ORIGINAL
ADDRESS. 32 ‘Doan

BY
C, Everett Koop, MD, ScD
SURGEON GENERAL

 

OF THE
U. S, Pupiic HEALTH SERVICE
U. S, DEPARTMENT OF HEALTH AND HUMAN SERVICES

SS

PRESENTED TO INTERNATIONAL ORGAN TRANSPLANT FORUM
PITTSBURGH, PENNSYLVANIA
SEPTEMBER ll, 1987
(GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.)

I’M DELIGHTED TO JOIN YOU TODAY TO PARTICIPATE, IF ONLY FOR A
BRIEF TIME. IN THIS HISTORIC MEETING.

FIRST, LET ME RELAY TO YOU PRESIDENT REAGAN’S VERY BEST WISHES
FOR A PRODUCTIVE MEETING AND A SAFE RETURN HOME. I KNOW YOU WANTED
THE PRESIDENT AND I DO NOT PRETEND TO FILL THOSE SHOES FOR YOU,

] CAN ADD, HOWEVER. THAT WITHOUT HIS SUPPORT AT THE VERY
BEGINNING, I DOUBT THAT THE FEDERAL GOVERNMENT WOULD BE AS FAR ALONG
AS IT IS,

YOU WILL REMEMBER THAT PRESIDENT REAGAN’S INTEREST WAS CAPTURED
BY THE PLIGHT OF ASHLEY BAILEY, AN 11-MONTH-OLD BABY GIRL ON WHOSE
BEHALF THE PRESIDENT MADE A NATIONWIDE APPEAL FOR A SUITABLE
LIVER.
ho

"ONE THING I KNOW.” THE PRESIDENT TOLD THE NATION IN JULY
1983, “WE LIVE IN A COUNTRY WHERE PEOPLE TRULY CARE FOR ONE
ANOTHER.”

JUST ONE WEEK BEFORE THAT APPEAL, PRESIDENT REAGAN DIRECTED ME
TO “CONDUCT A CONFERENCE ON ORGAN TRANSPLANTS,” WHICH I DID AND
WHICH FIRMLY PUT THIS ISSUE HIGH ON THE PUBLIC HEALTH AGENDA FOR THE
FIRST TIME...WHERE IT REMAINS, I MIGHT ADD,

I ALSO REGRET NOT HAVING THE CHANCE TO HEAR PRESIDENT REAGAN
SPEAK TO THIS ISSUE ONCE AGAIN, BUT I MUST TELL YOU, IN ALL
HONESTY, THAT 1’M PERSONALLY DELIGHTED WITH THE WAY THINGS TURNED
OUT. THIS WAY I HAVE THE OPPORTUNITY TO ADD MY WORDS TO THOSE GIVEN
BY SO MANY OTHERS WHO ARE HONORING DR. THOMAS E. STARZL TODAY.
Al

TOM STARZL HAS BEEN A GIANT NOT ONLY IN THIS FIELD BUT A GIANT

IN MEDICINE AND SURGERY IN GENERAL. I'VE KNOWN HIM FOR MANY YEARS
AND HAVE WATCHED -- SOMETIMES BREATHLESSLY -- AS HE HAS MOVED AHEAD

WITH GREAT COURAGE, YET WITH GREAT CARE, PURSUING YET ANOTHER NEW
WAY TO SAVE HUMAN LIVES,

HE’S BEEN DOING THAT FOR 25 YEARS, AND HIS IDEAS AND HIS
ENERGY NEVER SEEM TO DIMINISH,

THEREFORE, IN THE CONTEXT OF THIS GREAT INTERNATIONAL MEETING,
IT’S EMINENTLY PROPER THAT WE PAUSE FOR A MOMENT TO RECOGNIZE A
GREAT SURGEON...A GREAT SCIENTIST...A GREAT HUMANI- TARIAN...AND A

GOOD FRIEND: DR. THOMAS E. STARZL.
AND NOW 1’D LIKE TO OFFER MY OWN PERSONAL WELCOME TO EACH OF
YOU... THOSE WHO HAVE COME JUST ACROSS TOWN AND THOSE WHO HAVE COME
ACROSS OCEANS AND CONTINENTS TO BE HERE THIS WEEK,

YOUR NUMBERS AND YOUR ENTHUSIASM AND YOUR GENIUS ARE THE
REASONS WHY THOUSANDS AND SOON MILLIONS OF LIVES WILL BE SAVED
THROUGH THE TECHNOLOGY OF ORGAN TRANSPLANTATION,

AND SO THIS FORUM IS PERFECTLY TIMED, WE ARE CRESTING AT A NEW
HIGH-POINT IN THE HISTORY OF THIS TECHNOLOGY. AND FROM THIS HEIGHT,
WE CAN BOTH LOOK BACK AND SEE HOW WELL WE’VE DONE...AND ALSO LOOK
FORWARD IN ANTICIPATION OF THE CHALLENGES AND THE MYSTERIES THAT LIE
AHEAD,
THANK GOODNESS THAT THIS CONFERENCE IS SO WELL ATTENDED --
SOMEONE SAY THERE ARE ABOUT 2,000 PEOPLE HERE. AND THANK GOODNESS,
ALSO, THAT YOU’VE HAD SUCH A FULL PROGRAM OF MEETINGS AND SEMINARS
AND PRESENTATIONS AND LECTURES.

