"Ethical Imperatives and the New Physician: I. The Challenge of Medical Practice" [Reminiscence]
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Koop, C. Everett
Reproduced with permission of C. Everett Koop.
Ethical Imperatives and the New Physician: I. The Challenge of Medical Practice: Presented at the Commencement Exercises of
the F. Edward Hebert School of Medicine of the Uniformed Services University of the Health Sciences, Bethesda, Maryland (May
Presented at the Commencement Exercises of the F. Edward Hebert School of Medicine of the Uniformed Services University of
the Health Services
May 12, 1988
I thanked the student body for the invitation to have access to their ears, their minds, and their hearts, at least for the
moment. I also invited the family and friends of the graduates to listen to the conversation I was about to have with the
Class of 1988. I asked this for a specific reason. I wanted them to eavesdrop on what I had to say, because in a way, it might
help explain to them - today and in the days ahead -just why their young physician was so special.
I announced to them my intention of sending them a bound copy of all six-commencement lectures I was giving in medical schools
and told them I wanted to do it, because the term "ethics" is now a buzzword throughout our society. It was in fashion
with all professional people, but unfortunately, buzzwords go out of fashion also, and it was my hope that I might convince
this audience to keep ethics "in fashion" throughout their medical careers.
There were many theories why ethics is where it is today, but one theory has taken on an importance to me, because we - as
a people - are waking up to the fact that our extraordinary new technologies help us to get things done . . . but technology
doesn't help us to decide whether those things should be done in the first place or even the best way to do them. That
theory has particular pertinence to young physicians. Basic decisions to act - or not to act - are still ours. And those decisions
are guided more by one's own personal system of ethics and less by technical knowledge and expertise.
When I was a medical student there were no courses in medical schools on ethics as there are almost uniformly today. I did
see ethics at work and I had not trouble recognizing that my teachers had their own personal systems that impelled them to
do what they thought was "right". A subjective and intuitive approach that was also probably rather inefficient.
Personally, I didn't raise the question in my own mind why I had picked a life in medicine until I had finished my residency
in General Surgery and my fellowship in Pediatric Surgery. But, my answer to that question defined my professional career
from then on: I wanted to save lives . . . and I also wanted to alleviate suffering. Even then I realized that I could not
always achieve both objectives at the same time - for the same patient. All this I gave by way of warning that being aware
of my own ethical system of professional behavior did not necessarily make life any easier for me. But it did clarify many
things and made it possible for me to act with reasonable consistency.
Today's ethics are based largely on the consensus seeking approach to which our profession seems committed. That seems
natural in a vocation as complex as ours, yet, although I respect those engaged in the process, I must confess that I have
a bias that favors the older more personal system.
However faulty that old system might have been, at least it's an ethical system that reflects one's own ideas about
life, the human body and mind, human relationships, suffering, and death. These ideas emerge out of a mix of influences from
family, teachers, role models, school, community, religion, and from one's own personality.
It is too simple to say that I believe you practice medicine the same way you practice life. If you are inherently a sensitive,
compassionate, and communicative person, that's the kind of doctor you'll be.
If that's true, why is ethics needed as a formal discipline? I think the answer is that an understanding of ethics allows
one to strengthen ones own principles and impulses through actual daily practice. It also enables you and your patients and
your colleagues to evaluate your performance. Consensus ethics has much to recommend it in a democratic society, and it must
have a place in a profession of nearly half-a-million practicing members, but I also wonder, can an act ever be "ethical",
if the majority of people oppose it? Similarly, is an action always "ethical", if the majority of the people support
In short, the most important decisions that class would make during their entire career would spring from a personal vision
of the ethics of modem medical practice.
There is another aspect, even more difficult, and that is the relationship and rapport with the patient, the subconscious
estimate of that person, and the level of trust invested in each other. The computer can't do that. No program has been
written for the life and death decision to start a course of therapy that has only an outside chance of success . . . or to
stop a course of therapy that appears to be useless. That was the heart of the problem facing the emergency room physician
who first saw Karen Ann Quinlan.
I went through the possible thinking processes of that individual. When I concluded that mental exercise, I predicted that
as time went on the graduates would rely less upon precedence and technology and much more on the building blocks that had
formed their essential character - the influences of family and community.
I hope that they remember that I said, "Out of such richness in your own biography, you will find the course of action
that will be ethically just and morally correct."
I then raised a question about whether they saw themselves as a "parent figure" or did they see their patients as
partners, while they play a role that allows them to make certain decisions on their own. Questions like these would remain
throughout their professional lives and whether consciously or not; they will provide answers merely by going about their
daily tasks. The ethical conduct of medicine today is an amalgam of the day-to-day conduct of half-a-million licensed and
practicing American physicians. It is a "perceived consensus" rather than a "prepared consensus".
So, the way one delivers medical care over a lifetime will influence the entire profession's approach to ethical conduct
and will surely affect the general public's perception of how well medicine is being practiced.
I closed with the thought that medical ethics is - and will continue to be - a central concern for all physicians, not matter
what type of medicine they practice.