Is There a Duty for the Elderly to Die?

As a segue from my previous posting on sheparding of scarce resources by considering "social worth" of the patient, here is another topic from my now inactive "Bioethics Discussion Pages" which deals with an even more controversial issue: the suggested duty for the elderly to die. I should point out that since former governor of Colorado, Richard Lamm, allegedly made this comment years ago, there has been writings in the literature that he really didn't mean what has been publicly quoted. Nevertheless, this is an issue that is worthy of discussion since the concept might be extended from healthy elderly (Lamm's population of interest) to the sick elderly who seem to be the biggest consumers of healthcare dollars in our country. Certainly the visitors to my bioethics website took on the issue with some mighty interesting comments against the governor's view. Note: the oldest comments are at the bottom of this posting. And now, yours? Anyone think that there is any merit to the proposed concept? ..Maurice.




Is There a Duty for the Elderly to Die?

Former Governor of Colorado Richard Lamm had lit a firestorm of controversy when he suggested that old people have a duty to die. This concept has been elaborated by others. The reasoning is that our society, at least in the Western world, have no good financial plans for long-term care for the aged when they become incapacitated because of illness or mental debility. Often these persons become a financial and emotional burden for family members and may require family members to alter their own lives and goals simply to care for their aged relatives. It has been suggested that these burdens are not acceptable and that the aged should find a duty to terminate their lives before they have reached such a dependent state. This means that an elderly person while mentally competent and not terminally ill should arrange to die. The argument is that their life is almost over naturally and they should not interfere with the lives and careers of others who have yet many years of life ahead. Also implied is that society's monetary costs for caring for the elderly infirm could better be spent on children and younger people.

Here is the question:
Is There a Duty for the Elderly to Die?

---- THE DISCUSSIONS ----
Date: Tue, Mar 9, 2004 6:58 PM From: khmaio@earthlink.net To: DoktorMo@aol.com
"The" elderly is itself an unethical descriptor. I am not sure it has any meaning. Do people have a duty to die based upon their age? Silly. Proponents of the argument are not looking at people but at budgets, bottom lines. It is an academic discussion, mainly for entertainment. Harold

Date: Wed, Feb 11, 2004 3:56 PM From: tlrose@cox.net To: DoktorMo@aol.com
I was appalled by the suggestion that edlerly have a duty to die. I not sure how this man was ellected as a civil servant. I also wonder who will be taking care of him when he gets older, or if something was to happen to him now. I think his time would be better spent in trying to change social issues that impact the elderly.

Date: Wed, Jan 21, 2004 11:08 AM From: khmaio@earthlink.net To: DoktorMo@aol.com
I am amazed at the metaphor, "duty to die". I understand the "right to life" and living wills and advance directives which document an individual's choices, but a "Duty to Die" is a corporate metaphor, intent on a bottom line, and nothing else.

I also object to the employ of the term "burden", it is emotion-laden, and judgemental. Is it ethical for this site to reference a person as a "burden"?
Harold A. Maio, Consulting Editor Psychiatric Rehabilitation Journal Boston University

Date: Tue, Jun 17, 2003 6:56 AM From: wibarth@attbi.com To: DoktorMo@aol.com
I was glad to read that most believe that the elderly do not have a duty to die. I think as in other cultures that our elders should be shown respect and have a place of honor in our society and not just tossed aside to die. I think that society is beginning to change in this respect. With more parents having to work grandparents are now taking on a role of assisting the caregiver. Many grandparents are now living near or with their families. I also think their worldview should be valued. This is not saying that wisdom comes with age but they have had different experiences in their life and maybe knowledge gained through those events would give different perspective that should be valued. I think the only time that anyone might have the duty to die is when care provided is futile care.

Date: Tue, Jun 3, 2003 4:41 PM From: Meganterryhansen@aol.com To: DoktorMo@aol.com
In my opinion, the elderly have the right to live as long as possible. If anything their children, family, and society have an ethical obligation to take care of them. We will all be elderly some day (hopefully!) and won't we wish to be respected, cared for and granted the dignitiy we deserve?

Date: Mon, Apr 7, 2003 1:19 PM From: MEME760@aol.com To: DoktorMo@aol.com

Yes the elderly has the right to die, but only at there discretion. If they feel the quality of life is over for them and a terminal illness or some other medical disorder that would require prolonging a life that would not have the quality to care for themselves. No it should not be up to anyone else to decide when the quality of life is over for these indiviuals, furthermore did the elderly put there children up for adoption when they interfered with there careers and when they finiancial burdens increased due to expenses to care for a child, some children grow up and become so high strung with there careers that they forget where they came from and who was responsible for giving them the foundation they have. I think these indiviuals should doom themselves dead if they have no regard for the elderly, last but not least the older the wiser and the Lord did not spare there lives this long for someone else to decide it is over.

Date: Wed, Nov 13, 2002 12:47 AM From: BruceLinquist@aol.com To: DoktorMo@aol.com
Good evening Sir I see the debate is quite heated as the question posed speaks more to life as to death. Prior to my retirement from United States Air Force I would participate in medical exercises where we triaged our simulated war wounded. For instance their were those who given the combat situation were not the immediate priority due to the extent of their wounds but our attention would be the ones we could save on the battle field.

It seems the good governor has a combat battle field casuality ideology that he is applying to healthcare or his version death care. Only their wounds are from their age. That is at best misguided and at worst means we have a person in power with at least two potential characteristic of Psychopathy, lack of being able to empathize, and perhaps Axis II Narcissistic personality disorder. The god complex didn't work for the most beautiful angel and mankind doesn't wear it well either literally or figuratively.

I also taught value clarification exercises and it seems the author also see's us in a life boat situation. Let it be known that If I had to choose who stayed in the boat or didn't I don't think this politican would have a place in the boat. I would rather have men and women who through life experiences many through World War II knew about not just surviving but being a team and overcoming the impending tide of the enemy. Perhaps instead of wanting the elderly to "due their duty" he should realize many did and we are fortunate enough to have them. When is the last time he picked up a rifle and watched his fellow comrades die deaths dance prior to the victory at Normande. Where would he be without their sacrifice. Something to reflect on during Veterans Day.

[ Moderator's note: Governor Lamm or any other visitor may write a rebuttal to the above characterization.]

To take life is in direct conflict to every ethical code I've reviewed although I must admit I haven't read the aryian nations code. I have yet another lens perhaps that would be beneficial for the governor to look through. Lets say an age is set by someone else and adopted and it is the governors age or the age of his wife or perhaps he has a child that the criteria now includes. I think his ideology would be transformed to reality.

I'm usually not into throwing stones even intellectual ones because I'm painfully aware in us all is the capacity to be as deadly as Hannibal Lecter or as belevolent as Mother Thersa. I do not wish to attack this person but his ideology and the growing type of thought that puts not only the elderly but practically everyone that the list makers decide fits the criteria. Isn't that a scary thought.

My position at this point now tends to be more based on emotion and compassion. I've known so many older people that have been the tapestry of my lifes experience. They have imparted their hertitage, culture, values, and love. Without their mentoring I wouldn't have the compassion I have now for just about everybody other than those who would legalize hurting the ones I care about. I'm sure even for those who support death care must have some childhood memory that they hold like buried treasure. If not even they could not even begin to comprehend the loss of the elderly to this world. They are more precious than money because despite our age of efficency and cost effective measures you can not put a price on the human spirit.

Respectively, Bruce Linquist, MSW, CADC III, Retired USAF

Date: Tue, Nov 12, 2002 5:47 AM From: student@chesterfield.k12.va.us To: DoktorMo@aol.com
I believe that the elderly should live as long as nature or god permits. However, I don't think that we should take steps toward furthering their lifespan beyond what they have naturally been alotted. If science were to increase the lifespan of every human on the planet we would undoubtedly exhaust our resources and famine and disease would be rampant and nearly unstoppable. Certainly the elderly are entitled to a long natural life, but not an unnatural one that would make them a burden on society.

Date: Tue, Sep 24, 2002 5:10 AM From: ChigwellCh1ck@aol.com To: DoktorMo@aol.com
Hi, My mother had so many different illnesses during her lifetime, but was nevertheless an amazingly strong woman! To my mind she died much too young - she was 79. Up until the Christmas before she died she enjoyed her life - in fact she was much younger in disposition than most of her juniors. Just five months were fatal to her and even much of that time, when under medication and nursed at home by her daughters, was spent laughing, planning, cuddling and generally enjoying what was left of her life. She underwent no treatment other than 'love' and painkillers. A cerebral carcinoma (brain tumour) ensured that her mind was taken before too much pain took over, and she died in peace, seeming to return to a childlike state. How can anybody be so selfish as to think that there should be an upper limit on a person's lifespan? Euthanasia is another subject, and one which needs to be addressed separately if a person is suffering unduly - however, a happy life should be allowed to continue. A person contributes a huge amount to the lives of others before they die - even, and sometimes especially in their twilight years when they often gain a special kind of maturity and tolerance which they can pass on to those around them. Families do owe a lot to their elderly relatives, and my sisters and I put our lives on temporary hold while we stayed with her 24 hours a day until she died. After all, she devoted a lot of her life to us, so it was pay back time wasn't it? Come on people (at least those who know that I mean them) - take responsibility and stop being so selfish - especially Richard Lamm!

Jackie Sherlock
Date: Mon, Apr 22, 2002 1:13 PM From: saltex@intertex.net To: DoktorMo@aol.com
My grandmother was 70 when I was born. She died at 96. She had high blood pressure, chronic heart disease and arthritis of the spine, hands and feet. The spinal arthritis bent her double by the time she was 80, and her hands were crippled and painful to use. She nevertheless enjoyed life to its fullest, laughed easily, nurtured as second nature.

