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ADDRESS

BY
C, Everett Koop, MD, ScD
SURGEON GENERAL
OF THE
U. S, PuBLic HEALTH SERVICE
U. S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

PRESENTED TO THE ASSEMBLY OF THE AMA MepICAL STUDENT SECTION

ATLANTA, GEORGIA
DECEMBER 5, 1987
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(GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.)

THANK YOU VERY MUCH FOR YOUR INVITATION AND THE WAY IT WAS
PHRASED. 1 THINK YOU ARE ABSOLUTELY RIGHT TO BE CONCERNED ABOUT THE
RELEVANCE TODAY OF THE “HIPPOCRATIC OATH.”

WE ALL ASSUME THAT, SINCE THE OATH HAS BEEN REPEATED AND
REPRINTED FOR MORE THAN 2,000 YEARS, THAT IT MUST HAVE GREAT POWER
OF PERSUASION, IF NOT COERCION.

BUT OATHS DO NOT. OF THEMSELVES, HOLD ANY POWER AT ALL. WE
HOLD THE POWER. WHEN WE REPEAT SUCH AN OATH AND BELIEVE IT AND LIVE
BY ALL ITS TENETS, THAT'S WHEN THE OATH HAS POWER,
AND THAT'S WHAT WE HAVE TO DO TODAY. WE HAVE TO RE-DISCOVER
THE OATH FOR OURSELVES...AND IN SO DOING. WE HAVE TO TAKE A LONG,
HARD LOOK AT JUST WHO WE ARE,

ARE WE TALENTED ENOUGH,..ARE WE COMPASSIONATE ENOUGH...ARE WE
HONEST ENOUGH...TO BE PHYSICIANS?

THOSE ARE QUESTIONS LIGHTLY ASKED...BUT NOT LIGHTLY ANSWERED.

AND IN THE "AGE OF AIDS,” THEY ARE EVEN MORE DIFFICULT TO
ANSWER,
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AIDS IS A DISEASE THAT ENGENDERS MUCH FEAR AMONG MEN AND WOMEN
~- AND RIGHTLY SO. IT IS VIRTUALLY 100 PERCENT FATAL...AND WE HAVE
NO VACCINE TO PROTECT YOU AGAINST IT AND NO DRUGS TO CURE YOU IF YOU
DO BECOME INFECTED,

IS THERE CAUSE FOR PHYSICIANS TO BE CONCERNED? OF COURSE THERE
IS. EACH OF YOU OUGHT TO BE WORRIED ABOUT YOUR OWN HEALTH, AS MUCH
AS YOU WORRY ABOUT THE HEALTH OF YOUR PATIENTS,

THAT'S NOTHING NEW,

BUT WHAT AIDS HAS DONE IS TO BECLOUD THE SITUATION WITH THE
POWERFUL ELEMENTS OF FEAR...PREJUDICE...REJECTION...AND HOPELESS-
NESS,
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THE HIPPOCRATIC OATH WAS WRITTEN TO COUNTER EACH OF THESE
ELEMENTS OF HUMAN FAILING,

AND THE PRACTICE OF MEDICINE FOR THE PAST 2.400 YEARS -- EVER
SINCE HIPPOCRATES HIMSELF FIRST PRACTICED DURING THE GOLDEN AGE OF
PERICLES -- MEDICINE HAS BEEN ONE OF MANKIND’S MOST CONSISTENT
INSTRUMENTS...

FOR CHALLENGING FEAR AND PREJUDICE...
FOR REPLACING REJECTION WITH ACCEPTANCE...

AND FOR PROVIDING FAITH AND HOPE WHERE ONCE THERE MAY HAVE BEEN
ONLY DESPAIR,
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IF THAT IS SO, THEN THE INDIVIDUAL PRACTICING PHYSICIAN HAS GOT
TO BE THE FIRST LINE OF DEFENSE FOR THE HUMAN RACE AGAINST THE
SCOURGE OF AIDS.