THEREFORE. I CONSIDER MYSELF RELEASED FROM ANY OBLIGATION TO
TALK ABOUT EVERYTHING.

BUT I WANT TO RESERVE FOR MYSELF A FEW MOMENTS TODAY TO TALK
ABOUT A FEW ISSUES THAT ARE IMPORTANT NOT ONLY FOR THE FUTURE OF
THIS PARTICULAR TECHNOLOGY...BUT FOR ALL OF MEDICINE AND PUBLIC
HEALTH,
AND I SUPPOSE THIS IS THE RIGHT MOMENT TO CONFESS THAT I
PRESSED AHEAD WITH THE SURGEON GENERAL’S WORKSHOP ON ORGAN
TRANSPLANTATION BACK IN JUNE OF ‘83 PARTLY BECAUSE I FELT THAT IF WE
COULD ISOLATE AND IDENTIFY THE KEY ISSUES SURROUNDING THE TRANSPLANT
TECHNOLOGY, WE WOULD, IN EFFECT, IDENTIFY THE ISSUES THAT UNDERLIE
ALL OF CONTEMPORARY MEDICINE,

AND JUST WHAT ARE THEY?

FIRST OF ALL. I WOULD RAISE AGAIN THE ISSUE OF THE ROLE OF
SCIENCE ITSELF IN CONTEMPORARY LIFE,

 

T FEEL UNCOMFORTABLE RAISING THIS ISSUE, BECAUSE IT MAY, IN THE
MINDS OF SOME PEOPLE, CARRY THE ECHOES OF A PERSISTENT AND HISTORIC
STRAIN OF ANTI-INTELLECTUALISM,..IN OUR SOCIETY AS WELL AS IN OTHER
INDUSTRIALIZED SOCIETIES,
HOWEVER, I BELIEVE WE MUST TAKE THAT RISK AND RAISE THE ISSUE
ANYWAY, BECAUSE IT FORCES US TO JUDGE THE RELEVANCE OF SCIENCE TO
THE HUMAN AND SOCIAL NEEDS OF CONTEMPORARY SOCIETY,

I AM CERTAINLY AWARE THAT THE PUBLIC -- IN ITS MULTIPLE ROLE OF
PATIENT, FAMILY, AND TAXPAYER -- HAS ALREADY RAISED THE ISSUE
THROUGH A VARIETY OF FORUMS, THEY’RE ASKING A SERIES OF QUESTIONS
THAT HINT AT A GROWING POPULAR UNEASINESS WITH THE COURSE AND
DIRECTION OF SCIENCE.

THEY ASK IF THE NEWEST DEVELOPMENTS IN SCIENCE ARE FUELLED BY
REAL PATIENT NEEDS?

ARE THE PRIORITIES OF SCIENCE COINCIDENT WITH PUBLIC
PRIORITIES?
WILL THE NEW DEVELOPMENTS IN SCIENCE BE AVAILABLE 10 ALL WHO
CAN BENEFIT FROM THEM?

ARE THEY CONSISTENT WITH ACCEPTED SOCIAL VALUES?

AND DO THEY UNIFORMLY SUPPORT AND STRENGTHEN THE ETHICS OF
MODERN MEDICINE?

THOSE ARE DIFFICULT BUT RELEVANT QUESTIONS FOR ANYONE WHO
LABORS IN THE TECHNOLOGY OF ORGAN TRANSPLANTATION,

BUT I WOULD ARGUE THAT THEY ARE ALSO THE QUESTIONS TO BE FACED
BY ALL OF MEDICINE.