She grew her own garden and orchard, canned from their abundance, baked her own bread, cleaned her own house, washed clothes in a big black washpot, cuddled children, made tea cakes, wiped tears from small faces, and cooked three meals a day until she was 91 and entered a nursing home. In the 26 years my life and hers coincided, I learned more from this small, crippled, aged woman than I could learn from any other in a 100 years. That "elderly" wisdom has been passed now to my children, and my grandchildren. If she had "done her duty" and died, four generations would have been deprived of knowledge, wisdom, the ability to be self-sufficient, and all the other of those small but crucial everyday lessons that make life infinitely greater in sum than the whole of its parts would indicate.

In the South, we have a word -- "grit." If plural ('grits"), one eats it. If singular ("grit"), one is eat up with it. My grandmother was plumb eat up with grit, to use the vernacular. Until there is a way to measure the aformentioned grit, leave well enough alone. People come into their dying in their own time and place, just as they do their birthing.

And there's not a one among we humans qualified to make that call. Sally Rogers
Date: Thu, Mar 28, 2002 2:35 PM From: dntbfooledbyme@yahoo.com To: DoktorMo@aol.com
Even though I'm only a junior in high school I find it quite offensive for someone to tell me or anyone else for that matter that you have a duty to DIE when you are "old". What is old anyways? In some family's if you hit fifty you're old and likely to die soon, some family's the average is eighty. Although neither of these are the case in my family. In my family we have a tenancy to die later then most people we live our lives well into our 90's even our 100's therefore we are usually able to see our great-grandchildren grow. But we also have a tendency if we don't grow old we die a tragic death early in life. They tend to even out each other in the world as do the rest of the world and some families balance out other ones. You see that’s the way it works we go in our own time if that time is at age two so let it be if its at age one hundred and three you need to let that be too. Because people tend to have a way of evening out the ratio ourselves we don't need to go killing ourselves because "we're to old" and the society can't afford to pay for the medical costs or housing. No one knows when they're going to get sick or how it will affect the ones around them, but we deal with it every day, we have in the past as we should in the future. Because if we start telling people they need to die when they get into this age range what's next? Are we going to become like other countries and say only this many children are aloud to be born so we are able to deal with them when they're older? I hope not. Please think about it.JR Ostermeier

Date: Thu, Jan 10, 2002 6:57 PM From: Metman499@aol.com To: DoktorMo@aol.com
Hey, It is impossible for me to sit here and read some of the coments saying there is Thu, Jan 10, 2002 . I am in high school and feel that I should not begin to count down the number of years I know I have left. How can people urge a cap on life. If someone undertakes a lifelong humanitarian project that takes one day past the limit what happens? These people can not see the fruits of a life's work or it may never even be completed. We are the richest nation in the world and certainly have the resources to keep these people alive.Nick Zmijewski

Date: Wed, Nov 14, 2001 6:24 PM From: RITEWINGBC@aol.com To: DoktorMo@aol.com

God save us, what kind of Nazi is Lamm, anyway? I can imagine someone heinous enough to think such a thing, but it is hard to imagine a politician in the United States having the gall to say it publicly.

[ Moderator's note: Governor Lamm or any other visitor may write a rebuttal to the above characterization.]

No, there is no "duty to die", nor could there possibly be one. I will not elaborate on religious and ethical reasons to oppose such a duty, although I consider them binding. God would have us appeal to His providence, and not rely (to use the Biblical phrase) on the "arm of the flesh" (that is, taking such ultimate matters into our own hands). But, of course, those who do not acknowledge God's existance, or His authority, will not be impressed with such arguements.

However, even from a secular perspective, how can there be a "duty" to die? Who, after all, created the moral arguement that people have a "right" to publicly funded health care? And who wrote the rule that said that adult children have a "duty" to care for their parents? As a Christian, I am absolutely convinced that people have an obligation to help care for their elderly parents. It is a logical extension of the rule that says parents should care for their minor children, as well as an extension of the law of general benevolence ('do unto others as you would have them do unto you'). I can also see some reason to believe we ought to help the sick when they cannot help themselves.

But these dictates come out of a Judeo-Christian perspective, which I am sure the advocates of a "duty to die" are willing to toss out the window. Hence, what is their problem? Let Granny be. If she decides to go down swinging instead of just taking the 'easy way out', nobody is demanding that we give her a hand. So why are we insisting that she go out at a time and in a manner of our choosing? Because we may well find ourselves paying for it. The State is providing an ever-increasing amount of health care cost coverage. And what the State grants, it comes to believe it can withhold.

We must all beware of this line of reasoning. It may well not wait until we are 75 or 80 to catch up with us! We are constantly being warned that we need to be saved from war, pollution, crime, guns, bigotry, AIDS, ... the list of boogey men is long. But who will save us from our self-appointed saviors... i.e. the government and the activists? Let them learn their place, and stick to the needful tasks for which government is fit (which they all too often neglect to our great harm), and leave the question of who dies and when to the conscience of the people. Bill C.

Date: Sat, Feb 10, 2001 6:40 AM From: rthull@acsu.buffalo.edu To: DoktorMo@aol.com
Perhaps this is the wrong question. Daniel Callahan, co-founder of the Hastings Center for Society, Ethics, and the Life Sciences, has raised the question of whether there is a duty for the elderly (which he pegs at 80 or above) not to consume vast amounts of medical resources in attempting to prolong life. By that age, nearly everyone has achieved life's goals. Given that resources are limited, the cost of a heart transplant or other very expensive technology serves to deny resources to those who have not completed a full life. Therefore, medicine for the elderly should concentrate on improving the quality of their remaining life rather than extending the quantity.

It is a simple argument. Apart from the occasional example of a Grandma Moses whose life takes new directions in later years, what is the point of supporting full-bore allocation of medical technology to the elderly when it is to the detriment of those younger?
Richard T. Hull, Ph.D. Professor Emeritus, Department of Philosophy, SUNY University at Buffalo 4845 Spaulding Drive, Clarence, NY 14031-1563, 716-759-6692, rthull@acsu.buffalo.edu


Date: Tue, Jul 25, 2000 3:03 AM From: nolan_tina@hotmail.com To: DoktorMo@aol.com
All I can say is that I lament the kind of world we live in if we even have to ask this question. The elderly have so much wisdom and history to share with us. These are the people who cared for us when WE were in nappies, incontinent, and unable to care for ourselves! It is part of the cycle of life for us to care for them when they can't do it for themselves. To speak of dying as an act we perform out of a sense of duty towards someone else is a sad reflection on society. Death is something we will all be forced to confront someday, whether we accept it or not. Would YOU like someone to tell you, when you are coming to the end of your life that it is your DUTY to die?! This issue comes down to basic respect and human decency, which must be sadly lacking for this to be seriously posed as a question.

Date: Thu, Jun 22, 2000 7:25 PM From: skydive@brightok.net To: DoktorMo@aol.com
As both a Registered Nurse who works with the "elderly" and as a granddaughter who helps care for a 91 year old grandma and her 96 year old sister I would like to respond to this question. Who decides what age constitutes "elderly"? Is it 75? 85? What about the 60 year old with chronic lung disease from 40 years of smoking? What about the "crack" baby born 12 weeks premature who will cost society thousands of dollars in his/her first years of life. Yes, I have days when I am tired of caring for my elderly relatives, but this is the cycle of life. We all need care at the beginning of our lives, and some of us need care at the end of our lives. Nurses affirm the sanctity of human life and we dedicate ourselves to providing care to those who are experiencing illness or seeking a higher degree of wellness (preventative care). We also provide care to those who are dying; our goal is to assist the dying person and their family to acheive a death with dignity.

Date: Sat, Jun 17, 2000 8:27 AM From: vannostr@intellex.com To: DoktorMo@aol.com
In Jourard's classic 1957 article entitled "An invitation to die", he poses this question and makes numerous supportive observations. Be it conscious or unconscious, our general United States' society today, some 40+ years later, still "invites" many to die, including the elderly. Interesting that we still do not value individuals for who they are, what they were, who they will be, and how they can/will still contribute.

Date: Sat, Apr 22, 2000 5:59 AM From: davidh@midusa.net To: DoktorMo@aol.com
Hi DoctorMo
This is a rather stark way to ask a question and I think that is probably a valid way to draw attention to this difficult question.

I look at our nation spending a rather large and unprecedented amount of our GNP on health care and I think this is a very valid question. The fact is that to be born is to anticipate your death: death is inevitable. Can families (and nations) spend unlimited amount of financial and personal resources on individuals who will not tangibly contribute to the family over the long haul? I think the answer to that is "no" but I have several provisions. While I am willing to admit that the elderly and the disabled bring compassion, caring, wisdom (really good and valuable things) in to our lives, I don't think this real and compelling good outweighs everything else all of the time. Also, all persons, young and old, abled and disabled deserve CARE. To me, the crux issue is never the withdrawal of care. That should be an ongoing given. The crux issue is, more often, the withdrawal of life-preserving measures, procedures including the treatment of infections, feeding and hydration, surgical procedures.. My husband and I have had many, many discussions about the conditions under which we want our lives conserved and the conditions under which we want care but not curative measures. I feel like I know that for him (and our minor son) and he knows it for me and our son as well as possible. It is a beginning. we would have to apply it in the context of a real life situation.

I think some how we must help docs nurses and the general public to view life in the context of the family AND to help them understand the difference between care and aggressive life sustaining measures.janet, RN, KS

Date: Wed, Mar 1, 2000 2:15 PM From: vancec@uci.edu To: DoktorMo@aol.com
The whole human experience includes not only experiences of happiness and pleasure, but also those of suffering and pain. Being financially and emotionally strained by the aged population is part of living. And having the experience to care for elderly people makes us more well-rounded human beings.