THE U.S. PUBLIC HEALTH SERVICE RECOGNIZED THIS ISSUE VERY EARLY
AND PUBLISHED A SET OF COMMON-SENSE GUIDELINES FOR HEALTH PERSONNEL.
THE GUIDELINES SPOKE OF GLOVES AND FACE-MASKS AND OF BEING CAREFUL
AROUND NEEDLES AND SCALPELS. WHEN TREATING A PATIENT WITH AIDS,

AND THE GUIDELINES HAVE WORKED. OF THE NEARLY Z MILLION PEOPLE
INVOLVED IN HEALTH CARE IN THIS COUNTRY -- PHYSICIANS, DENTISTS,
NURSES, LAB TECHNICIANS, EMERGENCY ROOM PERSONNEL. AND SO ON -- ONLY
& HAVE BECOME ACCIDENTALLY INFECTED WITH THE AIDS VIRUS WHILE
PROVIDING DIRECT PATIENT CARE,
AND IN ALMOST EVERY CASE, THE ACCIDENT COULD HAVE BEEN
PREVENTED.

BUT DESPITE THIS EXTRAORDINARY SAFETY RECORD WE STILL HEAR --
EVERY DAY -- OF PHYSICIANS, DENTISTS, NURSES, AND OTHER HEALTH
PERSONNEL WHO REFUSE TO TREAT PERSONS WITH AIDS...OR EVEN TO TREAT
PERSONS WHOM THEY SUSPECT OF HAVING AIDS.

YOU KNOW WHAT'S GOING THROUGH THEIR MINDS, THEY’RE ASKING
THEMSELVES, “WHAT'S THE POINT OF SPENDING A LOT OF TIME AND MONEY ON
THESE PEOPLE WITH AIDS...AND RUNNING A PERSONAL RISK IN ADDI-
TION... WHEN THEY’RE GOING TO DIE ANYWAY?”
MAYBE EVERYONE DOESN’T PUT IT QUITE SO BLUNTLY, BUT THAT’S
WHAT OUR COLLEAGUES ARE THINKING, WHEN THEY REFUSE TO ADMIT AIDS
PATIENTS TO HOSPITALS OR TURN THEM AWAY FROM CLINICS AND SCHOOLS.

SUCH CONDUCT, I MIGHT ADD. IS NOT CHARACTERISTIC OF ALL HEALTH
PROFESSIONALS BY ANY MEANS. ON THE CONTRARY, THE OVERWHELMING
MAJORITY OF OUR COLLEAGUES HAVE PROVIDED -- AND WILL CERTAINLY
CONTINUE TO PROVIDE -- QUALITY, COMPASSIONATE CARE TO PERSONS DYING
OF AIDS.

BUT THE GOOD CONDUCT OF THE MAJORITY SHOULD NOT IN ANY WAY
SHIELD THE UN-PROFESSIONAL CONDUCT OF A FEARFUL AND IRRATIONAL
MINORITY,
HENCE, 1 REGARD AS EXTREMELY SERIOUS THE REPORTS OF A FEW
PHYSICIANS AND OTHERS WHO ARE WITHDRAWING CARE FROM PERSONS WITH
AIDS. TO MY WAY OF THINKING, THEIR CONDUCT THREATENS THE VERY
FABRIC OF HEALTH CARE IN THIS COUNTRY,

YOU WILL RECALL THAT HIPPOCRATES WROTE. ..

QUOTE..."1 WILL USE TREATMENT TO HELP THE SICK ACCORDING TO MY
ABILITY AND JUDGMENT BUT NEVER WITH A VIEW OF INJURY OR
WRONGDOING...”..CLOSE QUOTE,
DENYING TREATMENT BECAUSE OF THE PRESENCE OF AIDS... TURNING
AWAY THE SICK AND DYING...1S WRONG,

IT WAS WRONGDOING 2,400 YEARS AGO. IT’S WRONGDOING TODAY. AND
IT WILL CONTINUE TO BE WRONGDOING TOMORROW, WHILE THIS TERRIBLE
EPIDEMIC 1S STILL WITH US,

HEALTH CARE IN THIS COUNTRY HAS ALWAYS BEEN PREDICATED ON THE
ASSUMPTION THAT -- SOMEHOW -- EVERYONE WHO NEEDS HEALTH CARE WILL
RECEIVE HEALTH CARE. AND NO ONE WILL BE TURNED AWAY.

AS A PHYSICIAN -- AND AS AN AMERICAN -- I’M PROUD TO BE PART OF
A TRADITION OF CARE THAT WILL NOT ABANDON THE SICK AND THE DISABLED
» WHOEVER THEY ARE.
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THAT TRADITION IS WHAT IS AT STAKE TODAY. IT IS OUR TRADITION.
AS PHYSICIANS, AND IT STANDS AS A POWERFUL SHIELD BETWEEN THE PEOPLE
OF AMERICA -- AND THE WORLD -- AND A DISEASE WITH A SEEMINGLY LIMIT-
LESS POTENTIAL FOR HAVOC,

WELL, WHAT SHOULD YOU AND I DO ABOUT IT?