THE ROLE OF SCIENCE NEEDS TO BE EXAMINED PARTICULARLY IN LIGHT
OF THE LIMITATIONS THAT WE KNOW MUST HENCEFORTH BE PLACED ON RE-
SOURCES...WHETHER HUMAN, FISCAL, OR MATERIAL.
THE SCARCITY OF RESOURCES IS THE SECOND ISSUE THAT WE -- AND,
AGAIN, ALL OF MEDICINE -- MUST CONTINUE TO EXPLORE,

AS AN ASIDE, I WAS INFORMED EARLIER THIS WEEK THAT 1987 COULD
BE SOMETHING OF A BANNER YEAR IN THE STILL BRIEF HISTORY OF ORGAN
TRANSPLANTATION:

* FOR EXAMPLE, WE EXPECT TO TRANSPLANT OVER 1,000 LIVERS THIS
YEAR,

* WE EXPECT TO AT LEAST EQUAL, IF NOT SURPASS, LAST YEAR’S
LEVEL OF 1,300 TRANSPLANTED HEARTS,
10

* AND WE SEEM HEADED FOR A RECORD 9,000 KIDNEY TRANSPLANTS BY
THE CLOSE OF 1987,

NOW THAT THE TECHNOLOGY HAS BECOME MORE WIDESPREAD -- INCLUDING THE
REMARKABLE ACHIEVEMENTS IN IMMUNOSUPPRESSIVE THERAPIES -- WE MIGHT
WELL BE CONCERNED THAT THE TECHNOLOGY COULD OUT-PACE RESOURCES,

AND HERE WE SHOULD BE GRATEFUL TO OUR HONOREE. DR. JOM
STARZL. HE HAS AGAIN DEMONSTRATED HIS LEADERSHIP BY COMING FORWARD
WITH AN EQUITABLE WAY -- USING A POINT SYSTEM -- OF ALLOCATING
AVAILABLE KIDNEYS AMONG THE POOL OF WAITING PATIENTS.
1]

DR, STARZL’S POINT SYSTEM WILL NO DOUBT BECOME THE BASIS FOR
ORGAN ALLOCATION IN THIS FIELD GENERALLY. I THINK THAT'S REASONABLE
AND SAFE TO SAY,

BUT REGARDLESS OF THE PROCESS OF ALLOCATION, THE RESOURCE ISSUE
REMAINS THE SAME: WITH A LIMITED SUPPLY OF DOLLARS, PEOPLE,
MATERIALS, FACILITIES... AND ORGANS...HOW WILL WE DECIDE WHO WILL GET
WHAT ORGAN...AND WHEN...AND FOR HOW MUCH?

IF YOU CAN RESOLVE THIS ISSUE IN A SPIRIT OF FAIRNESS AND
GENUINE CONCERN, YOUR CONCLUSIONS WILL BE OF GREAT USE, I CAN ASSURE
YOU, ACROSS THE ENTIRE FIELD OF MEDICINE.,..BECAUSE, TODAY, SCARCITY
IS EVERYBODY'S ISSUE,
12

WHILE I WAS SKIMMING THE LIST OF PARTICIPANTS AT THIS IMPORTANT
MEETING, I WAS PLEASED TO SEE THAT A GOOD NUMBER OF PEOPLE ARE
REPRESENTING COOPERATIVES... ALLIANCES... JOINT VENTURES ...AND OTHER
ORGANIZATIONS THAT COMBINE RESOURCES AND USE THEM MORE EFFICIENTLY,

FRANKLY, THIS HAS BEEN A DIFFICULT LESSON FOR AMERICAN MEDICINE
TO LEARN, HAVING HAD A LONG PERIOD OF TIME AFTER THE SECOND WORLD
WAR DURING WHICH INDIVIDUAL SCIENTISTS AND INSTITUTIONS ACHIEVED
GREAT EMINENCE COMPLETELY ON THEIR OWN.

THOSE WERE HEADY AND INNOCENT DAYS. BUT I THINK THEY’RE BEHIND
US NOW,
13

TODAY WE NEED TO POOL RESOURCES...TO SHARE INSIGHTS AND
PEOPLE...TO COOPERATE...TO COLLABORATE...AND IN ALL OTHER WAYS TO
STRETCH AND EXTEND THE LIMITED RESOURCES WE HAVE IN ORDER TO MAKE
THE ACHIEVEMENTS OF SCIENCE AVAILABLE AND ACCESSIBLE TO ALL WHO CAN
BENEFIT FROM THEM,

THAT’S A BIG IDEA, AS WELL AS A LONG SENTENCE. BUT I SEE NO
OTHER WAY IN WHICH MEDICINE -- PARTICULARLY THE TRANSPLANT SECTOR --
CAN RESPOND TO THE PUBLIC’S EXPANDING REQUIREMENTS FOR SERVICE,
14

1 ALSO BELIEVE THAT A WILLINGNESS TO WORK COOPERATIVELY WOULD
BE MEDICINE’S BEST DEMONSTRATION TO THE TAXPAYER...10 GOVERNMENT...
AND TO SOCIETY IN GENERAL THAT IT WILL TRY TO HONOR ALL ITS COMMIT~-
MENTS TO PATIENTS AND FAMILIES. NOT JUST THOSE THAT ARE CONVENIENT
OR COMFORTABLE FOR THE PROFESSION.