Date: Wed, Apr 21, 1999 12:06 AM From: tcummins@unlinfo2.unl.edu To: DoktorMo@aol.com
I honestly do not understand the premise of the theory that elderly people have a duty to die. In my opinion, this duty to die theory completely contradicts the idea of self-determination that supporters of assisted suicide are always preaching. If someone has the right to choose to die, shouldn't they have the right to choose to live? I personally would never see another family member as a burden and would hope that in such a situation that I would rise to the occasion and do whatever it would take to make him/her comfortable and happy throughout the rest of his/her life. I think those in favor have forgotten the simple idea of getting joy out of life - you can still get it even when you're old - even when you're unable to care for yourself fully - even when you must depend on others. I think it's very selfish to say you are unwilling to care for an elderly family member because you don't want to change your lifestyle or sacrifice anything of monetary value. You should respect the people who cared for you when you weren't able to care for yourself.

Date: Wed, Feb 17, 1999 5:26 PM From: RNCFNP99@aol.com To: DoktorMo@aol.com

No one should be allowed to die just because they are elderly. Each and everyone in society has every right to live in whatever quality of life he or she chooses. What is the definition of elderly? Is it age? Is it the graying of hair? Is it the disease? Or is the incapacities that make them a burden to society? Old age is only a number. What is important are the attitudes they carry themselves in order to live. If we allow them to die just because they are mentally incompetent, or too old and weak, then what about those in coma, or neurologically incompetent? Should they die as well? We in this society still need to value the wisdom and the many stories that have transformed us to where we are now. It is a respect issue. Respect for the elderly and respect for human lives!

Date: Tue, Oct 27, 1998 5:57 PM From: aecjones@enkahigh.buncombe.k12.nc.us To: DoktorMo@aol.com
I think that the elders do have a duty to die. If the family members have to altar their life style, then I think it is up to them. I believe that the doctors should look at the financial support availible before they are allowed to treat the patient. The elder also has an opinion in this matter. He has lived his life and if he wants to die, let him go. The family is probably trying to hang on to the person for as long as they can. The elders do have a duty to die. Death becomes everyone. If it is time for them to go, let it be done. Think as if it was back in the day without modern medicine. The person would be let there to die.
Connie Jones

Jeremy McSpadden Enka High School, Candler,NC
Date: Mon, Oct 12, 1998 5:11 PM From: Tonester1@aol.com To: DoktorMo@aol.com
Hello, in my opinion I do not think that because someone is old they should have their life questioned. It does not matter if they are old and worthless to society, because that is the same as children. Children also have no relevant contribution to society, should we let them die too? This topic should not even be a question. Why would we want to let the elders die? They are really no different from me or you, except for their age. If anything we should respect our elders not kill our elders.

Date: Wed, Sep 30, 1998 9:46 PM From: osbornemanly@bigpond.com To: DoktorMo@aol.com
I believe that nurses are unaware that they hold true this belief that the elderly have an obligation to die. Daily I witness nurses caring for a patient in the final stages of their illness being treated as though their life was worthless & that the nurse begrudged the care required by this patient. I fail to understand why this trend is becoming more obvious or why. I would like to know if other nurses have witnessed this same impatience when elderly patients are TOO SLOW TO DIE.

Andrea Taylor, osbornemanly@bigpond.com.au
Date: Thu, Mar 19, 1998 7:50 AM From: pddoeppe@ehc.edu To: DoktorMo@aol.com
Hello, In my opinion, I do not feel that there is any "duty" whatsoever for a human being to die once they reach a certain age. In fact, I laugh at the very thought of it. It is my belief that if God wanted elderly people to die at a certain age, I am sure that he would take care of it. In The Bible, (if you so believe) it tells us that we are to use our elderly as sources of wisdom and gain strength from the things that they have testimonies in. I am a firm believer that every person on the earth was put there to meet who they meet and to do what they do, whether it is to help them in their life or someone elses life. This couldn't very well happen if we were to exterminate all elderly people. I would also like to ask all of those in opposition to my opinion a few things. How would you choose who was to live and who was to die first, if it was up to you? I think that in our society, it is more often than not easier to stand behind something that might never effect you, but this would. If you think that all elderly people should be extinguished, say at the age of sixty five, what would happen to your opinion if you woke up tomorrow morning and you were sixty four? In my opinion, your opinion would be quite different. Mine would. How would you kill them too? That's right. If you choose to do away with people of a certain age, you are still killing them. Who would be responsible for the millions of senseless murders each year? Would it be on the head of the voter? I would also like to bring up the fact that we all are here because of our parents and our grandparents, do you think that you could look them in the eye and then kill them? I would like to think that most of us wouldn't. In conclusion, I would like to say that in my opinion, I don't think we would ever have to worry about this problem. I think that there are enough people in the world who would never vote this in, reguardless of their morals, values and/or beliefs.Piper

Date: Thu, Mar 19, 1998 7:48 AM From: jjohnson@ehc.edu To: DoktorMo@aol.com
If one accepts the argument that it is the duty of the elderly to die, there would be arguments by others that other segments of the population must also die. For instance if it is established that the life of those who place a burden on society should be exterminated, many more besides the elderly would be affected. The poor, handicapped, children, criminals, and mentally incompetent may all be seen as burdensome. Thus should society decide that it is the duty of these groups to die too. The value of life is what is troublesome to me about this argument. Living in a society that prides itself in the advance of civilization, why are we resorting to Darwinian views that endorse the elimination of "our weak." Will sacrificing the weak segments of our population, really improve the quality of life for those remaining? Whether quality of life is improved or not, by reducing the diversity of our population do we not risk jeopardizing the resilience of our population to adapt to future ecological change. Although allocation of scarce medical resources is controversial and difficult problem, I believe simpler solutions exist then society deciding whose life still has value and whose does not. I do agree that medical costs associated with the end of life should be evaluated and some reform should take place. In my opinion, it is time society refocuses placing a bigger priority on a lifetime of activities to prevent disease, rather than a few months of expensive practices to prevent death.
Jeremiah Johnson, E&H Box 168, Emory and Henry College, P.O. Box 9001, Emory, VA 24327-9001, Voice:(540)944-4121 ext 6559, jjohnson@ehc.edu

Date: Fri, Feb 27, 1998 10:54 PM From: Minmei@prodigy.net To: DoktorMo@aol.com
Greetings
I think that if we could mandate a law that the wealthy would have to totally give up control of their money, we could then begin thinking about the duty of old people to assume room temperature. I doubt the wealthy will surrender their money, but if they do, then I would consider thinking making the elderly give up their life. I think the elderly are safe with my plan. I really enjoyed visiting your page.
Larry McManus

Date: Thu, Jan 8, 1998 3:03 PM From: Katie64273@aol.com To: DoktorMo@aol.com
The first thing that should be addressed in answering this question is the word "duty." This is a very strong word and it implies that once an elderly person reaches a certain age that it is their obligation to give up their life to benefit the rest of society. If an elderly person should choose to sacrafice their life because they feel that they are a burden, then this would be a different issue. However, it is not our position to tell a person that since they are a burden, that they are required to die. Personally, I feel that we should respect our elders. The elderly population is made up of our parents, grandparents, and friends. The elderly should be seen as wise and experienced. They are the best ones to teach us about our history and events that they have lived through. I think that we should respect them and love them and not treat them like useless objects. Also the idea that elderly people are a burden to us is a stereotype. We often use the elderly as scapegoats and we blame our problems on them. Not all elderly people are like this. Many are healthy and not burdens at all. Also, if we start to get rid of the elderly, what comes next? Will we begin to get rid of everyone who we don't like, or who inconviences our lives? We should respect the elderly and enjoy with them the time they have left in this earth. Afterall, they were hear before we were. We should love the elderly and care for them. Katie

Date: Wed, Jan 7, 1998 2:03AM From: sztrajt@netlink.com.au To: DoktorMo@aol.com
A duty by definition means a legal or moral/ethical obligation to commit suicide once a person reaches an age which is classified as 'elderly'. That 'age' is not beholden to wealth, sickness, infirmity, education, intelligence or anything else other than a numerical number based on the years one has lived. It is an artificial concept without regard to the rights of the individual and would mean that the power of the State becomes paramount as the 'age' would shift depending upon the perceived needs of the State. For example should the State wish to reduce health care costs then the 'age' of death would be lowered. A person has an autonomous right to make his/her own decisions as to life and death as long as those decisions do not impinge upon the rights of others. To say that 'life' or 'death' is a duty is an abhorrent concept that would lead to totalitarianism.

Date: Thu, Dec 18, 1997 10:08 PM From: EAKR07F@prodigy.com To: DoktorMo@aol.com
This is essentially a social worth issue and, as such, need not be restricted just to the elderly. The position seems to be that when, in someone's opinion, an individual is too much of a bother, i.e., in terms of social exchange theory that the costs outweigh the benefits, one should cut one's loses -in this case die. If that is someone's position (and it isn't mine), there will be a very long line of people who the Governor thinks have a duty to have their flame extinquished.

Date: Wed, Dec 17, 1997 8:14 PM From: j97b1171@human.waseda.ac.jp To: DoktorMo@aol.com
I think there is no duty for the aged to die. Needless to say, all human being,even if he or she is too old, has a right to live with autonomy! therefore I could say man should live a life basically for him,herself.The most important thing I want people to understand is that especially regarding to the elderly, they have good wisdom and know tradition more than young aged people, so we should not forget their values. We should be willing to respect their existance!!
Thank you for reading my opinion.(from a Japanese university student)

Date: Mon, Nov 24, 1997 4:24 PM From: Babyblu953@aol.com To: DoktorMo@aol.com
I think that even though people grow old, if God wished for them to die at a certain age, he would do so. Just because someone isn't as young as the rest of us, or can't be as capable of doing things as younger people can, it doesn't give anyone the right to tell them that they should arrange to die. There are a lot of people in the world who have older people in their lives such as grandparents, and even parents. Who are they to tell these older people that they should arrange to die? Are they God? I don't think so.Kelly

Date: Tue, Aug 5, 1997 8:30 AM From: mfournier@courrier.usherb.ca (Vinay Mathey) To: DoktorMo@aol.com
Dear Dr. Mo, We all have the duty to live. Death is not a duty- its an obligatory passage. If such a thing is possible, "a duty to die" is conflicting with the universal duty to live.

