Good afternoon. Welcome back to mid-day on Minnesota Public Radio. I'm John Raby sitting in for Gary eichten living wills doctor-assisted suicide palliative care or the lack of it. All subjects. Not so many years ago were hardly ever discussed. But now they're the stuff of headlines on our speaker in this our Doctor. Robert Butler says those end-of-life subjects are best discussed in the context of what he calls preventive ethics. Robert Butler is a psychiatrist in one of the nation's foremost gerontologist in 1982. When he was at the Mount Sinai Medical Center in New York. He founded the nation's first Department of geriatrics is the founding director of the National Institutes of Health National Institute on aging and is a leading researcher into Alzheimer's disease earlier this summer. Dr. Robert Butler spoke at the American Association of retired persons National Convention in Minneapolis. His speech is titled end-of-life decision-making now the assignment that I was asked,It's not only end-of-life decision-making but the management of our aging well, that's a double task and I'll try to do my best to its large territory to be sure. Course we have to begin by realizing that management of one's aging could it could be argued would be gained from birth because aging is a process but from a practical point of view. I need to remind ourselves myself included that 65 and above women are getting close to having 20 years of life and man close to 15 years of life ahead. So it's a. In which we can do a great deal. But my principal point today is going to be that end-of-life decision-making cannot be made at the end of life. But must be made earlier in life. We must work to overcome the taboos about both aging and dying and that's not an easy assignment. It's frightening. It's threatening to people but we have to introduce preventive ethics and I'll try to explain what I mean the first with respect a g. I would like to emphasize our need to prepare from four different perspectives. None of which are going to surprise you most of which probably this audience already has undertaken. Health habits, of course social network purpose in life and financial preparation and by health habits, I no longer mean just the elimination of tobacco or attention to diet and exercise but we are getting into some very exciting new possibilities very important terms of ethical decision making because of informed consent and that's preservation of our intellectual functioning. There is now the possibility of preventive strategies in France they call it but brain Jogging cerebral exercise was a term used by one of the greatest of the scientists of the central nervous system over 100 years ago and the attention that we need to get to high blood pressure because it can when not cared for and treated later small repeated Strokes which can dramatically affect our brain and our senses to we can have a lot of control over our hearing and our vision. I'm not going to go into great detail and either these topics of course because that's not the main thrust of my remarks, but I did want to get across the fact that the prescription for good health is beginning to broaden far beyond the elements that we usually think of diet Health tobacco. And then I mentioned social network. Well as a fellow as a Minnesotan wife friendship is really a straightforward way of describing what social scientists call the Social Network my father-in-law who lives in near Rochester Minnesota in 94. When asked what was most important to him and his life. It was friends. These are the people you can call up on if you need somebody to take you to the doctor fetch medications groceries if you're alone. Third is purpose in life. We discovered in our studies at the National Institutes of Health that those individuals who did have purpose in life and structure to their everyday lives. We're not only the ones that live longer but with a higher quality of life men toughest evolve courses in Need for financial preparation. And this becomes particularly a concern to me these days when we recognize the possibilities of a changing stock market and yet continuing talk that would suggest some severe cutbacks in Social Security the very basic social network social security network that we need. Clearly these are all interrelated and all important and you may ask why do they got to do with ethical Choice? What do they have to do with what I've been calling preventive ethics if we maintain ourselves in decent shape for as long as possible and are reasonably financially prepare and have a purpose in life and friends and relationships. We've gone a long way to avoid some of the types of painful choices of an ethical nature that all through my years of practice I ran into And I especially want to bring attention to the lives of women since women outlive man now by 6.8 years in the United States, although I am happy to say this, but just a little bit of a movement with respect to increasing life expectancy of men but not enough but we have to be particularly attentive to the issues that do affect women and couples must deal with these issues that relate ultimately to end-of-life decision-making and preparation for age. Women are becoming more sophisticated financially than was present in the past, but they are still subject to the greatest likelihood of poverty particularly upon widowhood. They are more air to chronic illness and disability and they are confronted often with caregiving burdens at the end of life and talk about the types of decisions. We have to make in terms of allocation of resources and choice when I run for example in to say a 90 year old woman who may be taking care of her 69 year old daughter who may have had a stroke. So that's just a brief effort talk a little bit in response to my assignment namely the management of Aging itself and the kind of preparations. We do and should make and many of us do and how much that can help us in dealing more effectively with some of the painful choices terms of allocation of resources and ethical decisions. We must make So now let me go on to talk a bit about the management of end-of-life decisions themselves and