item Woodmore to be very careful In explaining to you that I make no claim. To being an expert in the area that I'm going to talk about. But I've always been leery of experts. And I think I became. Mostly ready at an early age when in the Fitzgerald Public Schools where I was raised and educated deep in south, Georgia. A woman came during these times of prohibition to speak to the kids in the grammar school on the evils of alcohol. She was sent by the women's Christian Temperance Union all the anti-saloon league because each each alternated and sending a speaker to warn us off. I don't know what they thought we were going to do at the age of eight. But in any of that this woman was billed as an expert. And it was said that she knew a lot about the subject and knew a lot about the scientific aspects of the subject. So she took his our call a glass of water. And then a glass of alcohol she said and she took a healthy, Georgia South Georgia earthworm and dropped in the glass of water and hell they Wiggly happy. Joyous earthworm up for Salton Sea. And then this expert took the earthworm and dropped it and what she said was alcohol and held up the fried dead earthworm shriveled for us to see and look up great self-satisfaction achievements experts had no children. What does that grow in Georgia cracker in the back of the room with one breaks his leg up and one down and no shoes for it was May. In south Georgia stood up and said woman that proves that if you got worms you're better drink whiskey. so I am I want you to understand that I do not pose as an expert indeed. I don't know that there are many experts in the field of medical ethics. I know that one cannot expect certainty in the field with any degree of assurance. And when I speak to you about certain beliefs, I have I want you to understand that if you push me shove me, I don't move because all of the evidence is never in and all the nuances. Change the so-called absolutes. Now the issues that I want to discuss here today are all around us and they're not going to leave they're going to increase in volume intensity and seriousness. Maybe a few illustrations. You can't pick up the paper in a week without confronting an issue such as this. Your call that frozen embryo the fertilized egg egg of the wife sperm of the husband fertilized in a Petri dish in Australia Frozen until later implantation expected to occur in the mother. They go up in an airplane the killed and there's a big controversy as to what to do about that that fertilized egg. Revolving around the question. Is it life? Can you dispose of it? What do you do with it? If you don't implanted it, there are a thousand dishes if it isn't planning which has a mother which is the father who inherits. The real issue in that case as I saw it. What's a possibility indeed the probability they wear as each of us can have our own grandchildren in the year 2050 poses the possibility that you can have your own children in the year 3000? And then there was another experiment not experiment. It passed beyond that stage in Monash Hospital in Australia. There was a case of this post-menopausal woman. Who borrowed an egg from some other woman fertilized in Petri dish by her husband sperm and then she was propped up estrogen and then it was implanted in her womb and the child is moving towards gestation. All kinds of issues about womb renting who is a mother who's entitled to the child if there should be a call all kinds of issues like that the Press loves to deal with But there's a overriding issue here men have been able to have children past the age of 70, but women have not been able to have children. At a late age. Are we going to have postmenopausal mothers? As a result of modern science, and then there was the famous case of baby failure the baboon heart transplant it at Loma Linda hospital in to this child. That was otherwise to die much controversy about should you transpose animal tissues into the human? And of course, they'd rather important issue of how much informed consent and the issue. Watch is it Justified to do human experimentation that probably has very minor therapeutic value but very high risk, but all the question of the use of animal tissues has no issue at all. We've been using pig hearts pig valves and heart. You're my heart's four years and we've been using insulin which is an animal product derived from cows since 1922. The real issue in that case it seems to me is a probability that we are going to have a transplant rash or epidemic. Which is going to raise enormous questions with respect to cost of a liability and maybe even rice me and just two months ago. I saw that someone had isolated the human growth Gene from the human genetic material and it implanted that human growth Gene and a mouse and had produced a super Mouse. Very interesting this business of Crossing species. Now you weren't so concerned about it and I don't want got terribly upset but suppose one were able to take the rat growth Jean and transported into the human genetic material. people would have some concerns and finally an almost inexhaustible catalog, but you remember when Governor dick Lamm I find governor in Colorado got in hot water last year when he stood up and said in a very loud voice and very sincerely There is a duty to die. Speaking of the fact that in nursing homes, which 10 years ago at an average population age of 73. And now it's 83 in the climbing indeed. Arnold almond who is the distinguished editor of the New England Journal of Medicine says that's a day for every illness. There is some medical intervention. That can delay the moment of death. And that is created a rash problems. interracial dilemmas now all of the questions I've mentioned all the issues are generally thought I didn't have been for Generations thought of as medical questions. None of these a medical question. True they are closed in the language of Medicine. They require medical knowledge in order to understand them