Taking care of the elderly has a price The lives of the elderly has no price.
Mirabelle Kelly, mkelly@courrier.usherb.ca

Date: Sat, Jul 26, 1997 7:11 AM From: DocReading@sprintmail.com (William H. Reading, MD) To: DoktorMo@aol.com

Please, read my whole comment before forming a reaction. This is an interestion question after the absurdity subsides. We expect young men to die or at least risk death for alturistic reasons in times of war and there is legal punishment for those who don't. As well, a soldier may be shot by commanding personnel for behavior which is endangering the lives of others during certain circumscribed situations. Certainly, there is no constitutional duty to die but what the law fails to demand would not necessarily be considered unethical. There apparently exists a duty for an unborn human child to die prior to a certain gestation for the convenience of the person (I intentionally do not use the term mother) who has that child within them. I would suppose along the same line of reasoning that the elderly should die for the benefit of conserving scarce resources. What about the handicapped? They use more resources and require more government funds for health care. They certainly have no more right to be alive than an unborn child or an elderly person. They (with the Americans with Disabilities Act) are more costly to American businesses and result in higher prices. Consider then the people who have genetic defects which result in higher utilization of healthcare. And what about the people who carry the high likelihood of genetic defects? Should they be allowed the opportunity to bear children? The testing for genetic defects in utero to decide whether to abort the genetically defective human fetus is costly. Then consider the poor. They are a drain on the economy and use more resources than they can afford on their incomes (that is if they have any income at all). Is there a duty for those who have HIV to die? What about the mentally retarded? Or the mentally ill? What about the whole concept of spending money in research to help diseases which few people have? What about the money spent on HIV research? What about criminals? What about the people who have a high degree of criminality in their families? What about the people with poor eyesight? What about the overweight? What about those individuals who have a higher than average number of physician visits or hospitalizations. What about people who drop out of school or fail a course? What about people who have lied or stolen anything in their lifetime? What about people who are using or have ever used drugs or substances which could harm their bodies? What about people who aren't physically fit? What about the people who have any illness at all? Have I left anyone out? No one has a more of a right to be alive than anyone else does! We are all exactly the same in this respect. To argue differently would be to suggest more of an intrinsic value in one human life as compared to another. To suggest this would also be unconstitutional based on equal treatment under the law so I doubt that legislation to this effect would ever pass. At least I hope that it wouldn't. There can certainly be no inherent duty for anyone to die.
Date: Mon, Jul 14, 1997 7:30 PM From: Nrse4morph@aol.com To: DoktorMo@aol.com

The issue is NOT do the aged have a duty to die, it is do we have a DUTY to keep them alive. It is a mistake on both sides of the issue to think that a finite stance can be taken on an issue that involves so many factors. Two examples are: Religious beliefs are varied and full of emotional as well as philosophical traps and in some interpretations, if no effort is made to save a person it is construed as the equivalent of an act of suicide, or murder. Thus the patient is hesitant to make decisions before getting ill, and /or the family is reluctant to stop or withhold treatment after the patient is incapacitated and can't make decisions for themselves. Ethnic beliefs in which some minorities feel that they have been persecuted enough, and that to live as long as possible is a form of "pay back," and that any questions asked regarding DNR, or living will are viewed as efforts to "kill the brother." I don't understand this one, but I have had it stated in almost exactly these terms on more than one occasion. Add in the Guilt Factor, and you have a situation in which patients are left to the mercy of the healthcare system. Which after all has traditionally charged with the mission to maintain life as long as possible. Mix in the complication of the dissolution of the nuclear family, and the movement of death from the home to the hospital over the last 100 years or so, and you are left with a population that not only doesn't want to deal with these issues, but doesn't know HOW. NO the elderly do not have a duty to die. They are owed the dignity of appropriate care and consideration by their families, and the healthcare profession.

Date: Sun, Jul 6, 1997 3:24 AM From: shaolin@henge.com@henge1.henge.com (Robert Wesley) To: DoktorMo@aol.com
Ever since Richard Lamm raised this issue, apparently by an inadvertent (Freudian?) slip of the tongue, the question of a moral duty has become conflated with a that of a social, political or economic duty. If I do have a moral duty to die so that I will not become a burden on my family, then should I fail to perform that duty, I no doubt ought to feel ashamed of myself, and perhaps others might express their disapproval, etc. However, the question of a "duty to die" in the context established by former Governor Lamm's remarks and by the recent resurrection of this issue involves public policy: if the elderly have a duty to die, then that duty entails a justification for a political decision to withhold medical care, not to fund medical care, not to allow the elderly to spend their own money on medical care, etc. What former Governor Lamm did was to transfer the emotional content of the former to the latter. When we look at the case of someone who refuses expensive medical treatment in order not to become a burden to his or her family, we may well admire the nobility of the sacrifice, but that approval does not carry over, except by a concealed illicit inference, to the case of a governmental body making the decision for that same person.Robert Wesley

Date: Wed, Jun 11, 1997 4:02 PM From: af485@lafn.org (hans g engel) To: DoktorMo@aol.com
Maurice: Do the old have a duty to die? This question is as illogical as asking whether children have a duty to die. They also are unproductive and of no "use" to their society (of course, if such duty existed, that society would end rather abruptly!). And just what is "old"? a seventy year old today is probably in the same physical condition as a thirty year old was 150 years ago. If we are speaking of those with physical or mental disability only, then age is not pertinent either; also what degree of disability should demand the "duty" to die? "Duty to die" implies death due to outside demand or suasion rather than the aged person's own wishes and is therefore unacceptable. This is an issue totally separated from euthanasia; it is essential that the two concepts not be linked in our thinking.
HGE, M.D.

Date: Mon, Jun 9, 1997 10:11 AM From: acholson@counsel.com (craig cholson) To: DoktorMo@aol.com
(Throughout the following first thoughts, I follow the example of most of our colleague-writers, using the term "duty" in its common form rather than the more specific philosophical usage.)

Some colleagues have recently answered the question in the affirmative: that there may, in fact, be a duty to die given certain circumstances. The most prevalent circumstance seems to be an illness with catastrophic results for the family of she who is ill. Surely, it is argued, it is better for one person to die rather than an entire family be put to great hardship economically (or otherwise).

Although arguments of this kind have a certain first blush appeal, it seems to me that these arguments cannot do the work asked of them. Firstly, to insist that any person has a duty to die is, I submit, in violation of the Kantian ethic. Further, such insistence cannot respond adequately to any model of either beneficence or nonmalificence. Secondly, the majority of such arguments beg the question, who shall decide who must die, and at what point? The inference is that the family decides, the person accedes, and a third party assists. Any scenario resembling this can best be described as coercive and, thus, could hardly be considered ethical. Finally, the only method advanced to date for determining whether/when a person has a duty to die has been that of a modified Quality Adjusted Life Year assessment. While I personally find QALYs repugnant and try to avoid their use, it seems to me that most institutions and people have accepted QALYs with regard to life-extending procedures such as organ transplantation and have rejected end-game scenarios rooted in a cost-benefit analysis of the QALY form.

I do not make a case for a person who wants to die being prevented from so doing, nor do I wish to advance an argument concerning restrictive covenants. My intent is to submit that, while there may be good reasons (social, economic, etc.) for a person suffering from an illness with catastrophic consequences to others to want to die, there is no duty to die.Agree/Disagree/Comment? Please feel free to respond to acholson@counsel.com Craig Cholson

Date: Wed, Jun 4, 1997 6:42 PM From: NBelle3189@aol.com To: DoktorMo@aol.com
The elderly have no more duty to die than the newborn. I come from a family where a majority of us live well into out 100's. My aunt is 101 now and fully mentally and physically competent. I can't imagine Aunt Bertha having a duty to die no more than I can imagine me having a duty to die at age 45. She is a vital link to the 19th century and I hope she makes it into the 21st century. She remembers her grandmothers tales of slavery and her grandfather's experiences with the undergroud railroad. She has heard stories of her grandfather's experiences as an indentured servant in New York and how he came to Virginia to seek farmland and a living. Her grandmother was able to tell her of the Great Emancipation and Abraham Lincoln and the Civil War from both the Union and Confederate sides. Aunt Bertha is living history and the future because most of my generation can expect to see our tenth and eleventh decades. I just hope we can put our emphasis on quality of life and preventive medicine so that scarce heath care is available for those who need it.
Natalie Belle, Medical Student, Howard University

ADDENDUM: For an excellent and extensive discussion of the ethics of “duty to die” by John Hardwig, Department of Philosophy, University of Tennessee
which was published in: Hastings Center Report v27, no. 2 (1997): 34-42, go to this link. ..Maurice.

"Social Worth" in the Allocation of Scarce Resources

The following post is taken from my now inactive "Bioethics Discussion Pages". The issue is one of "rationing at the bedside". Does every patient who needs a scarce resource for health should be eligible for the resource? Should factors other than need be considered at the bedside and should thought be given to other patients who might need same or similar resources or should the costs of medical care be considered in treatment decisions of the patient in the hosptial bed or across the desk? Though the responses from my visitors (beginning at the bottom of this post) are from 1996, they are as pertinent in today's period of medical care where resources such as organs for transplant are still scarce and the cost of medical care in general is rising. Feel free to add your views in the Comment section of this post. ..Maurice.