BUT HERE WE HAVE SOME NEW PROBLEMS AND THEY OUGHT TO BE
ANTICIPATED,

MODERN MEDICINE HAS EVOLVED WITHIN A SYSTEM OF LAW AND WITH THE
HELP OF FISCAL RESOURCES THAT WERE MOST COPMPATIBLE FOR BOTH THE
SOLO PRACTITIONER AND THE UNITARY INSTITUTION.

BUT TODAY, BOTH THE LAW AND THE FINANCIAL COMMUNITY NEED TO
DEMONSTRATE SOME NEW FLEXIBILITY IN ORDER TO HELP FOSTER NEW AND
MORE EFFICIENT INSTITUTIONS,
15

I BELIEVE THIS CAN BE DONE WITHOUT PLACING ANYONE AT RISK...
NEITHER OUR PATIENTS NOR OURSELVES. BUT IT MUST BE DONE THOUGHT-
FULLY. WITH SUFFICIENT PUBLIC DEBATE.

AND I WANT TO STRESS THE ROLE OF THE PUBLIC BECAUSE,
ULTIMATELY. WE'RE TALKING NOT ONLY ABOUT THE EVOLUTION OF A
TECHNOLOGY BUT ALSO THE EVOLUTION OF PUBLIC POLICY TOWARD THAT
TECHNOLOGY...AND TOWARD MEDICINE, AS ITS HOST,

 

I SAW THIS PROCESS BEGIN, AS A MATTER OF ACT, DURING THAT FIRST
SURGEON GENERAL’S WORKSHOP, THAT I MENTIONED A FEW MOMENTS AGO.

THE DIALOGUE AT THAT WORKSHOP HELPED SET OUT THE FRAMEWORK FOR
MOST OF THE PUBLIC POLICY DEBATES IN TRANSPLANTATION THAT HAVE COME
ALONG SINCE THEN,
16

OUT OF THE DISCUSSIONS AT THAT WORKSHOP CAME THE RATIONALE AND
THE INITIATIVE TO ESTABLISH THE AMERICAN COUNCIL ON TRANSPLANTA-
TION.,.7O0 PROMOTE A STRENGTHENED COMMUNITY OF NETWORKS OF ORGAN
DONORS AND RECIPIENTS,..AND. MORE RECENTLY, TO SUPPORT AN UMBRELLA
ORGANIZATION, THE “UNITED NETWORK FOR ORGAN SHARING,” THE U.N.O.S.,

THE FEDERAL GOVERNMENT, CLEAR ABOUT ITS POLICY IN THIS AREA SO
FAR, HAS INVESTED A MILLION DOLLARS IN U,N.O.S. AND I BELIEVE THAT’S
BEEN MONEY WELL-SPENT.

AND IN THE NEW CONTRACT, WE ARE COMMITTED TO THE SUPPORT OF
U.N.O.S. FOR 3 MORE YEARS,
17

WE OUGHT TO BE VERY PLEASED WITH OUR PAST...1 KNOW THAT WE’RE
PROUD OF OUR PRESENT...BUT 1 SUSPECT WE’RE STILL A LITTLE UNCLEAR
ABOUT THE FUTURE,

ONE WAY WE MIGHT ACHIEVE MORE CLARITY, AS WELL AS STABLITY,
WOULD BE FOR US TO BUILD UPON OUR SUCCESSES THUS FAR, BUT TO DO SO
STRUCTURALLY AND INSTITUTIONALLY, AS WELL AS SCIENTIFICALLY AND
ETHICALLY,

I] SUGGEST THAT THESE ARE SERIOUS ISSUES WHOSE RESOLUTION COULD
BE VERY FAR-REACHING. THEY REQUIRE A CLOSE LOOK AT CURRENT PUBLIC
POLICY, WITH AN EYE TO PROGRESSIVE ADJUSTMENTS,

AND FOR THIS WE NEED FRESH, NEW THINKING. AND WHY NOT BEGIN
HERE?
18

AND, TO LET YOU DO JUST THAT -- TO LET YOU GET BACK TO THE WORK
OF THIS EXCELLENT FORUM -- I WILL AGAIN OFFER MY BEST WISHES 10 YOU
ALL... AND A VERY SPECIAL WISH TO TOM STARZL THAT HE PROVIDE US WITH
25 MORE YEARS OF HIS BRAND OF MEDICAL EXCELLENCE.

THANK YOU.

Hdd # Ht