, HE DOESN’T ANY LONGER. AND THAT GOES FOR
THE “PHYSICIAN-MOTHER,” ALSO.
8
I'M STILL OLD-FASHIONED ENOUGH TO THINK OF MYSELF AS A

PHYSICIAN, NOT A “PROVIDER.” AND I THINK OF MY PATIENTS AS
PATIENTS, NOT “CONSUMERS.” THE OLDER TERMS CARRY THE
IMPLICATIONS OF A PERSONAL RELATIONSHIP -- SOMETHING
CONFIDENTIAL AND TRUSTFUL -- THAT THE NEWER TERMS LACK, AT LEAST
FOR ME.

BUT WHATEVER TERMS YOU PREFER, I WOULD URGE YOU -- AT THE
VERY LEAST -- TO INVEST THEM WITH THE FEELING OF PERSONAL
INVOLVEMENT THAT HAS BEEN THE HALLMARK OF RESPONSIVE MEDICAL
PRACTICE FOR CENTURIES.
9
THERE HAVE BEEN OTHER CHANGES, ALSO. PHYSICIANS ARE MORE

INCLINED THESE DAYS TO BE OPEN AND HONEST ABOUT THEIR
UNCERTAINTIES, WHEN DISCUSSING A DIAGNOSIS OR A PROJECTED REGIMEN
OF THERAPY WITH THEIR PATIENTS.

IF THEY WERE NOT SO INCLINED, THEN A CONCEPT SUCH AS THE
"SECOND OPINION” WOULD NEVER HAVE ACHIEVED THE LEVEL OF
ACCEPTANCE IT HAS.

UNDER MOST CIRCUMSTANCES, THIS “NEW HUMILITY” COULD BE QUITE
BECOMING, I’VE ALWAYS BELIEVED THAT ACCEPTING ONE’S OWN HUMAN
FALLIBILITY 1S A STRENGTH, NOT A WEAKNESS. AND NOW I SEE THAT
PHYSICIANS HAVE COME TO AGREE WITH THAT POINT OF VIEW ... ALBEIT
WITH SOME RELUCTANCE.
10
PATERNALISTIC -- OR MATERNALISTIC -- MEDICINE MAY BE FAST

DISAPPEARING, BUT IT HASN’T YET BEEN REPLACED WITH ANY OTHER
SINGLE ETHIC THAT HAS THE SAME SIMPLICITY AND POWER. BUT IT
DOES LOOK AS IF WE’RE SEEING THE EVOLUTION OF A “”PHYSICIAN-

PATIENT PARTNERSHIP.”

IN SUCH A PARTNERSHIP, THE PATIENT “HAS A RIGHT TO KNOW” AS
MUCH AS POSSIBLE ABOUT HIS OR HER CONDITION. THEN, ARMED WITH
THIS KNOWLEDGE, THE PATIENT MAY THEN BECOME INVOLVED IN THE FINAL
DECISION-MAKING PROCESS REGARDING THERAPY.
11
BUT -- ETHICALLY -- HOW MUCH CONTROL OF THIS “RELATIONSHIP”

OR “PARTNERSHIP” ARE YOU PREPARED TO GIVE UP? AND IF YOU DO
RELINQUISH SOME OF THAT CONTROL, THEN HOW MUCH RESPONSIBILITY
SHOULD YOU STILL BEAR FOR TREATMENT OUTCOMES?

IN EITHER CASE ~~ WHETHER AS A PARTNER OR IN LOCO PARENTIS
77 YOU NATURALLY MAINTAIN THE PROFESSIONAL RIGHT AND OBLIGATION
TO MANAGE YOUR PATIENT IN THE WAY YOU THINK IS BEST.

IT IS TRUE THAT IN THE CASE OF THE PHYSICIAN-ACT ING-AS-
PARENT, THERE MAY BE A TENDENCY TO QVER-TREAT ... TO EXERCISE THE
MORE UNPLEASANT “COMMAND AND CONTROL” ASPECTS OF PATERNALISTIC --
OR MATERNALISTIC -- MEDICINE.
12
ON THE OTHER HAND, WHEN YOUR PATIENT IS YOUR PARTNER, THERE

IS THE EQUALLY UNPLEASANT TENDENCY TO UNDER-TREAT A CONDITION...
TO RELY TOO MUCH UPON THE PATIENT’S PARTICIPATION IN HIS OR HER
OWN THERAPY. YOU MAY PLACE TOO MUCH FAITH IN THE “INFORMED”
ASPECT OF “INFORMED PATIENT CONSENT.”