and discuss them in, San Mateo. They arise in the context of medicine, but they are not medical questions. They are ethical questions and they are some of the burning ethical questions of our time and they're going to become more burning. They're going to Pummel and upon us and they're going to demand some kind of resolution. They're important because they involve the issues of life and death. Bear curry in a public setting and therefore will not be ignored. and since much of a medical practice and scientific progress involves public funds most of it now or one Chihuahua or another you are involved. all of us my grandfather was a doctor graduated from Jefferson Medical College in 1881. I knew him very well. Course, he had ethical questions that were presented to it. They didn't they didn't really. Involve the great issues that we're talking about. He could do solo. He could get quinine for malaria. He could paint you with iodine. If you had an infection he could do a simple operation is anaesthesia is of the time permitted. He could saw off a limb. If it became gangrenous he going to knock you late you against a few things, but mainly he waited. He never heard of respirator. Keeping a dead body. Giving the appearance of life. He never heard of artificial feet. And he never accepted as no doctor could in those days because there weren't any public funds for medical payments and most of his patients were treated in the privacy of the home. I never knew a child in picture of Georgia who was born in a hospital. And therefore all the problems of the neonatal Clinic with a defective child. Whatever they occurred. They occurred in practice. It is because of the fact these questions are erupting are serious involved matters of life and death. So the president's commission was established which I had it for 4 years. It contained doctors lawyers. theologians geneticist sociologist 11 people Who work for 4 years turned out 16 volumes, which I think are significant. and always started with entire array of Carter appointments and ended with eight of our members from the Reagan Administration and two of them members of The right-to-life Movement. We never had a single to send. on NE fundamental issue and I have Cricket that to two things. First of all, if you get beyond the question of when life begins, which is a theological question. He got me on that. And start the discussion from what one does with life. You can get a jury consensus after you discuss the matter fully and kept your ears and Minds open with your fellow citizens. Oh, yes the question of when life again. If we did as we did get there the issue when we were discussing genetic screening and genetic engineering and what to do in the neonatal clinic and in vitro fertilization. We were very close to the issues of abortion. And sometimes the debates got very hot. But when they did I usually got to make this point that there are three points of view about when life begins very is the Catholic part of Europe again for the moment of conception. There is a Protestant part of you again to the moment of quickly and then I was a Jew would say there's a far wiser order more practical point of you going out of five thousand years of tradition the Jewish View, under the Jewish view life begins when the children leave home and And somebody but usually add and when the dog dies but beyond beyond the question of theology we found a cork and since we didn't find a consensus by turning to look to see what St. Thomas had and then try to apply what St. Thomas's principles word of every medical ethical issue nor do we look the car ought to Jeremy Bentham Auto John Stuart Mill As a matter of fact, we found no overarching medical or legal or ethical Prince. But we came to our point of view by listening. Hearing facts listening to debate and then inductively building a consensus on the basis of what our human conscience told us was right and wrong and there are extremes but we usually took I think the middle way because that is where the jury and it was an American jewelry and it has to be as I will tell you from my viewpoint that American Jury decision not precise but conscientious it has to be something that is moderate. Let me give you an example. I believe in the commission believed in giving the human preference a great deal of weight. A person who is at a condition of Nursing Home. suffering terrible living on machine The person says I want it stopped if that person is fully informed. And it's had time to think about it and consult with whomever he or she wishes to we said personal preference should Prevail human autonomy is in a first-order model principle. Yes, that's true. But you push me too far there and I'll retract from that because I do not my cell phone. I do not myself believe that in a world of scarce resources if you had only one kidney dialysis machine. It ought to be you was no matter what the person says on an 85 year old terminal case when it could be used on a 55 year old case that is otherwise healthy no matter what the preferences. If you push me I move. I also understand that there are times when one has to think of the greater good for the greater number the utilitarian principle, but I don't think anybody on the commission would have ever advocated that in the Extreme as the eskimos do by putting old folks on an ice floe. So as to increase the food supply for those with workers. I believe in treating on the Commission. In treating people equipment and their fault for the first time in history a presidential commission said outright. 