I've identified at least for today 6 key issues first. I want to point out the inaccuracy of the alleged High Cost of dying and that's important because if we believe the Miss Seven Deadly mist is I will describe that high costs are associated with the end of life. We may be subtly coerced into making decisions as a society and as individuals that we should not make because they're not required. The first deadly meth is an older people receive heroic high-tech treatments at the end of life. It's simply not true. In fact, we know that as we grow older that per individual Medicare expenditure decreases, I have the privilege of sitting on the Congressional Physicians payment review commission during its first term of existence and it was very plain as we review the data that both with regard to the doctors attitude and patience order patients, of course preference function and Common Sense prevailed more than otherwise and it's also very important to point out that when one raised from time to time painful letters to the Press about a relative that's had tubes and lines and their arms to recall that some of this technology also alleviates many of the discomfiture Payne air hunger that unfortunately can afflict Us near the end of our lives. So technology is not been all bad and in fact compared to the last century the physic care of the end of life is actually improved but not improved enough the second deadly myth is it most older people die in hospitals most older people today Diane nursing homes address of hospital care for older people is futile and a waste of money, but studies show that unfortunately we Physicians or not so brand that we can make correct diagnosis and prognosis and more than half of individuals and whom aggressive treatment is undertaken not only are spared death through those interventions, but live in extended. Of time beyond that intervention, 4th deadly Miss is it living wills are advance directives would solve all the dilemmas about Care at the end of life. Now, that's a possibility ultimately but I'm afraid it's not been up to today the Robert Wood Johnson Foundation conducted a major study call the support study. That's an acronym which I won't go into detail to describe except to say that it was a nine-year major study would show that unfortunately those of us who may prepare are advance directives don't go far enough in discussing them openly and comprehensively with our doctor with our specialist without a lawyer perhaps with our spouse and with our children and then those advance directives get lost believe it or not in hospital charts despite the information age. We in Madison haven't quite gotten good enough to put it all together effectively. 5th limits on Medicare at the end of life would save money fact is that it probably accounts for no more than one to one and a half percent. And as I said since we can't make those diagnosis and prognosis that explicitly that would get us into very dangerous ethical territory to assume that we will cut people off in terms of end-of-life sixth. The population aging is the main reason for Rising healthcare costs know maybe that will be true in the next century. When the Baby Boomers hit Golden Pond and 20% of the population is over 65, but at the moment it's technology and really the demand of all of us not just doctors but the demand of consumers that is the most striking reason for those Health costs transplants coronary bypass operations are just a few examples and 7 the population aging will bankrupt the nation. Well, Sweden already has about 5% more of its population over 65 China already has over a hundred and twenty million people over 60 and the sky has not fallen in population aging will not bankrupt the nation so long as we are prunes and wise and think I had which I think we're beginning to do the second of the six points about end-of-life decision-making that I'd like to make is it it's not enough to Simply think in terms like do not resuscitate do not treat and have those part of our chart. We must really comprehensively complete are advance directives and health proxies. That means we must have sign these rights to persons dearly trust and who act on our behalf. We must also sign durable power of attorney. This is likely to be our spouse and as I already mentioned it's so important to have an open and Frank discussion with every member of the family and everyone who may be concerned with us as our life draws to a close. And this means really dealing also with the daughter that may live in another city. I can't tell you how often I may have had a patient at the Mount Sinai Medical Center and the patient was very clear as to how she and it usually isn't she living longer and being more of them in the older age group has made clear what she would like to have done at the end of her life her immediate family in the New York area agrees, but then the son or daughter from California or Oregon or Michigan flies in and out of perfectly understandable deep concern about Mom or might be dad once every possible thing done. Despite the wishes of the parent very important that there be a clarification and there can be conflicts within families as I needn't tell you and we must deal with them ahead of time denial and pretense or avoidance putting things off does not contribute well to the kinds of critical choices of an ethical nature that may have to be made coming to grips with end-of-life considerations is not just a matter of more of a preoccupation. It really is a matter of good common sense. And again, it's what I think of when I speak a preventive ethics. I'm have the pleasure and privilege and responsibility of being associated with a program called the project on death in America, which is supported by the open Society Institute. And it has so far spent over 20 million dollars to identify wonderful people in major American Medical institutions, but also within prison systems de iguala Su among homeless people's in a variety of minardi populations to see what we can do to effectively transform the experience and the culture of dying in America because there has been both too much Denial on the one hand and in