GENERALLY SPEAKING, I’VE FOUND THAT MANY PHYSICIANS WHO
"TAKE CHARGE” OF THE RELATIONSHIP WITH PATIENTS ... WHO ACCEPT
FULL RESPONSIBILITY FOR PROCESSES AND OUTCOMES ... TEND ALSO TO
BE THE PHYSICIANS WHO ARE CONCERNED ABOUT THE “SANCTITY OF HUMAN
LIFE” ... POSSIBLY BECAUSE THEY DO IN FACT SEE THEMSELVES AS THE
ULTIMATE GUARDIANS OF OTHER PEOPLE’S LIVES,
13
AND THEY TAKE THAT ROLE VERY SERIOUSLY. THEY REGARD THEIR

MEDICAL PRACTICE AS BEING DIRECTLY TIED TO THE MORAL BASIS OF
THEIR “CALLING,” A BASIS THAT CLAIMS EACH HUMAN LIFE TO BE UNIQUE
AND PRECIOUS AND WORTHY OF BEING TREATED ACCORDINGLY,

ALL WELL AND GOOD. BUT THEN ANOTHER TENDENCY MAY APPEAR
vee THE TENDENCY TO DO ABSOLUTELY ANYTHING TO SAVE THE LIFE OF A
PATIENT ... OR TO PROLONG THE LIFE OF SOMEONE IN THE FINAL THROES

OF DYING BY USING MEASURES THAT ARE “HEROIC” OR “EXTRAORDINARY”
cee AND THOSE TERMS, BY THE WAY, ESCAPE ANY PRECISE DEFINITION.
14
HOWEVER, BY TAKING “EXTRAORDINARY” MEASURES IN A HOPELESS

SITUATION, THE ASSERTIVE PHYSICIAN CAN TURN A PATIENT‘S DEATH
AGONY INTO A GHASTLY, DRAWN-OUT, AND INHUMAN SPECTACLE, INSTEAD
OF HELPING THAT PATIENT LEAVE THIS LIFE WITH THE LEAST POSSIBLE
DISCOMFORT, YET WITH AS MUCH AS POSSIBLE OF HIS OR HER PERSONA
STILL INTACT,

BUT THERE ARE SOME QUESTIONS AS WELL, REGARDING THAT NOTION
OF A PHYSICIAN-PATIENT PARTNERSHIP. IF YOU BELIEVE THE INDEPEN-
DENT, AUTONOMOUS PATIENT CAN BE A TRUE PARTNER IN THE WAY YOU
PRACTICE MEDICINE, THEN HOW WOULD YOU VIEW THE PATIENT WHO
BECOMES SERIOUSLY OR EVEN PROFOUNDLY DEPENDENT?
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HOW DO YOU SEE THE ELDERLY PATIENT WITH ALZHEIMER’S DISEASE,

FOR EXAMPLE ... OR THE RECOVERING STROKE VICTIM WITH MULTIPLE
SENSORY AND MEMORY LOSS ... OR THE DISABLED NEONATE SO DEPENDENT
ON HOSPITAL STAFF AND PARENTS ... OR THE PARENTS THEMSELVES,
TRYING TO MAKE THE RIGHT DECISION, DESPITE THEIR OWN EMOTIONAL
TURMOIL?

THIS WAS AN ISSUE THAT I MYSELF HAD TO RESOLVE, DURING MY
OWN YEARS OF PRACTICE AS A PEDIATRIC SURGEON, I WANTED EVERYBODY
INVOLVED IN WHAT WAS GOING ON. PASSIVE, DEPENDENT PEOPLE WERE
NOT ENOUGH. AND SO, FOR ME, THE CONCEPT OF “PARTNERSHIP” BECAME
FUNDAMENTAL TO MY DAY-TO-DAY PRACTICE,
16
FOR EXAMPLE, I ALWAYS TRIED TO GAIN AS MY ALLIES THE

PARENTS OF EACH OF MY YOUNG PATIENTS. I EXPLAINED TO THEM AS
WELL AS I COULD JUST WHAT IT WAS WE WERE UP AGAINST AND WHAT THE
ODDS WERE OF OUR BEING SUCCESSFUL.

I NEEDED MORE THAN JUST THEIR INFORMED CONSENT. I NEEDED
THEIR INFORMED LOVE AND CONCERN AND ENERGY, SO THAT WE COULD
FIGHT ... TOGETHER ... THE PARTICULAR ANOMALY OR DISEASE THAT WAS
THREATENING THEIR CHILD. AND WHETHER WE ULTIMATELY WON OR LOST
OUR BATTLE, WE RETAINED THAT BOND OF PARTNERSHIP.
17
BY THE WAY, I BELIEVE THIS WAS THE SINGLE MOST IMPORTANT AND

TOTALLY UNANTICIPATED REASON THAT I WAS NEVER ONCE SUED FOR
MALPRACTICE IN A SURGICAL CAREER THAT SPANNED SOME 40 YEARS.