8 Reagan people free Carta people American society has an ethical responsibility to be sure that everybody was in it has access to adequate level of healthcare without excessive Burton. Who said that? And I can remember one of the new appointments having read that document that had been just stated by the older members of the commission. He gets it. He's a vastly wealthy Man Redman and medical technology. He didn't have pureed. Snoop commission he calls me and he says Morris do you expect me to sign this thing? I said, I hope you will. He said look 5000 years ago. Genesis ask the question Am I My Brother's Keeper and you mean to tell me you expect me to answer it? He did. He answered. Yes. Because Medical Care is different than house. It's different than clothing. It's different than Transportation all of which we need the lack of Medical Care causes suffering. The lack of Medical Care keeps people from functioning as free function working agents Medical Care. Sometimes I need for this serendipitous without your fault. And sometimes I need Ford is Extreme beyond your ability to pay. But we didn't say that everybody should have the same level of Medical Care. Not everybody can go to the Mayo Clinic. It couldn't serve everybody and you cannot have the Mayo Clinic at every town and Village in the possible on an equal basis nor should a one tail medical system. Be favored because I asked God to be in room for Innovation research differentiation. And from that research and Innovation and that two or three or four tier system. They're developed. techniques and treatments which help the least and the poorest although we don't have a adequate system yet in this country by any means for everybody. At the highest level the Japanese may make better cars the Germans better cameras American Medical Technology is something off of which the whole world. and we were of the opinion that Injustice do everybody it ought to be permitted to continue to innovate and to experiment now I'd like to turn if I may for just a few minutes. To tell you some of the things that we decided and some of the ways we went about it. The first thing we've tried to decide is whether or not these body. Is it an old machine? being fed by artificial means Without any brain function at all the Breath of Life. ingest food excrete whether their lives for their living or dead. Conventionally under the common law they're alive. We said they would do that. That they were bought it and it was it was ghoulish to treat them as if they were alive. It prolong the suffering in the family it prolong the medical cost to society. And it was an absurd. That when the whole brain is dead. The body is a body and it should be given decent to dues grief should begin and burial should take place and organ friends if they are permissible in the case should occur. well the many results What is that organ transplants can occur more frequently and with greater greater efficacy? Second cost or reduce third strain on family so reduced and forth so we didn't say this, but I asked you to think about it for a minute. Doctor will Galen 10 years ago who's one of the premier of people in this field wrote an article in Harper's? In which he pointed out that these bought is what she called me on marks with a fit subject under the proper permission for human experimentation of a kind that cannot be done. on a live person I know not of any use or proof When Donald animals. But could be performed on a dead body. We're the same reading as if the person was alive. That's why I suspect all these are a combination of reasons of why this statue that we propose is now been enacted in near the 20 States and the District of Columbia. But this definition of death leaves a person like Karen Ann Quinlan alive. She will take it off that machine and the expectation that she would die, but she hasn't. She's able to breathe on her own. How long should she be allowed to breathe without any hope ever of regaining any person hurt? Hello. we said that in the case of an adult fully informed the person has a right to say enough in the case of an adult who cannot speak the decision should be made by surrogate together with a healthcare team in that tension between the healthcare team and the loved ones speaking for the person who is, toes Because we felt in that tension that anxiety the fear of the doctor that he will commit a crime or malpractice the fear of the loved ones of the finality. of a decision good decisions will be made many people set up a commission. Why didn't you lay down rules? Why do you put us? Why didn't you pass a law passed a regulation? Agony is good for you. You Oughta be in agony And you are not to be able to resolve this by having some young lawyer from the Department of Health and Human Services or who knows our regulations flipping through the pages of a loose leaf folder to see what the latest pronouncement of Margaret Heckler Waze. Sorry, these decisions are being made and are usually being made responsibly provided full information is available and discussion takes place at a very high and serious level. Well, I know time is short and I do want to turn to just two little other matters. I Harlan point out that I'd had a lot of experience in hospitals. From that experience. I had reached a conclusion. That when Congress asked us to look at that document called informed consent, you've all signed it and say what we thought was the ethical value of it. I felt that we shouldn't do that. We should we had to do but we should do a lot more. We should look at the whole doctor-patient relationship. Because a whole bundle of ethical considerations in deep raps of central ethical considerations are bound up in what is known as a doctor patient for healthcare patient relationship. surprisingly we found that by getting mujeres to do a survey that 79% of patients thought that this document was only for the doctor's benefit. think it had any ethical value You know 55% of doctors agreed. We found it 85% of patients. Wanted to know their condition. And we found that when patients and the healthcare team really interchanges shared information. It has a therapeutic as well as a model that now I was treated in a vast permission induction. Enterprise At the very front area of a science. Chemotherapy that was administered have never been administered before the immunotherapy have never been