THAT’S AN IMPORTANT QUESTION. AND I THINK WE HAVE TO CONFRONT
IT AND COME UP WITH SOME GOOD ANSWERS. OTHERWISE THE VIRUS OF AIDS
WILL FURTHER WEAKEN THE ETHICS OF MEDICAL PRACTICE IN THE UNITED
STATES,

AND THAT WOULD BE ANOTHER AND JUST AS DEADLY A KIND OF EPIDEMIC
FOR OUR SOCIETY,
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A RELATED ISSUE CONCERNS THE COST OF CARE FOR AIDS PATIENTS:
WHO SHOULD PAY FOR THOSE COSTS?

YOU KNOW, OF COURSE, THAT YOU’RE HEADING FOR A CAREER IN WHICH
PRIVATE METHODS OF REIMBURSEMENT EXIST SIDE-BY-SIDE WITH PUBLICLY
SUPPORTED SYSTEMS.

THE AMERICAN TAXPAYER SUPPORTS MATERNAL AND CHILD HEALTH PRO-
GRAMS, FOR EXAMPLE, AND DIABETES CONTROL AND HYPERTENSION SCREENING
PROGRAMS. RELATED PHYSICIAN SERVICES, NURSING CARE, LABORATORY
FEES...MOST OF THOSE ARE PAID FOR OUT OF GENERAL TAX REVENUES.
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TAXPAYERS ALSO SUPPORT PROGRAMS FOR ALCOHOLICS, DRUG ADDICTS,
AND SYPHILITICS. YOU MIGHT ONE DAY PROVIDE THOSE SERVICES, OR --
TRAGICALLY -- YOU MIGHT ONE DAY NEED THEM FOR YOURSELF.

IN ANY CASE, THOSE ARE PROGRAMS THAT CLEAN UP AFTER PEOPLE WHO
BEHAVE POORLY. IN ADDITION, THEY ARE GEARED TO BRING -- OR TO BRING
BACK -- MEN, WOMEN, AND CHILDREN 10 A STATE OF GOOD HEALTH.

WE LIKE THOSE PROGRAMS, AND THEY AREN’T VERY EXPENSIVE TO RUN
EITHER.

BUT AIDS 1S DIFFERENT. IT IS BOTH TECHNOLOGY- AND LABOR-
INTENSIVE AND, HENCE, THE AVERAGE COST OF CARE FOR ONE AIDS PATIENT
FOR ONE YEAR IS $20,000, ACCORDING TO FIGURES RECENTLY PUBLISHED IN
JAMA,
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BUT THEN, AFTER CONSUMING TENS OF THOUSANDS OF DOLLARS WORTH OF
MEDICAL CARE AND SOCIAL SERVICES... THE AIDS PATIENT DIES. AS I
MENTIONED EARLIER. AND AS YOU KNOW FULL. I'M SURE, THIS DISEASE IS
VIRTUALLY 100 PERCENT FATAL.

NOW, THE AIDS CASE-LOAD IS CLIMBING. AND SO ARE THE COSTS. IN
1991, WE ANTICIPATE LOGGING IN 74,000 NEW AIDS PATIENTS. THE TOTAL
COST OF PATIENT CARE THAT YEAR COULD BE AT LEAST $8 BILLION...OR AS
MUCH AS $16 BILLION,

WILL THE AMERICAN PEOPLE CONTINUE TO SUPPORT HIGH-COST PATIENT
CARE FOR PEOPLE WITH AIDS? WILL YOU BE WILLING TO SUPPLY SUCH CARE
-~ HOWEVER YOU'RE REIMBURSED?

 
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WILL THE GENERAL PUBLIC ASK FOR RELIEF? WILL THEY ASK THAT
CORNERS BE CUT? WILL THEY ASK FOR A KIND OF “SECOND-CLASS CARE” FOR
AIDS PATIENTS?

AND WILL YOU GO ALONG WITH THAT? OR WILL YOU MAINTAIN YOUR
INDEPENDENCE AND. AS THE OATH SAYS, “ABSTAIN FROM EVERY VOLUNTARY
ACT OF MISCHIEF OR CORRUPTION...”