certain sense a certain obsessive preoccupation on the other but most of all sadly, even we in medicine have not had good enough training in palliative Medical Care. Many young Physicians do not know frankly do not know how to handle opiates do not know how to handle pain relief do not know how to handle the in Zayed in the air hunger the indigestion and nausea the very uncomfortable events that can occur near the end of our Lives. They have not had adequate training Great Britain and Australia have a specialty of palliative medicine. We do not even some of our young doctors are afraid that if they use opiates, they're going to quote create an addict unquote hardly a very sensible concern if you're talkin about somebody right near the end of life. So what we've tried to do as a means of fulfilling our mission of the project on death in America is to create kind of Trojan horses of some power and and persuasiveness within American Medical institutions to help favorably change what happens at the end of life. Now a few words about death at home is a lot of romance about death at home. It's not that I wouldn't like to die at home and most of his wood and many of our families would but it takes a lot of fun and a lot of planning and we have to be aware of some of the issues that arise including the issues of reimbursement under hospice and the kind of availability or unavailability of services. We have seen over the last several decades the effectiveness of the right-to-die movement and helping us move towards a sense of autonomy over the end of our lives and more recently. We've seen the more controversial movement toward physician-assisted suicide. When the United States Supreme Court decided against the constitutionality of physician-assisted suicide last summer. It really spoke clearly within the language of a set of opinions to the right to palliative care how historically hospice which originated 1st and France then was mobilized wonderfully and Great Britain and then brought to our country has done a lot to help us all deal not only with physical pain relief and suffering but to liberate us so we can deal with a more personal existential spiritual aspects of the end of our lives. And this is a great step forward but we don't always have the advantage of the use of hospice nor do we always have the advantage of a family that can care for us particularly women who may live alone and as you know, 40% of Americans do live alone and 80% of those are women. So we must also think about how to create new reimbursement structures within hospitals and hear talk about the proper use and allocation resource is an ethical choices many conscientious doctors will assist people at the end of their lives, but we'll be using diagnostic Frameworks that are not really App Store appropriate and that's because we do not have what's called a diagnosis-related group or a drg for palliative care at the end of life something. I think we should begin to think about and I am very proud to say that in our own institution doctor Diane Myers, but doing a fabulous job and trying to create an effective palliative care structure. What is the center of course is the deal with the personal aspects of the end of life in to be free to do with do that to have a life for you to come to terms with the kind of Life? We've left to reconcile with brothers and sisters. With whom we may not have spoken for some time. These are the real issues to be dealt with and we also have to begin to think about bereavement and how to assist the family in dealing with how we memorized remember memorialize the love Den deceased one. Physician-assisted suicide is certainly a powerful discussion point and one that has brought a lot of ethical considerations to ahead and as you know a number of states have been dealing with Michigan Washington, California and Oregon in particular one of the Beauties and great things about our country was expressed by Justice Brandeis in the 1920s when you spoke about our state's being great Laboratories in Oregon will be a laboratory since it now has the right and the law in order to provide physician-assisted suicide. I see greater. Development of end-of-life care palliative care will we see some unfortunate events for people may feel set late or even less supplycore worst because of expenses to their family or to the state to bring their lives to an end. We have some very real concerns about that having seen some of the developments in the Netherlands in Europe where although it's not strictly legal a kind of right to euthanasia has occurred. And in our country, we don't have long-term care that may seem a far cry from a discussion of end-of-life decision-making and ethical choices. But society makes ethical choices to the Netherlands has a long-term care system. Germany has long-term care public financing system. Japan despite its present Financial perturbations is moving toward the implementation of its gold plan in public. Long-term care public insurance plan. We still depend upon the spend-down in order to be accessible to Medicaid spend down which can be humiliating for families who saved all their lives and then thoughtful prudent what reality is caught up with them, especially since the nursing home costs alone in United States to become staggering and my state they can be as high as eighty and $90,000 a year. Not many of us can afford that Persons who are of sound mind do have the right to withdraw or withhold treatments. This is established the crouzon decision in Missouri and other and we now are beginning to have studies such as we supported through the project on death in America that show that patients who decide to discontinue kidney dialysis in general. RIT doing it because of progressive deterioration. Do not view that decision to discontinue as a suicidal act nor are they subject to depression or other psychiatric disorders? They just feel that this is more than they personally want to tolerate at this time. And again, I want to remind us of the very special facts of women because any decisions that we make us a Nation about Medicare and any cutbacks Social Security and any cutbacks or long-term