AT FIRST HEARING, THEN, THESE QUESTIONS DO HAVE AN ACADEMIC
RING TO THEM:

WHAT DOES “INFORMED CONSENT” MEAN?

WHAT IS “DEPENDENCE” IN THE CONTEXT OF THERAPY?

WHAT IS “AUTONOMY” AND HOW [S IT EXERCISED?
BUT VERY SOON, THEY ARE NOT ACADEMIC AT ALL. INSTEAD, THEY ARE
REAL-LIFE QUESTIONS THAT REQUIRE IMMEDIATE, REAL-LIFE ANSWERS
THAT SQUARE WITH WHAT YOU KNOW ABOUT MEDICINE AND WHAT YOU KNOW
ABOUT YOUR OWN COMMITMENT TO AN ETHICAL LIFE.
18
TO SOME DEGREE, THESE KINDS OF QUESTIONS HAVE ALWAYS BEEN

PERCOLATING IN THE CONSCIOUSNESS OF MEDICAL PRACTITIONERS. BUT,
IN BYGONE DAYS, THEY COULD BE ANSWERED RATHER ROUTINELY BY
PHYSICIANS WHO PRACTICED WITHIN A FRAMEWORK OF FIXED AND
PREDICTABLE RELATIONSHIPS ALL AROUND.

BUT THAT CONTEXT HAS CHANGED QUITE A BIT. WE NOW HAVE A
MUCH HIGHER DEGREE OF SPECIALIZATION IN MEDICINE. HENCE,
PATIENTS MAY BEGIN WITH THEIR FAMILY PHYSICIAN, BUT THEY’RE OFTEN
REFERRED TO SPECIALISTS FOR THIS OR THAT PARTICULAR COMPLAINT.
19
AND FOR SEVERAL MILLION AMERICANS WHO USE A GROUP PRACTICE

OF ONE KIND OR ANOTHER, THE ORGANIZATION ITSELF IS THEIR
PHYSICIAN OF RECORD, RATHER THAN ANY ONE INDIVIDUAL,

WE ALL ACCEPT THE GROWTH OF MEDICAL SPECIALIZATION AND THESE
NEW GROUP-PRACTICE ARRANGEMENTS AS HALLMARKS OF PROGRESS IN
AMERICAN MEDICINE. AND THEY ARE.

BUT ONE TRADE-OFF FOR SUCH PROGRESS IS THE FACT THAT FEW
PHYSICIANS TODAY GET TO KNOW THE WHOLE PATIENT AND, THEREFORE,
ARE UNABLE TO TREAT THE WHOLE PATIENT. THEY HAVE LIMITED
INFORMATION, IF ANY, ABOUT THE PATIENT'S FAMILY, WORK SITUATION,
EDUCATIONAL ATTAINMENT, CULTURAL BACKGROUND, OR SPIRITUAL OUTLOOK
~~ OR LACK OF IT,
20
AND PATIENTS, ON THEIR PART, ARE EXERCISING MORE AUTONOMY

«s+ MORE DISCRETION ... MORE CHOICE ... AND LESS DEPENDENCE UPON
ONE PHYSICIAN FOR ALL OR EVEN MOST OF THEIR HEALTH NEEDS. WE
MAY BELIEVE IN CONTINUITY OF CARE, BUT OUR PATIENTS MAY SET A
HIGHER VALUE ON THEIR RIGHT OF PRIVACY AND THEIR FREEDOM TO PICK
AND CHOOSE THEIR DOCTORS ... AT ANY TIME.

WHAT HAPPENS TO THE “PHYSICIAN-PATIENT PARTNERSHIP” UNDER
SUCH CIRCUMSTANCES? WHAT ARE YOUR ETHICAL OPTIONS NOW? OR DO

YOU HAVE ANY?
21
T RAISE THOSE QUESTIONS BECAUSE MEDICINE -- AND THE AMERICAN

PEOPLE -~ ARE IN THE PROCESS RIGHT NOW OF TRYING TO SORT OUT THE
ANSWERS. THIS PROCESS IS OF MORE THAN ACADEMIC SIGNIFICANCE FOR
EACH OF YOU.