administered before. Not in its totality. The doctors talk to me and all I wanted to know is is there a theoretical basis for what you're doing? Cuz I have no hope for that. I could never give me laetrile because it has no theoretical basis. Or anything that had a theoretical basis, okay. How does one drug called cytosine arabinoside which is a very powerful chemotherapeutic agency? Which is under the artist to be infused in my veins for seven days and seven nights. At the end of the fifth day. They comment take the thing out of my van. I say why are you doing try not to Kaman stock that vain again the end of a Six-Day that take it out at choir you taking it out now because you've had seven days can't you count but it back again. I don't know what I needed seven days, and they didn't know but the orders were 7 days. I had as you have if you are seriously ill in the hospital a whole coloring specialist. I have a hematologist. I had a oncologist I had a cardiologist I had internist. I had a renal adjust at a hepatologist. I had the whole battery. Finally I said after 2 weeks. I'm tired of all of it. You're all great, but I want a. And I got one it was a woman hematologist chemotherapist or my own age who I figured had to be about twice as good as the men of her own age because she came up out of the ranks before there was any preference. She was wonderful. But you see hospitals of vast institutions. And the commission found that if there is shared information. Can help the doc. see that the orders Account app monitor side effects report adverse side effects and in every way help the health care tea, but it can't be done except on the basis of shared information now. After all the Epocrates who was not done an unethical man. Put it this way. He said go about your duties quietly and adroitly telling your patience as little as possible. Preferably. Tell them nothing about their condition. I've always said that the Epocrates was probably right in those days because anything he told them would have been an unwitting lie, but today doctors and do know a great deal and the only way that the medical profession can be transformed is for these young doctors to be modeled on older doctors. Not the other young Ender you had a great deal of experience role modeling is terribly important and unfortunately too much of the role modeling is done on young Britney Spears who are residents and not upon skilled healers and practitioners. Now I want to conclude by saying that I recognize that we've got some terrible problems before us that we never touched. They're going to be worse and worse more and more serious. and they're going to rise out of the fact that we can do so much now. Such great cost. I don't know if anybody wants to be Tethered to Bonnie Clark type of heart. I don't see anybody lining up that the Humana hospital to get another one of these things, but you just wait a little instrument is bigger than no bigger than the human heart, which can be implanted in the chest. Like a pacemaker with an autonomous power supply like the pacemaker all these open heart surgery cases. They're going to be clamoring for. And it's going to cost $250,000 a coffee and nobody really is going to be able to pay for it. Except Jay Paul Getty and Nelson Rockefeller. both of them now so consequently it's going to add to a medical bill which is a proportional by gross national product is highest is 11% And that's to be compared to 6.8% in Great Britain. Which has a Universal Health Care system is much higher than that in any other country in the world. I don't say that there are limits, but I don't know what the limits are, but they will be like it'll press up against education. It'll press up against the University of Minnesota. It'll it'll do all kinds of things if you let it. now some people say you can control all of this because all you got to do is to cut out waste fraud and duplication commission suggested that ways of doing that but the real problem And the growth of American medicine is for three reasons first. There's a Greed for life. Who wants to breed for that? And the second thing is that the doctors are praying to support that Greed for life, but who wants some trading to support something else, but the thing that has made the difference is that doctors now have to satisfy in many cases that green for life at the march of the margins of newborns the margins of old age and somewhere in between. Now these are going to be terrible problems and how we resolve them and how we ration. I don't know. But I could discussion talk about some principles. I want to conclude by saying the whole issue that I have been trying to to open up yet this morning. Was Willis traded by something or doctor told me the other day. He said that a mother who had given birth to two very premature babies one 750 G and function fairly well with Needles and Pins and everything else the other 750 grams blind obviously very distorted and obviously a very very very wrecked piece of baby in the nursery by superhuman memes and the mother stands before the nursery and looks in at her two babies. She looks at the one that seems to be going to make it. As a well child and she says thank God for modern medicine. And then she looks at the oven and she says damn modern medicine. And I think that's the predicament that we are in but we've got to sort out the good from the bad I think. I remind you that the questions should be addressed to the microphone so that the live radio can pick it up. Pick up your voice as well as a virus a broom. Let me ask you was the first question time. Mars did you find that like Norman Cousins and help to laugh? To get well, I am Norman is a friend of mine and we've discussed this. I think it helped to laugh. But it also helped the curse. I must tell you to Holland that sometime later. I was writing about my experiences and the Cheap doctor sent me my file which was about this thick and a medical administrative to help me read