care mostly affect women. Not men. We men go usually with an acute illness usually as I say six nearly seven years before women do and we must remember to the dementia predominately outside. Rasicci's is more common among women than among men and we used to think that was simply because women outlive men, but we now know that the very fact of gender appears to have some relationship to the Advent unfortunate Advent about timers disease. Did I mention that in the context of ethical choices because of the issue of informed consent? Our mind is our main means of personal and social adjustment. If we do not have our intellectual capacities intact, how can we make decisions? That's where proxy become so important not only course with Alzheimer's disease, but other conditions as well. I'm hopefully we will neither. Used National budget-cutting enthusiasm nor political ideology to in such a way that that we forget the fundamental values of human life and the special circumstances of women and of men and their families are these thoughts come to my mind in the context of observations. I've made when I have official travel is an agency had the Nationals doing aging and private travel. in many many countries here are the concerns that concern me and I think she concerned you five big questions. Can we afford older persons? Are they a burden given pension and health care costs how much can and shoot society and the individual bear? II will costly physical and financial dependency take away resources from The Young creating intergenerational conflicts 3 will the overall aging of the population and it's burdensome Claus call stagnation of the economy and Society at large for will there be an excessive concentration of power in the hands of older persons a kind of gerontocracy and 5 will growing numbers of older persons contribute further to the already overpopulated blow. These are serious questions in many ways. They've reached and permeated the media. They have reached and permeated governmental decision-making. And they clearly profoundly affect both the societal and individual decisions that each and every one of us make within a family that has her own family or in the larger Community with respect to both the management of our aging and the end of Life Care. Ethical choices must be made on an individual basis and a national basis. We certainly hope that we will have a just society and that we will maintain our ethics at home at present. It seems to me the rapidity in the profundity with which population aging and Longevity have move forward have caught us somewhat on a way. We haven't quite caught up preventive Essex is not quite in place and we have to beware ageism the Prejudice towards age. We have to be sensitive to the potential impact of further managed care and the kind of decisions will be made and what some call manage cost rather Managed Care organizations in short corporate ethics and we have to consider Promises of government and of the private sector and the prospect of various forms of rationing subtle and not-so-subtle in short my message to you. All is it we must think long and hard each and every one of us and we have to prepare early and we have to think through these ethical decisions that are likely to affect us way in advance and not wait until that time when they are upon us. Thank you very much, and I'll be very happy to discuss all this with you and to answer any questions. Since the lights are upon us have to warn you it's a little hard to see who's there. I think there's someone right here at the beginning of your presentation. You mentioned the term bring jogging. I'd like to know more about that place. We used to think it's really a very complicated and fascinating story. We used to think that when the brain Was established in the newborn that there are no further possibilities of either cells dividing of new cells or repair. This despite the remarkable contributions of ramonica Hall who probably is one of the truly great scientist and Nobel Prize winner who lived in the end of the last century and he already in a famous lecturer in 1898 was speaking about cerebral exercise brain exercises. There are now studies underway at the National Institute on Aging under the acronym active in which efforts at retraining and terms of memory problem solving creativity or being studied in a variety of centers. I think it's seven centers. Weather which suggests on the basis of present information that that gloomy view that we can't keep growing and changing intellectually is not true how the Romans even had a method which they called things the Roman method of places and things loci address is a little bit like a string on your finger in their homes. They would have a relationship between different parts of that house and a way to remember it's time to go get groceries or go to the doctor or go to the senate or whatever Romans may have done. So in a way the idea of being able to continue to grow intellectually is not altogether brand new. To me it was important in terms of our managing our aging remarks which were the first part of my remarks because if we have our intellectual capacity and we keep our minds alive then clearly. We're in a better position to make decisions for ourselves. Dr. Kevorkian, I'd like to talk about dr. Kevorkian. What impact has he had on your thinking about the whole issue? I don't mean to sound in a sense arrogant but most of what I've been thinking about in terms of the issues of end-of-life long predated Jack Kevorkian who never saw a patient in this life. It was a pathologist not a clinical physician who saw a patient's hand who if anything is troubling me greatly because he's a person for example thinks that we should take prisoners take their organs from them and give them to a patients who need them. Which on the one hand might sound nice but he's rather extraordinary figure. I think perhaps much more important than Kevorkian was Derek Humphries the Huntley Hemlock Society and the book no exit and some other writings of people's over the age of people over the years who tried to address the importance of are having autonomy and some control over