TO MY WAY OF THINKING, OUR ETHICAL COMMITMENT TO -- AND
INVOLVEMENT IN -- THE CARE OF OUR PATIENTS IS THE REAL ISSUE
UNDERLYING ALL THE TALK ABOUT MEDICAL MALPRACTICE, PERIODIC RE-
LICENSING, “DEFENSIVE MEDICINE,” AND PROFESSIONAL ACCOUNTABILITY,
22
UNFORTUNATELY, THE SORTING-OUT PROCESS IS FAR FROM OVER. AS

A RESULT, PHYSICIANS FOR THE MOST PART ARE STILL HELD FULLY
ACCOUNTABLE UNDER THE STANDARDS OF THE OLD, PATERNALISTIC MODEL
OF MEDICAL PRACTICE, WHEN, IN FACT, THAT'S NO LONGER THE MODEL
THAT'S ACCEPTED ACROSS-THE-BOARD,

HENCE, SOCIETY -- AND OUR OWN PROFESSIONAL LEADERS -- ARE
INVESTING MUCH TIME AND EFFORT IN IRONING OUT THE PROBLEMS THAT
ARISE WHEN PATERNALISTIC MEDICINE BEGINS ADJUSTING TO THE
BEHAVIOR OF THE AUTONOMOUS PATIENT.
23
PART OF THAT PROCESS MEANS THE DEVELOPMENT OF NEW MEDICAL

LAW ... SOME NEW REGULATION OR SELF-REGULATION ... AND A RE-
COMMITMENT -- IN CONTEMPORARY TERMS -- TO THE FUNDAMENTAL ETHICS
OF MEDICAL SERVICE.

HEARING ALL THIS, YOU MIGHT WELL ASK IF THERE IS LIFE AFTER
MEDICAL SCHOOL? YES, THERE IS. NOW MORE THAN EVER ... THANKS IN
GREAT MEASURE TO THE RE-ADJUSTMENT GOING ON IN THE ETHICAL
RELATIONSHIP BETWEEN PHYSICIANS AND PATIENTS.
24
MANY CHANGES WILL OCCUR IN THE YEARS AHEAD, AS YOU MATURE IN

YOUR CHOSEN PROFESSION OF MEDICINE. AND IT’S FAIR TO SAY THAT
MANY OF YOU WILL HELP BRING ABOUT THOSE CHANGES, WHILE ALL OF YOU
WILL AT LEAST EXPERIENCE THEM,

BUT I AM CONFIDENT THAT THE PHYSICIANS OF AMERICA WILL
EMERGE FROM THIS TIME OF GREAT FERMENT WITH A STRONGER ETHICAL
FRAMEWORK WITHIN WHICH TO PRACTICE THEIR KIND OF APPROPRIATE,
RESPONSIBLE MEDICINE ... MEDICINE THAT SERVES THE NEEDS OF
INFORMED AND INVOLVED PATIENTS.
25
DR. EDWARD PELLEGRINO, OF GEORGETOWN UNIVERSITY AND THE

KENNEDY INSTITUTE OF ETHICS, HAS OBSERVED THAT “SOME DEGREE OF
EFFACEMENT OF SELF-INTEREST IS ... PRESENT IN EVERY MEDICAL OATH,
THAT IS WHAT MAKES MEDICINE TRULY A PROFESSION.”

AND I WOULD AGREE. I DON’T THINK YOU SHOULD ABDICATE YOUR
ROLE OF THE KNOWLEDGEABLE PROFESSIONAL. I DON’T THINK YOU SHOULD
BE AMBIVALENT ABOUT YOUR ROLE EITHER.
26
BUT, AS DR. PELLEGRINO SO NICELY PHRASED IT, I THINK THE

ROLE IS ACTUALLY ENHANCED BY A “DEGREE OF EFFACEMENT OF SELF-
INTEREST” ... BY A DEGREE OF EGO RELAXATION, IF YOU WILL ...
WHICH ALLOWS YOU AND YOUR PATIENTS TO MEET AND TO KNOW EACH OTHER
NOT MERELY ON THE BASIS OF SYMPTOMATOLOGY OR OF BILLS PAST-DUE
»+. BUT ON THE BASIS OF YOUR SHARED INTEGRITY AS HUMAN BEINGS.

] HAVE A REPUTATION FOR STRAIGHT TALK AND I HOPE I‘VE
LIVED UP TO IT THIS MORNING. BUT DON’T LET ME DAMPEN YOUR
ENTHUSIASM FOR MEDICINE ONE LITTLE BIT. WERE I YOUR AGE -- YET,
KNOWING WHAT I NOW KNOW -- I WOULD STILL CHOOSE A CAREER IN
MEDICINE ABOVE ANY OTHER.
27
YOU’VE CHOSEN WISELY AND WELL. MEDICINE IS A MAGNIFICENT

CAREER ... A “CALLING” THAT IS DEDICATED TO THE HIGHEST HUMAN
VALUES: THAT IS, OF RELIEVING SUFFERING AND SAVING HUMAN LIVES
oe A PROFESSION THAT HAS BEEN LED OVER THE CENTURIES BY
SENSITIVE MEN AND WOMEN WHO PRACTICED MEDICINE ACCORDING TO THE
HIGHEST -- AND MOST RIGOROUS -- ETHICAL STANDARDS.

I KNOW YOU’LL FIND IT REWARDING.

I ALSO KNOW IT WON’T BE DULL.

THANK YOU.
RHE # #