In medicine, allocation of scarce resources has always been a problem but it is more so in these days of organ transplants and expensive technical procedures. Laura MacLachlan raises the ethical issue of to whom the scarce resource should go when there is more than one patient waiting for the resource and wonders if the patient's "social worth" should be a criterion for the decision regarding allocation. Here are her questions:

Date: Mon, Jan 1, 1996 5:30 PM EDT From: lmaclach@chat.carleton.ca To: DoktorMo@aol.com
Given that we are currently attempting to manage scarce health care resources, a new area of ethical dilemmas has risen to the forefront. The subject of importance is that of the ethics of subscribing to "social worth" as a criteria for determining which patients receive expensive procedures. Is it ethical for health care providers to allocate organs and dialysis to those who are younger, healthier and more wholesome? For example, a long time alcoholic requires a liver transplant at the same time as a young child who has a congenital liver disorder (given organ availability and that histocompatability is desirable for both). Can we favour one person over another? Is this ethical?

Here is the question:
Is it ethical to favor one patient over another when considering allocation of scarce medical resources based on the "social worth" of the patient?

---- THE DISCUSSIONS ----

Date: Fri, Mar 28, 2003 9:26 PM From: prislark@yahoo.com To: DoktorMo@aol.com
With today's advanced medical technology, it would seem that somehow the plethora of life-saving procedures available would be able to address the needs of almost all the critically ill or injured, at least in the U.S. The method of allocating these resources, however, has only grown into an increasingly complicated and perplexing issue. Since ancient times, man has struggled with the fundamental question of the nature of human worth, from which these concerns in the distribution of health care stem. Therefore, the ancients of Greece may shed some light in this discussion, despite the stark contrast between their health care resources and America's today. In Plato's "Republic," as Socrates describes the ideal state in his quest for the nature of virtue, he discusses this very issue of allocating health care resources. Condemning those who call for a doctor to cure their illnesses caused by irresponsible, unhealthy lifestyles, Socrates calls this kind of medicine the "nursemaid to the disease." If a man must spend his life consumed by keeping himself alive by constant medical treatment, though he may live a long time, Socrates deems that life worthless. Socrates commends the attitude of an ordinary craftsman, such as a carpenter, who visits the doctor expecting a quick, effective treatment for his disease. The carpenter cannot afford to spend his precious time on prolonged treatment; therefore, if the doctor prescribes such a regimen that will interfere with the man's work, the carpenter will simply return to work and either recover his health naturally or die. In his contempt for the rich and idle who can afford to spend their time being sick, Socrates explains that the doctor should only practice on people with healthy lifestyles who have been attacked by some specific disease. In the event of a terminally ill patient "riddled with disease," Socrates deems treatment useless, since it would only make the person's life "a prolonged misery." Similarly, in the Hippocratic Writing "The Science of Medicine" the author defends doctors for not treating hopelessly sick patients, sayign that "Our practice is limited by the instruments made available by Nature or by Art. When a man is attacked by a disease more powerful than the instruments of medicine, it must not be expected that medicine should prove victorious." Socrates argument against treating the terminally ill more closely relates to the question of social worth of the individual, while the Hippocratic doctor desires to preserve the reputation of those in his trade by not taking on too incurable cases. In Socrates' view of the ideal state, each individual's worth depends on his or her relation to the state. Since the weak, idle, and all those lacking somehow in body or mind cannot contribute as much to the state, doctors should not be as concerned with treating them. The healthiness of a patient's lifestyle and his productivity as a citizen in part determine whether or not a doctor will decide to treat him. The terminally ill cannot contribute tangibly to society and might even produce offspring weak like themselves, rendering them of relatively little worth in the state-minded doctor's eyes. Some of Socrates' judgments may seem harsh to modern readers, but the question he addresses still burns. Should patients receive preferential treatment in the allocation of resources based solely on their contribution to society? Socrates' portrayal of a society operating in this manner might cause doctors to shy away from this method of decision-making. However, if society today judges this criterion too arbitrary, what other measurement can doctors use? The light shining from ancient thought on this issue may serve only to cause modern thinkers to abandon currently-held ideas in their pursuit of more satisfying answers.

Date: Mon, Feb 15, 1999 9:59 AM From: J.Perkins@unsw.edu.au To: DoktorMo@aol.com
Surely "social worth" criteria operate anyway in global terms in that access to even basic medical treatment treatment is denied to most citizens of develping countries. It operates in the allocation of research and other medical expenditures, largely concentrated in developed capitalist economies, towards life-threatening conditions mainly specific to those advanced capitalist economies. The result is a distortion in terms of input (cost) and output (return in terms of lives saved).
John Perkins

Date: Wed, Apr 8, 1998 2:00 PM From: StudentComputer@ACS.WOOSTER.EDU To: DoktorMo@aol.com
My answer to your question is this: No, it is not ethical to use non medical "social worth" factors to favor one patient over another. The use of such a criteria to choose between candidates for scarce medical resources can be critiqued both from Kantian and Utilitarian perspectives. I believe the most basic and powerful objection to "social worth" is that such a criteria reduces patients to their potential for maximizing social benefit. Kantian ethics argue that people should never be treated merely as a means to an end. By selecting between patients based solely on their potential contribution to society, they are being reduced to merely a means of achieving the most possible social good. They are not regarded as people with basic intrinsic value that goes beyond their ability to contribute to society. Any patient that does not have the ability to contribute much to society, because they are elderly, mental, or physically handicapped, automatically is unfairly at a disadvantage.

On the face of it, Utilitarianism would seem to favor the use of such a criteria. Choosing people to save based on their potential future contribution would seem to produce the most net benefit. However, the physican/patient relationship would suffer greatly if patients felt that their physicians were continually looking past their personal welfare to the potential for social benefit. Distrust and suspicion would result if patients perceive that physicians were making treatment decisions based on their potential social value. Thus, over a longer period of time, the eventual erosion of the physician/patient relationship could result in less net benefit for society, a result not favored by Utilitarianism.

Addtionally, there are a host of other practical difficulties with appling a "social worth" criteria. Use of such a criteria would require some type of ranking of respective social worth. How does a professional athlete rank against a priest, or an insurance salesman, or a physician. Hwo much should patients' personal life be involved in selection decisions? Given the pluralism of our society, development of such a list is nearly impossible. And even assuming that such a list could be compiled, whose ideas of social value should we use to make the list? Inevitably, personal bias would influence the ranking of "social worth". Ultimatley, the use of medical factors, such as need, amount of resources required, and potential for success, should be used for patient selection, not non mendical "social worth" criteria.
Aaron Glasgow

Date: Sat, Jan 31, 1998 9:23 PM From: andrew@blissnet.com To: DoktorMo@aol.com
A solution to your social worth dilemma: a formula can be devised to determine who will be most productive in the society. It would go something like this: Last year's earnings as reported to the IRS (or earnings of active parents if under 18) 2(age) x 3(tested IQ), normalized to the same scale. Demerits for past behavioral and health abuses are awarded at the end. Highest score gets the liver. This of course, applies only to those candidates who can afford the procedure, through insurance, wealth, or even community drives. If the person is valuable enough to inspire hundreds of thousands of dollars in donations, s/he deserves consideration. This system helps to insure that the individual whose life is saved is one who is a contributing member of society and one likely to continue to do so after the procedure, and for many years to come.

Date: Sun, Oct 5, 1997 4:08 PM From: cabnoon@kear.tds.net To: DoktorMo@aol.com
My answer is yes, it is ethical and necessary to make the best use of scarce resources but not before clear criteria of "social worth" are spelled out. Well, OK, but where to start with criteria? My choice (since this is a health-related question) would be to first establish the patient's "general state of health" (aside from needing the scarce resource). From there, I'm going to use this question as an exercise for my students in a "medical law and ethics" class and I will follow this issue throughout the coming months.
Brian Nooney RPh, cabnoon@kear.tds.net

Date: Sat, Jul 26, 1997 9:05 AM From: DocReading@sprintmail.com To: DoktorMo@aol.com
In allocating scarce resources, social worth (meaning to me utility to society) is almost always considered. For example, in the classical example of a falling plane with 10 parachutes and eleven passengers, how do we decide who will not get the parachute? There are some that suggest that the most able to wrestle the parachutes from another should get them or consider "the first come, first served method". But what about the young child? There are some that suggest that drawing straws is the most fair. But what if the one who gets the short straw is the one who is capable of finding a cure to cancer? Most people tend to settle on the societal worth method. Are we wrong to apply this to medical procedures? The problem arises when social worth does not mean societal worth. Some define social worth as having wealth or insurance. This is where I believe we run into unethical decisions. If it is unethical to allow people to preferrentially buy organs for transplantation, then it is also unethical to allow them to buy the procedure without regard to others. Is it ethical for the government to fund for some what others cannot afford? More specifically is it ethical for the government to fund a life saving transplant for an aging medicare recipient and not to fund the same type of life-saving procedure for a 10 year old underinsured boy or girl?