it and she said to me with affection. She said I want to tell you you are known as the worst patients they ever had. Yes. One of the main issues facing doctors now is whether or not it's ever ethical to withdraw food and drink to a patient. In other words. Is it ethical to allow someone to starve to death at some point if you can no longer feed them in a normal fashion. Do you think it's ethical to withdraw food and fluids from a patient? That's a tough question. But Spring Court of New Jersey a month ago answered it. In the case of an 84 year old lady named mrs. Conroy. Who was not? Was not in a vegetative state, or she certainly looked at you. There was no evidence that she had cognition but she had certain reflexes and she certainly was breathing on her own. So she was by no means bring that. Her guardian who was her nephew and the court said he had nothing but her interest at heart. Decided that he would like in combination with a doctor's advice to remove the nasogastric tube by what she had to be fed. And he took the case through the court of New Jersey. The Lower Court held that you could take the tube out which means that you could let her go on a course of starvation. The Appellate Court said no. The Supreme Court of New Jersey which is been very active in this field granted certiorari and it was obvious that this was going to be an extremely important opinion from a very fine Court. The staff for the president's commission. We had already disbanded. Got together and we wrote many of us an amicus brief, which was submitted to the Supreme Court of New Jersey and speaking now as private individuals and not as a commission. We are urged that the court Grant permission under these facts to remove that nasogastric tube. The court decided that he could be removed and cited the principles. all the presidents commission's report and that's the way the body of a law is built up at the common low-level by which the courts take experience take individual facts and then come to what we hope our rational conclusions for Oliver Wendell Holmes Supreme Court Justice once said, The life of the law is not logic but experience and experience in this case was that this woman was gaining? No benefit whatsoever had no possibilities to ever gain benefit and we're simply a living corpse in the sense that she no longer had personhood and she was very old and the people were making the decisions were entirely interested in her welfare and made the Judgment which they asked Court approval for on the basis of her interest. Now, I know this will offend certain people because low I find it very difficult to say that you can withdraw a respirator which is keeping something moving that otherwise wouldn't move which is the artificial ingestion of there and that's all right, but that you can't stop the artificial ingestion of food because I know and you know, too that are is more vital than food and is more meat Play You're needed then food. But there's something about the word nourishment. There's something about food that makes us that makes us go into Agony. And as I've said I can is good for you. What do you think about the establishment of Ethics committees in hospitals a group that is on site and is formed to helping the deliberation maybe education maybe assist informing policy in the hospital is it totally a good idea? What are some of the difficulties that they might be with establishing such committees? Well, let me separate two things all hospitals that are engaged in federally funded research and if they have any research that federally funded to some extent have to have institutional review boards to review the experiments that doctor be carried out and those are required by law and I assume you're not talking about those. The next level of committee that might be concerned with the protection of human subjects is the so-called Ethics Committee. We favor them. We favorite them knocked on the theory that they would be tribunals. It would have answers. We favored them on the basis that they would set certain principles and guidelines for a hospital conduct in such areas as the promulgation of orders when not to resuscitate and what to do with defective newborns have two procedures. They would be useful in making people beforehand think of the procedures that should govern cases that always and I'm sure to arise then we thought so they ought to be available as a panel to which to start families or doctors could refer matters for at least the purpose of getting the right questions asked. But looked upon as tribunals to Shield you from that agonizing a problem or two to preserve you and protect you God help you from liability. We did not favor. Mainly they ought to be the places in which a a problem can be sounded and the echo is heard. The juror Commission address the issue of animal rights. It seems like that has come up more and more. I want something that I used to not even think about research on animals leading toward medical progress was something I think about, you know, you pick up magazines newspapers and you see that on the front page. How did you deal with that issue? We didn't deal with animal rights Centrist in you raise that question because in talking to colleagues in the same field in England, it's amazing so much of the English literature deals with animal rights not so much in this country my own view about it is that the animal experimentation is perfectly appropriate if it's done in a humane way and and not to trivialize research but to but to really Advanced research Are you certain should be done under supervised conditions and it certainly ought not to be done in a careless or unfeeling way. But the commission did not address it that address the question of the protection of human subjects. Very very specific issue was want to be absolutely sure there was informed consent and absolutely sure that the investigator laid all of his cards on the table to the institutional review board, which