THAT MIGHT NOT BE EASY.

WE ARE ALREADY SEEING MORE AND MORE CASES IN WHICH A JUDGE OR A
NEWSPAPER EDITOR OR A C.P.A. OR A PUBLIC OFFICE-HOLDER OF SOME KIND
DECIDES THE KIND OF TREATMENT TO BE GIVEN A PARTICULAR PATIENT...A
PATIENT WHO HAD THE POOR TASTE TO BECOME THE CENTER OF A PUBLIC
CONTROVERSY,
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THERE'S BEEN "BABY JANE DOE” AND KATIE BECKETT AND KAREN ANN
QUINLAN AND BILLIE BROWN AND ANGELA CARTER. IT'S AMAZING HOW MANY
OF THESE CELEBRATED PATIENTS ARE WOMEN,

IN ANY CASE, MEDICINE HAD SOMETHING TO SAY FOR EACH OF THEM,
BUT THE REST OF SOCIETY DID, TOO,

I'D LIKE TO SURPRISE YOU AND COME UP WITH SOME HARD AND FAST
ANSWERS TO ALL THESE KINDS OF QUESTIONS, BUT I DON’T HAVE ANY.
NONE OF US HAS.

YET, ALL OF US SHOULD BE DEEPLY CONCERNED ABOUT THE ANSWERS
THAT WILL BE EVOLVING OVER THE YEARS AHEAD,..AND WE SHOULD BE DEEPLY
INVOLVED IN THAT PROCESS, ALSO,
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FINALLY, LET ME RECALL THAT LINE FROM THE OATH THAT SAYS...

"WHATEVER, IN CONNECTION WITH MY PROFESSIONAL PRACTICE. OR NOT
IN CONNECTION WITH IT, I SEE OR HEAR. IN THE LIFE OF MEN. WHICH
OUGHT NOT TO BE SPOKEN OF ABROAD, I WILL NOT DIVULGE. AS
BELIEVING THAT ALL SUCH SHOULD BE KEPT SECRET...”

THAT’S THE FOUNDATION OF THE UNIQUENESS OF THE DOCTOR-PATIENT
RELATIONSHIP. IT IS ALSO THE BASIS OF THE QUANDARY AS TO WHAT TO DO
IF YOU KNOW SOMEONE IS INFECTED WITH THE AIDS VIRUS,.,IN OTHER
WORDS, A PATIENT WHO IS SEROPOSITIVE.

HOW MUCH RISK CAN THE COMMUNITY TOLERATE IN ORDER TO PRESERVE
THE RIGHT OF PRIVACY FOR EACH INDIVIDUAL WITHIN THE COMMUNITY?
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AS YOU KNOW, IT’S BEEN A LONG-STANDING PRACTICE IN PUBLIC
HEALTH TO PROMISE FULL CONFIDENTIALITY IN ORDER TO GET AS MUCH
SENSITIVE, HEALTH-RELATED INFORMATION AS POSSIBLE FROM INDIVIDUALS.

WITHOUT SUCH A SYSTEM, WE WOULD NEVER HAVE SUCCEEDED IN
CONTAINING MOST OTHER INFECTIOUS DISEASES, AS WE HAVE DONE.

BUT NO PREVIOUS DISEASE HAS HAD SUCH A HIGH MORTALITY RATE AND
ALSO BEEN SO RESISTANT TO THERAPEUTIC PREVENTION,

NEARLY ALL PUBLIC HEALTH PROFESSIONALS WITH WHOM I‘VE DISCUSSED
THIS MATTER BELIEVE THAT THE ASSURANCE OF TOTAL CONFIDENTIALITY IS
THE KEY TO HAVING POTENTIAL -- AND ACTUAL -- CARRIERS OF THE AIDS
VIRUS PRESENT THEMSELVES FOR VOLUNTARY TESTING AND COUNSELING,
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BUT 1S TOTAL CONFIDENTIALITY EVEN POSSIBLE?

IN MANY STATES IT IS NOT, SOME 13 STATES NOW HAVE LAWS THAT
REQUIRE NOTIFICATION TO EMERGENCY PERSONNEL, FUNERAL DIRECTORS, AND
HEALTH-CARE PROVIDERS IF SOMEONE THEY’VE CARE FOR HAS DIED OF AIDS.