Date: Sat, Jun 14, 1997 12:03 PM From: shaolin@henge.com@henge1.henge.com (Robert Wesley) To: DoktorMo@aol.com
The way this issue is formulated begs the question of what should be "allocated" and obscures the question of "who" should do the allocating. Whenever one talks about how "we" should "allocate scarce resources," it conjures up a picture of these resources (undefined except insofar as they are "scarce") as if they are already "ours" to distribute. At this level of generality, it will necessarily be the case that someone will be "favored" over another; it is trivially true that when any one person receives a treatment, some other person does not. With regard to organ transplants in particular, there is not one answer to the question of how "we" should "allocate" organs because it is not one question. Should "I," as someone who has no connection whatsoever to the transplant program at, say, the USC medical center, have a say in how "you," as a transplant physician decide who should receive an organ? After all, both "I" and "you" are "we," are we not? Again, is "my" liver or kidney a "resource" that "you" ought to allocate? Suppose that I would like to specify that my liver be donated to my alcoholic uncle? Or are we really talking about the expenditure of federal dollars? If so, livers and dollars really are not equivalent "resources" even if both are "scarce," and the answer to the question of whether someone should get a liver paid for by the federal government is not the same as the answer to the question of whether some other individual should get a liver that he pays for out of his own pocket (i.e., unless you have a socialist medical system in which private enterprise is outlawed). There are many ethical decisions in which "we" do not have rightful stake but in which only the relevant individuals have an interest, and not every health care decision is a "resource" to be allocated. To assume otherwise is to beg the question in favor of "collective ownership" of the "means of production."

Date: Mon, Apr 7, 1997 4:24 PM From: S Ryan 63@aol.com To: DoktorMo@aol.com
I do believe that it is ethical to allocate scarce resources to those who have more social worth. In the case of the alcoholic with cirrhosis, I do not believe they should even be allowed on a transplant list unless they have become sober and are no longer drinking. A child has an entire future ahead, and may be a more productive member of society. Although I do not abdicate letting these people die, Since resources are scarce, it is essential that we do what is good for largest majority of society and a child clearly fits this description in my mind.

Date: Mon, Apr 7, 1997 2:29 PM From: sthievon@REX.RE.uokhsc.edu (S&E Thievon) To: DoktorMo@aol.com
I do believe that health care resources are scarce, and when resources are scarce there must be rationing. To ration, there must be criteria to use in allocating the resources. I feel that the term "social worth" is vague and that the lack of clarity leaves the door open for decisions that may be based on stereotypes and/or prejudices. However, allocating resources based on the best and maximum use of those resources is appropriate. For example, giving a liver transplant to one individual rather than another based on the individual's better ability, capacity, potential, and past history for maintaining health regimens is, to me, the best and maximum use of that resource. The chances that that liver will survive longer are greater. If a patient has been advised about such things as eating a healthy diet, regular exercise, and smoking cessation, but chooses not to adopt and/or maintain these habits then perhaps they should not receive the heart transplant. People must start taking responsibility for their own health. If an individual is not willing to invest any energy into his/her own health, then he/she has not earned the privilege of advanced health care resources. And investing these resources in such individuals is not the best and maximum use. Failing to maximize resources is wasteful.

To address the vagueness of social worth, criteria should be clearly and behaviorally defined. The behavioral criteria should assess the individual's past health behaviors and potential for maintaining the needed/prescribed future health regimen. I realize that this will not address all issues. Issues such as age and financial resources remain. I do not know what would be the maximum or best use of resources when comparing the young with the elderly if behavioral criteria are equal. I do not know whether, behavior criteria being equal, resources should go to a private paying individual or an uninsured individual that has limited financial resources.

Also, some will question what is the best use of resources. Maybe it is not determined by number of years. And if it is determined by an individual's contribution to society, then we may be back to social worth. I always end up in circles with ethical issues. I feel strongly on this issue that resources are scarce and therefore must be allocated. The best and most just way to determine allocation is much more difficult for me. I have included some of my ideas as well as some of my questions. My ideas are always growing and changing with new information and thought.Susan Thievon, Student Nurse in a Bachelor's Program

Date: Thu, Nov 21, 1996 5:52 AM EDT From: prenella@uci.edu To: DoktorMo@aol.com
I do not feel that the allocation of organs for transplantation, should be based primarily such a vague criterion as "social worth." How is this accurately assessed? What will be said about a very kind and loved person, who also happens to be poor and on welfare and yet is still struggling to support his or her family, when it is time to place them on an organ waiting list? Under current guidelines, certainly this person would not be considered to have much "social worth."

Date: Sat, Oct 26, 1996 2:03 AM EDT From: gfalkson@lia.co.za To: DoktorMo@aol.com
I think that it might add perspective if you looked at social "worth" evaluation in a developing country such as South Africa. The "expensive" transplants need quality of life evaluations as well as survival time evaluation. This gives additional perspective when you foreward only an American. or Eurocentric, based arguement. How many patients with testicular cancer could be cured for the price of one heart transplant? Can you make a value judgement? Do you argue that the individual persons "desire" for treatment [attention] is unrelated to "social worth". Do you exclude the patients right to die from the discussion of allocation of resources? I believe that, when properly informed, many are less enthusiastic about the use of "scarce" resources. For the sake of discussion I sugest that many doctors in the first world "believe" in some of the costly treatments and that this is the major reason for the resources being limited, as unjustifiable disinformation is propagated.

Date: Thu, Oct 3, 1996 1:48 AM EDT From: sion@dowco.com To: DoktorMo@aol.com
Am I right to say that in the American system of health care, to even get on an organ waiting list, you have to have insurance, or be covered by Medicaid? What about all those people (for argument's sake, let's say they're all 'worthy' in the sense that they would comply, don't engage in risky behaviour etc) who cannot afford insurance? By excluding access to these people, is that not a bold statement about social worth criteria in itself?

Shelley Ion, Vancouver BC
Date: Tue, Jul 30, 1996 4:44 PM EDT From: 71600.1123@compuserve.com To: DoktorMo@aol.com
The question of how to allocate scarce resources on the basis of social worth begs the real question: why have we defined our abilities in terms of scarcity? Are resources really scarce? In the 1970s, debate in the US House and Senate on dialysis, for example, ended with a determination that a nation as rich as the US should assure dialysis for all, irrespective of income. Now, however, we have defined ourselves not in terms of wealth but poverty. It might be better to ask if the cost of health care seems prohibitive, how can the delivery system be changed to assure fair and necessary treatment for all?

The US spends a great percentage of its GNP on health care, and returns less coverage to its citizens, than any other industrialized world. So perhaps, the issue isn't scarcity but a system of health care which puts people after profits, etc.

In cases where scarcity does reign, organ transplant allocation, for example, no system has yet been well defined which allows us to adequately measure "social worth" as a criterion. In pediatrics, for example: Is the dyslexic with low school scores less worthy than the normal child with high grades in reading? Is there any reason to believe the ninth grade basketball center will be a better member of society than, say, the dream and somewhat uncoordin- ated nerd who sits in the back room and fiddles with computers? (for a discussion of organ transplant, see my Normative and Prescriptive Criteria . . . in Theoretical Medicine 1996, 17:1.

No. The question as framed restricts the way we can, indeed, meet the challenges equitably, and with concern for all.Tom Koch

Date: Fri, May 31, 1996 5:57 AM EDT From: Warren@cafenet.co.uk To: DoktorMo@aol.com
While we all have an equal right to life, it does not follow that we have an equal right to healthcare, which is a social good rather than an absolute right. This suggests that, while a basic level of healthcare should be provided by society for all on an equitable basis as an expression of the common good,we cannot be expected to treat every patient in exactly the same way. The dilemma is how to reach an equitable settlement in which each is given their due value and worth, but which at the same time recognises that society must ask the question "ought we to do what can be done?" when allocating health care resources that are increasingly expensive and scarce. Where cost, both personal and clinical, is disproportionate to the good to be achieved it is not unjust, I believe, to decline to treat the patient. In such cases it is not wrong to favour one patient over another, where the good to be achieved - health and extended life expectancy - is greater for one and not the other.

Date: Thu, Apr 25, 1996 11:44 PM EDT From: Findingman@epix.net To: DoktorMo@aol.com
As a physician for 30 years, practicing medicine from a perspective of "hearing the story" of the person, trying to ascertain the depth of their understanding, what motivates them to live, go on, do the unfinished, resolve those difficult relationships, be productive, make a difference, I find that those patients who have had transplants as adults have risen above the flat line of their lives and choose to see life as something to be lived and not something to be chased. "Social worth" has the unfortunate connotation of value, of something to be contributed, something that inherently gives a sense of future. We the elders decide who and again unfortunately are imperfect yet our decisions are irreversible. Committees are covenient because the decisions take on a vote situation based on the facts of the particular case. Sometimes I think that we do too much cerebrating and not enough feeling and deciding from the heart. The heart knows, where the brain has too much debris and stereotype to render fair decisions in who gets what organ. The system is flawed because we try to make sense out of something that exceeds our understanding and we forget what our hearts are telling us.
James C. Barton