is composed of his peers and also people from the outside. I am precise people from the outside because quite frankly these issues are not very beginning issues of medicine. And therefore you do require Marley should have a verdict of people other than those who are primarily involved in the research no matter how moral they may be. I think you've raised many important issues today that have gotten all of us to begin to think about one of my concerns this if there does not seem to be public dialogue going on in any great amounts amongst people who aren't experts or interested in the subject and I think in a democracy such as ours that kind of dialogue is it's very important that your commission after your 4 years of struggle come up with any suggestions about how to structure or begin that kind of dialogue. I might say that some newspapers have been very good about it. I have my calls for the New York Times, but I will say this the New York Times And if science section Kara's Kara The Works of the Commission in great detail and continues to carry enormous volumes of material on the subject of the ethical problems and medicine. I don't see it in the Press outside New York. And I think that's a terrible mistake. I suspect it's probably because most people as did I end of the field and felt that it was something that was really reserved for doctors because he's with medical problems. And if I've said nothing else, I think important things that might be said that I said is that these are not medical problems. You know when the commission's work was finished. I did a piece for the New England Journal of Medicine with a young associate Susan Wolf and which I opposed. the continuation of this presidential commission Because I felt we had been drawn from private life people at all returned Academia. But if he institutionalized you would have people say now the commission on medical ethics in the department of h e w is a conscience of a Nation. I'm so tired of your commissions becoming the conscience of the nation. I serve on the Civil Rights Commission people talk about as a conscience of a Nation if a conscience of a nation is embodied in some kind of bureaucracy or permanent government establishment the nations in bad shape. So what we recommended was that a new commission be appointed sometime in the future drawing again from the streets and Academia and I have a sunset provision. So they would go out of business and not become the Vestal virgins of of medical ethics. The other thing we ought not to be turned over to the National Institutes of Health wanted it to the National Institutes of Health. It's a fine but if red robins is a great man a great Noble scientist, but the Institute of medicine is dominated by the medical profession and we didn't think there should be a permanent body there and we certainly didn't think that should be a permanent body in the that great though. The rock wrestler known as the Department of Health and Human Services. We thought they should be more presidential commission as suitable and evokes in the future and I would daresay it sometime the next few years. It needs to be one to deal with a pro. Songs of in vitro fertilization and also the problems of rationing the use of scarce resources if that's the name two issues. I'd like you to address to Concepts one is generational equity and the others the national deficit. One of our Senators is very concerned about this Revolution. And what is possible bankrupting the future in any number of ways, so could you help me with that? Well generational Equity. I don't know why you know, this is a perfect example of the way people feel. I thought that's English for the Stop kidney dialysis at the age of 65 under the National Health Service was great until June 19th last year. And then I change my views about generational equity. I think it's not so much put it as generational Equity as the equity between people who? For whom life is is a joy or something less than Agony and those to whom life is merely a nagging. I have a one who's idea to me right now who is in a nursing home 83 as not recognize any member of the family for 7 years and I do not believe it is an issue of generational Equity because her husband was 89 is in fine condition, but the question as to whether or not to remove life-supporting mechanism from the mother is quite a different thing from moving it from the following doesn't need it. By the way of a car's. It isn't generational. It's just conditional Now as to the what was your second question about the federal national deficit? Well, I don't I don't have any knowledge or expertise about the national deficit except that I do know that health care costs are bound to grow and Probably we're going to enter a stage in which they will be color by rationing and when you get the rationing, I don't know how you're going to do it. But I do know you shouldn't do it. Like Seattle did Handel's famous. God commit is when they had a few dialysis machines. They just had a group of pointed. I don't know who appointed them to say who got on the machine. It depended on whether or not you went to church brother not to a Boy Scout leader in a few things like that. That's bad. But the other thing is bad to under the Social Security. We immediately set up a scheme which cost forty million dollars the first year now cost over two billion dollars so that kidney dialysis available to every American without cost but I cost. regardless of age and regardless of other condition which is absurd. And it distorts the use of medical resources and you know, you have a you have the illness of the week the oldest of the month of illness of the year and we are Americans of all money into that particular healness without regard to a general plan of what's best in the National interest. But again, I suppose it if you push me again, I would love to have more money spent on bone marrow research then another face. Well, I thank you very very much.