MANY STATES ROUTINELY PERMIT NOTIFICATION OF HOSPITAL PERSONNEL
CONCERNING THE INFECTIOUS STATUS OF PATIENTS -- WHETHER IT’S AIDS OR
ANY OTHER SEXUALLY TRANSMITTED DISEASE,

AND THE TARASOFF CASE IN CALIFORNIA CONFIRMED THE DUTY OF THE
PHYSICIAN TO DISCLOSE INFORMATION ABOUT A PATIENT THAT COULD PROTECT
A THIRD PARTY FROM HARM,
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THE FIRST PRINCIPLE OF MEDICAL PRACTICE IS PRECISELY THAT:
"FIRST, DO NO HARM.” BUT...”HARM” TO WHICH PERSON?

IF I’M BEGINNING TO SOUND LIKE ONE OF YOUR FORMER PROFESSORS,
I’M SORRY. WHAT I’M SAYING TO YOU IS FAR FROM ACADEMIC. THESE ARE
REAL ISSUES THAT HAVE ARISEN AS THE HIPPOCRATIC OATH HAS COME FACE-
TO-FACE WITH THE REAL WORLD OF AIDS.

DR. OTIS R. BOWEN, SECRETARY OF HEALTH AND HUMAN SERVICES, JUST
SENT A LETTER TO THE GOVERNORS OF ALL 50 STATES ASKING THEM TO FOCUS
ON THE FOLLOWING THREE ISSUES, AS THEY GO ABOUT RESPONDING TO THE
AIDS EPIDEMIC IN THEIR OWN STATES:
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FIRST, THE ISSUE OF CONFIDENTIALITY OF PATIENT RECORDS AND
PROTECTIONS FROM INAPPROPRIATE DISCLOSURES...

SECOND, THE ISSUE OF PROTECTING INFECTED PERSONS FROM
DISCRIMINATION, WHETHER ON THE JOB, IN SCHOOL, IN HOUSING, OR IN
HEALTH CARE ITSELF...

AND THIRD. THE ISSUE OF PROTECTING THE PUBLIC FROM EXPOSURE --
OR FURTHER EXPOSURE -- TO THE DISEASE OF AIDS.
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IT SHARE THIS WITH YOU BECAUSE MEDICAL CARE IS A STATE-LICENSED
AND STATE-REGULATED PROFESSION. I CAN STAND HERE AND DISCUSS MANY
ISSUES WITH YOU. BUT. AS A FEDERAL OFFICIAL. I ACTUALLY HAVE LESS
DIRECT EFFECT UPON YOUR PROFESSIONAL LIFE THAN IF I WERE A STATE
OFFICIAL.

OBVIOUSLY, I ENCOURAGE YOU TO BECOME INVOLVED IN THESE ISSUES
AS SOON AS POSSIBLE -- MAKE THEM PART OF YOUR OWN PERSONAL
CONTINUING EDUCATION PROGRAM -- AND, IN THAT WAY, CONTRIBUTE TO
THEIR ULTIMATE RESOLUTION,

THE HIPPOCRATIC OATH AND THE PRAYER OF MAIMONIDES ARE ANCIENT
DOCUMENTS, TO BE SURE. BUT THEY ARE PRECIOUS NEVERTHELESS AND THEY
ARE THE BEST GUIDANCE AVAILABLE TO THE PRACTICE OF MEDICINE FOR, LO,
THESE HUNDREDS AND EVEN THOUSANDS OF YEARS,
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THEY CONTINUE TO SPEAK TO US ACROSS THE CENTURIES. BUT WHAT IS
OUR REPLY... TODAY...IN THE FACE OF ONE OF THE MOST DEADLY PANDEMICS
IN THE HISTORY OF THE HUMAN RACE?

THE AMERICAN PHILOSOPHER, ALFRED NORTH WHITEHEAD. WARNED US
THAT. A

“WE MUST NOT EXPECT SIMPLE ANSWERS
TO FAR-REACHING QUESTIONS, HOWEVER FAR OUR GAZE,
THERE ARE ALWAYS HEIGHTS BEYOND
WHICH BLOCK OUR VISION,”
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MY PLEA TO EACH OF YOU TODAY IS THIS: KEEP PROBING, KEEP
CLIMBING, AND KEEP YOUR VISION AS CLEAR AS YOU CAN THROUGHOUT YOUR
CAREER IN MEDICINE.

ONCE AGAIN. THANK YOU FOR YOUR INVITATION TO JOIN YOU TODAY,

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