Tue, Mar 12, 1996 3:54 PM EDT From: Serratia1@aol.com To: DoktorMo@aol.com
I have been a transplant nurse at a large university-affiliated hospital for nine years. In the course of my employment, I have seen examples of many different transplant scenarios, many involving ex-active alcoholics and/or drug addicts. I feel that "social worth" is not a relevant tool for determining allocation of organs. If there is a choice between giving a donor liver to a patient whose disease was caused by alcohol abuse, and a patient whose disease was "not his fault" e.g. related to Hepatitis C from a blood transfusion, other factors must be considered. If we pay too much attention to assigning "fault" to victims of disease, then we must also reconsider our treatment of patients who develop disease related to cigarette smoking, improper diet, and insufficient exercise. That is a very broad category, which I daresay includes most human beings. In the past nine years, I have seen many past alcohol abusers who have received new livers, are grateful for their second chance at life, follow their medication and treatment regimens religiously, and are enjoying life. Who can tell what the future might hold for such a person? His/her potential could be just as great as that of the newborn baby with biliary atresia who is yet a "blank slate" and could potentially grow up to be either a boon or a nuisance to society. I believe the best criterion to use in transplant decisions is *compliance*. This is not the same as "social worth". This has nothing to do with vocation (or lack thereof), educational level, race, or the cause of the original disease. The key question is this: How likely is this person to value this transplant, and to demonstrate that he or she values it by cooperating with the accompanying medication, diagnostic, and treatment regimens? I am regularly amazed by the number of transplant patients I care for who have a *recent* (right up to the day of transplant) history of flagrant noncompliance with their medical treatment. Not surprisingly, many of these people go home and decide that it is too much trouble to take their medicines or show up for their clinic visits. Then they are angry that they must be hospitalized for aggressive anti-rejection treatment. Even in the hospital, the doctors and nursing staff must waste time threatening or coaxing these people into taking their medications, having their blood drawn, or having their vital signs taken at "inconvenient" times. Not surprisingly, the heroic anti-rejection treatments are unsuccessful, and the person goes back on insulin, back on dialysis, or (in case of a liver) simply dies. When you add up the waste of staff hours "babysitting" these people, the squandering of expensive anti-rejection treatment, and ultimately the waste of the organ, the cost to society is staggering. All of this could be avoided by better screening measures aimed to insure that potential transplant candidates: 1. Are properly educated as to the demanding post-transplant regimen. 2. Have a record of sincere *recent* compliance with medical treatment, regardless of their past behavior. 3. Demonstrate an understanding of the costs and sacrifices involved in the transplantation process from the donor family to the hospital down to the doctors, nurses, and other staff, and an *appreciation* of the gift of the organ. To some, this may sound paternalistic, but the fact of the matter is this: if you receive a gift that you don't appreciate, you're not going to be likely to take good care of it, be it a piece of clothing, a houseplant, or a kidney. Recently, I cared for a patient who lost his kidney graft due to severe, continuous noncompliant behavior. This gentleman had a recent history of medical noncompliance and one of the most uncooperated, unappreciative attitudes I have ever seen. The last time I saw this man, he was being dragged from his hospital room by several security guards. The doctors had discharged him (finally!!) after he had refused all medications, vital signs, and procedures for two days and then, of course, he refused to vacate his hospital bed. As I watched him being wheeled down the hall, a stream of abusive language trailing in his wake, the thought that the organ that had been implanted in him could have been given to someone who would have treasured it, someone whose life would have been truly enriched by it, was almost overwhelming in its sadness.

Date: Wed, Feb 7, 1996 6:36 PM EDT From: froboz@indirect.com To: DoktorMo@aol.com
As Gloria J. Banks, Esq., points out in Am. J. of Law & Medicine, V. XXI, (1), s"social worth" allocation criteria have been used to determine a patient's potential to be a "productive citizen" after transplant. "Productivity" criteria have included the person's relationship to authority figures, past irresponsible behavior, intelligence, marital status, number of dependents, income, educational background, and employment record. In order to create a more equitable, random allocation system, some havee suggested a first-come, first-serve or lottery system. However, some argue that this type of system will tend to b enefit only those educated individuals who have greater access to those services. The NY State Task Force on Life and Law concluded that the patient's medical criteria should be the sole basis for organ allocation decisions. The "criteria to select transplant recipients must be uniform, public, and fair...[and] be applied in a process that ensures that like cases be treated alike and precludes the operation of bias based on race, social class, sex, or other invidious criteria."

Signe A. Dayhoff
Date: Tue, Feb 6, 1996 10:43 AM EDT From: jbeltran@mail.calypso.com To: DoktorMo@aol.com

I believe that unless and until the transplant business is based upon the concept of presumed consent (we take your parts unless you tell us otherewise) there will always be a shortage and thus we will be dealing with a system that is "unjust" from the get-go.Joe Beltran jbeltran@mail.calypso.com

Date: Sun, Feb 4, 1996 4:36 PM EDT From: jflamini@erie.net To: DoktorMo@aol.com
Re: the question of "social worth" when determining medical treatment and allocation of scarce resources, Dickens' Christmas Carol comes to mind. The scene between Scrooge and Christmas Present is most germaine, and I apologise for not having an exact quote, but the ghost points out that Scrooge would do well to hold his tongue rather than condemn others to die for lack of apparent worth "for in the eyes of God (here substitute any unknowable power if you want to remain PC) mllions may be more worthy than you" or words to that effect. Still a powerful story, and still socially conscious, at times far ahead of his time.John A. Flamini MD

Date: Mon, Jan 29, 1996 8:40 PM EDT From: froboz@indirect.com To: DoktorMo@aol.com
Thanks for Majeske transplant criteria studies' info.[BELOW] Neither science nor public policy is value-neutral because the people doing them aren't. Another interesting area touched by "social worth" question is assignment of responsibility for health outcomes. The question generally asked is to what degree should idividuals be "blamed" for consequences of perceived "life style" behaviors/choices? Perhaps,the companion question to it should be to what degree should big business, advertising, the entertain- ment industry, and agricultural subsidies be blamed for obesity; tobacco, alcohol, and drug use; violence; and STDs?
Signe A. Dayhoff, Ph.D. Social Psychologist Bioethics-Genetics-Social Policy Consultant ELSI lecturer at University of New Mexico Health Sciences Center email froboz@indirect.com


[Ed.Note:The following review of the criteria for selecting transplant candidates by Rachel Majeske was originally posted on the bioethics list BIOMED-L. I felt it was pertinent to the current discussion of "social worth" in candidate selection and I think the information is rather interesting. It is reposted here with her permission. -M.B.]

Date: Wed, 16 Aug 1995 10:16:44 -0400 From: Rachel Majeske Subject: Criteria for transplant candidate selection

Criteria for transplant candidate selection (who gets put on the waiting list to receive a cadaveric donor organ through UNOS) differ radically from transplant program to program, and across organ types.

One recent study of psychosocial criteria used among transplant programs found, for example, that for heart transplantation, IQ <70 was an absolute contraindication for 25.6% of U.S. programs (and 54.1% of non-U.S.), and an irrelevant consideration for 15.4% U.S. (5.4% non-U.S.) (Olbrisch and Levenson 1991). For IQ < 50, 74.4% of U.S. programs considered it to be an absolute contraindication (91.9% non-U.S.), 19.2% a relative contraindication (2.7% non-U.S.), and 6.4% irrelevant (5.4% non-U.S.). They also found great differences in the type of testing used to evaluate candidates: in the U.S., 80% of programs required that each candidate be evaluated by a "mental health professional" with candidates not beinglisted unless considered acceptable by one or more of these evaluators. 24% of U.S. programs required formal psychological testing for candidates. This study reviews a number of psychiatric and psychosocial criteria, and finds agreement on some criteria (active schizophrenia, currently suicidal, history of multiple suicide attempts, dementia, current substance abuse, e.g.), but major disagreement among programs on other criteria (cigarette smoking, obesity, noncompliance, recent alcohol or drug abuse, criminality, personality disorder, controlled schizophrenia, affective disorder, e.g.).

The other issue in the California case seems to be ability to adhere to the posttransplant regimen. A recent study of kidney transplant programs (Ramos et al. 1994) found signficant heterogeneity regarding the means of evaluating the likelihood of medical compliance posttransplant. A review of the literature on transplantation found that for heart transplant programs, for example, medical compliance was a frequently cited selection criterion (Corley and Sneed 1994), but it would be my guess that the means/criteria for assessing compliance differ radically among these programs as well (since the situation with kidney transplantation is probably more stable, given the maturity of the procedure and some fairly obvious criteria--e.g. attendance at dialysis--for which there are not clear analogues in the case of heart transplant).

The Ramos study also found great differences in the types of health care providers who participate in selection/evaluation committees (e.g. only 16% report having a psychologist and 16% report having a psychiatrist). A study of heart, lung, and liver programs (Finder et al. 1993) found that although only 11% of programs reported having someone with some ethics training on their transplant committee (about half of which were specifically identified as "ethicists"), 69% of programs reported that "explicitly ethical information or judgments" were utilized in decisionmaking.

Corley, M.C. and G. Sneed. Criteria in the selection of organ transplant recipients. Heart Lung 23:446-457, 1994.

Finder, S.G. et al. The ethicist's role on the transplant team: a study of heart, lung, and liver transplantation programs in the United States. Clin Transplantation 7:559-564, 1993.

Olbrisch, M.E. and J.L. Levenson. Psychosocial evaluation of heart transplant candidates: an international survey of process, criteria, and outcomes. J Heart Lung Transplant 10:948-955, 1991.

Ramos, E.L. et al. The evaluation of candidates for renal transplantation: the current practice of U.S. transplant centers. Transplantation 57:490-497, 1994.

Hope this information is helpful!

Rachel Ankeny Majeske, M.A. Center for Medical Ethics, University of Pittsburgh and Ethics Consultant, Cardiopulmonary Transplant Selection Committee University of Pittsburgh Medical Center email: rama@med.pitt.edu
Date: Fri, Jan 26, 1996 11:56 PM EDT From: froboz@indirect.com To: DoktorMo@aol.com

Distribution of scarce medical resources should be predicated upon urgency of need, one's place in line for that resource, and the likelihood of medical benefit to be derived from having it. Allocation by "social worth" is subjective, value-laden, and arbitrary. Too often those deemed as less deserving, such as individuals with Down Syndrome, receive less medical care, lower quality care, and fewer expensive pro- cedures. Social justice should obtain in medical/health care resource allocation even when rationing of such resources becomes greater.
Signe Dayhoff

Date: Tue, Jan 16, 1996 8:49 PM EDT From: gbower@ic.net To: DoktorMo@aol.com
Regarding the question about considering social worth is deciding how to use a scarce resource eg organ for transplantation: the easy way out is to give it to the person who is deemed sickest and in most urgent need. That, too, is a somewhat subjective evaluation. If one has a list of potential recipients should acuity of illness be the final deciding factor, since all on the list have been screened and felt to be candidates? I have seen a number of transplant candidates whom I felt got on the list by some quirk of fate: blind, diabetic, arteriosclerotic with bilateral leg amps. I think the scarce resource needs to be given to the neediest of those on the list, but that the list itself must have as one of its factors what you might term social worth. The totally recalcitrant IVDA [Intravenous Drug Addict] who needs a liver or kidney or heart should not be on the list.george bower

Date: Thu, Jan 4, 1996 9:36 PM EDT From: dpnelson@mmm.com To: DoktorMo@aol.com
Scarce resources have always been allocated, one way or another. They always will be. The real question is whether or not "social worth" should be used in the mechanism. What is "social worth" anyway? If it is how many tools a person can turn out in a machine shop, or how much profit a person can bring to the bottom line of his/her company, we are in trouble. "Social worth" may be the best mechanism for allocating scarce resources, but perhaps we have to look at it's definition. For instance, few people can see that even a severely handicapped child or adult has "social worth" in that they teach the rest of us how to serve and give unselfishly in their care. That is worth a lot! Unfortunately, sometime you have to have "been there" to understand. I am looking forward to other comments on the issue.
Dwight Nelson

Real Medical Reality vs. TV’s Brand

If the TV program “Miracle Workers” represent TV produced reality, here is an example of real reality. My second year medical student, last week, interviewed and examined a man who has a history of recurrent deep vein thrombophlebitis of his legs which causes leg swelling and pain but also carries the risk of lethal blood clots to the lungs. He was being maintained on a warfarin anti-coagulant pill. When he entered the hospital recently with a flare up of the thrombophlebitis, it was found on testing that the degree of anti-coagulation was far below acceptable. When asked by the student whether he had been following his doctors prescribed dosage schedule for the warfarin, he stated “no”. He had been taking only half the dose to “let the pills last longer.” Why? He didn’t have enough money to buy the pills and still buy important pills that his wife needed to take. So here is some sort of a system failure. The patient is unable to be compliant because of medical costs but yet someone is going to pay for the hospital readmission that will amount to many times more than the cost of the patient’s warfarin pills. This example is but one drop of what is happening in real life in the sea of rising medical costs and burden on those who can’t afford these costs.

Although the medical cost problem is not due to one single cause, there is no doubt that the public’s insistence for tests, medications and other treatments that in many instances is unnecessary or even in some cases irrational fuel the rising costs. This then reflected back, for example, to that thrombophlebitis patient, who can’t afford medical insurance and can’t afford to pay for essential medications both for his wife and himself. My point has been that the media through magazines, newspaper reporting, TV programming and direct-to-consumer pharmaceutical advertising is responsible for a large part of the public’s unrealistic expectations of medical care including “miracles”. Of course, it is also physicians who are then yielding to the pressure of their patients by ordering these treatments or tests.

May I suggest that my visitors read about the ABC television program “MiracleWorkers” in an article in the March 5th 2006 Cleveland “The Plain Dealer” The article describes the concern of doctors and others about “Miracle Workers”, other TV doctor programs and medical ads contributing to medical misinformation and unrealistic expectations by the public. Let me know what you think. ..Maurice.

Physicians Are Not Miracle Workers. Period!

I have written on numerous posts here over the past year or so about my concern regarding the widespread use of the word “miracle” in relation to medicine and medical practice. It is the use of this word by the media and the public that I think has led to the demand of the public for medical treatment to promote a miracle response when realistically there is virtually no chance for that response to actually occur. This demand has led to an unneeded rise in the cost of medical care due to tests and procedures which are being ordered by physicians under pressure from patients and their families. Also the physical and emotional burden of these futile attempts at a miracle on an incurable patient is another consequence.

Back in November of 2004, I complained about the tagline for the advertisements of a medical specialty group which used the expression “Blurring the line between medicine and miracles” which I thought was spreading an unrealistic relationship. Now on TV is the promo by ABC for their “Miracle Workers” to be started this week. Apparently the program will show patients with difficult medical conditions get free help from physicians and surgeons, presumably out of the goodness of the network. The intent of the program is meritorious, the title of the program is misleading and sends a wrong message. Physicians are not miracle workers.. period! As I have written previously, hope for a miracle cure is fine but don’t expect miracles from your physician, they come from some other source. ..Maurice.

Altruistic Toddlers Do Exist

Continuing on with the thread of my July 6, 2005 posting here, there is an article in the March 3 2006 issue of Science titled "Altruistic Helping in Human Infants and Young Chimpanzees" by Felix Warneken and Michael Tomasello. The authors'abstract of their paper follows:

"Human beings routinely help others to achieve their goals, even when the helper receives no immediate benefit and the person helped is a stranger. Such altruistic behaviors (toward non-kin) are extremely rare evolutionarily, with some theorists even proposing that they are uniquely human. Here we show that human children as young as 18 months of age (prelinguistic or just-linguistic) quite readily help others to achieve their goals in a variety of different situations. This requires both an understanding of others' goals and an altruistic motivation to help. In addition, we demonstrate similar though less robust skills and motivations in three young chimpanzees."

These toddlers were able to discriminate when, as part of the test, an object was apparently accidentally vs intentionally dropped. They retrieved and returned the object if they recognized that the dropping was accidental.

It is good to see that research scientists are trying to explain the phenomenon of ethical behavior and expand ethics from philosophical discussions to science. ..Maurice.

Invasion of Patient Privacy, Physical and Historical: Are Doctors Unaware?

There has been at least two issues that I have presented on my blog where the responses of the visitors have given me professional and ethical pause. I mean I have been made aware that there are some strong feelings and attitudes that patients carry which has never been previously stressed to me nor, I think, to other physicians. As the example, I have had the discussion of physical modesty of patients in relation to their interaction with their physicians. There were some strong concerns about unprofessional physician behavior in this regard. And the last posting was about physician history taking, specifically about taking a history about firearms in the household. The suggestion was made that some of the questions which physicians feel are important medical questions may not be considered as such by some patients. In this post, I don’t intend to defend the merits of the unhappiness by some patients regarding these issues or the merits of any physician’s rebuttal. What I am concerned about is that this may be just the tip of an iceberg of ignorance of what we physicians know (really don’t know) about how patients feel about our behavior as we treat them. Is this ignorance because we physicians just don’t listen or is it because patients don’t talk to their doctors about it? Whatever the reason, this ignorance on our part is not a healthy condition to lead to the best relationship with the patient. If the patient is unhappy about what the patient feels is the physician’s disregard for their physical modesty or thinks that the doctor is unnecessarily invading the patient’s privacy by asking unnecessary questions or even other issues that I haven’t even mentioned, this can be a obstruction to any attempt at the best of medical care. Also, as a teacher of medical students, I wonder,in this regard, if our medical schools need to emphasize certain issues of patient concern which we have not emphasized in the past. Any thoughts on this subject? ..Maurice.

Legislation in Virginia to Prevent Physicians Asking About Household Guns

From The Virginian-Pilot on February 23,2006,

A pediatrician who asks a child's parent about firearms in their home could lose his or her license or be disciplined under legislation being considered by a [Virginia ]Senate committee today.
The bill would prohibit health care professionals from asking a patient about gun possession, ownership or storage unless the patient is being treated for an injury related to guns or asks for safety counseling about them.

The bill was passed in the Virginia state lower legislative chamber last week 88 to 11. The article continues:

The legislation is opposed by The Virginia Chapter of the American Academy of Pediatrics because it blocks a common practice by medical professionals to inquire about gun ownership and safety when they go over a safety checklist with parents during a child's regular checkups from birth to puberty. ?
The National Rifle Association supports the bill because it will protect gun owners "from intrusive, unnecessary questions from medical professionals," according to the NRA Institute for Legislative Action Web site.

Here is my response to this likely unconstitutional (denial of free speech) but also irrational political action:

I think that the Virginia bill represents either meddling into the practice of medicine for the legislator's
own personal political benefit or that they are totally unaware about the process or value of medical history taking as practiced by physicians and as responded to by patients. Physicians take a medical history, both a present illness and past history to attempt to get facts that may or may not be immediately useful in making a diagnosis or in teaching the patient about health matters. The past history may include a variety of psycho-social questions and other questions including questions about understanding about risks for physical injury including controlling those risks. These may include not wearing helmets, not using seat belts, using ilicit drugs, sexual behavior, unlocked medicine cabinets accessible to children and risky management of guns in the household. These are only what the physician believes are pertinent questions for the patient to answer if the patient wishes to. Note that the responses are not made under oath. Patients may refuse to answer or may provide an answer to the physician that is inaccurate or intentionally a lie. But for the physician to be punished simply for asking a question that could in the individual case have profound significance ("oh, I keep my loaded gun under my bed so I will be ready for an intruder at night!") is beyond rational belief regardless of what the general risk statistics show and represents irrational lawmaking. Do the legislators know that at my medical school we actually teach our students to ask the patient about the number of individuals the patient has had sex with over their lifetime, whether with men, women or both, about sexual practices and more sensitive questions? Some argue that physicians should not lecture to patients about issues in medicine that have not been proven by research study. However, physicians often deal with issues that have not been statistically studied with regard to pertinence to a specific outcome but possibly may be of great physical/psychologic and social importance to the life of the individual patient. I think we should all face the fact that what physician advise or carry out is not all evidence-based medicine and often we may end up saying and doing what we think is the best for the patient in our own judgment based on our knowledge and experience. Now I will get off my soap box and will be eager to read what my visitors think. ..Maurice.

FOLLOWUP: In yesterday’s news comes the word that the Virginia Senate Education and Health committee voted down legislation that would have made it unlawful to routinely ask patients about firearms.