our life, but I must have been deeply troubled at the first it seemed to be largely women who he helped to die. Not men has also very much troubled by the fact that some of the patients he didn't even really know their histories carefully. So I consider it very frightening especially in the context of what we saw happened to Nazi Germany with the insensitivity to individuals and the extent to which seeming doing good can lead to public disaster and I'm not just thinking of the Holocaust that's so terribly affected the Jewish Community about gypsies doctors of people who did not agree with the political climate of Nazi Germany in the 1930s. in early 1940s Just a fellow that up a little bit. What what do you think will happen? And what do you hope will happen with respect to the physician assisted suicide in the next 20 years or so of our studies show that when doctors know how to administer properly at the end of life the concept of needing physician-assisted suicide or Rises no more than about 1 or 2% That is a 98% of the time it is possible to assuage pain and suffering in order to make it possible for people to deal with the real stuff of life, which is so important to them. So I think we're talkin about 2% of the population of most all so I'm not really sure that I want either our government nor the medical profession to be involved in suicide is my personal view what you ask for because you know if people want to commit suicide They can commit suicide but I'm not quite sure how wise it is for the helping professions to be involved in bringing death to people it changes the whole concept of what medicine has been all about. And I wonder what it would mean to to patients if they know the doctors do bring people's lives to an end to not know when the syringe is coming their way. If this is a death-dealing syringe or a syringe it supposed to help them. So I have to say at least at my present stage of thinking I am personally deeply troubled by physician-assisted Suicide and the find it the very difficult to reconcile with the philosophy of Medicine. I was wondering what there is in you mentioned Alzheimer's is there any new breakthroughs in the offing anything happening in that area? Respect. Simon says he's there are now three medications on the market 2 in the American Market went overseas, which relate to a memory chemical called a sativa colon, which transmits information from one nerve cell to another there are perhaps another six such medications related to that memory system that are being studied and evaluated and Laboratories in various parts of the world. In addition number of Laboratories are trying to create agents that will inhibit the laying down of a substance called amyloid which is found in the so-called senile plaques in the brain and which many believe are toxic to the brain and play a major role in the destabilization of memory function and intellection. So there is at least the active efforts underway. But also as you may know it's been very interesting that women on estrogen May and still not absolutely certain may have some preventative and therapeutic effects from estrogen with regard to Alzheimer's disease. So I'm imagining we may soon have kind of a combination medicine a kind of a cocktail and which they'll be neurotransmitters which of the chemicals that carry information in the brain, they'll be agents which will help reduce the scar tissue which is created by the substance amyloid which I mention which might for women if it pans out have estrogen might have some neural growth factors to help and repair for the reasons. I was mentioning in the earlier question about rain jogging the extent to which repair mechanism materials may be available to us. It's a very hot subject we know so much more now than we did before. I don't know how to put Which one we're going to get there, but it could be within a decade or so. They will have some genuine efforts underway to really do a lot with respect out simers disease. Doctor, I have a question. Who do you feel has the jurisdiction of Health Care in the United States Physicians or insurance companies? Well at the moment, I think the figures are that about 40% of doctors work for someone else now that for someone else might be University. It might be Managed Care Organization or HMO. It might be the Veterans Administration might be various hospitals so that I think but I'm not absolutely sure I'm up to date on my figures at maybe 60% or still autonomous set Physicians certainly one of the new developments that are beginning to occur is a doctors are beginning to group together and in California Calpers, which is the big retirement organization as I understand it is now bypassing some of the insurers and going directly to doctor groups to pay them directly for services rather than Insurance mechanism. I must say it does bother me that We have such a highly expensive administrative cost the United States compared to Canada compared to Japan compared to Europe and that all goes to sales to marketing to all things that I very little to do with the direct that provision of care. I think the system should change. It is changing not necessarily for the good but it is changing. Do you see any possibility individual insurance does not provide a large enough base to make it reasonable. It makes sense to have a national population base for this kind of protection. Is there any possibility for it would be very interesting to hear a John Rather and and others from the American Association of retired persons. Speak to that point. I had the privilege of following Alan Greenspan before the bipartisan Commission on the future Medicare and I argued that while I run out realize they had a very important terribly important set a responsibilities and dealing with the financing the Medicare. I hope that they would also deal with the structural delivery system where I thought there was a real cost savings involve too and I specifically said there had to be a better integration between the provision of acute care and the provision of chronic care in long-term care. I don't know if I'm right on the figures at the moment, but one of the last figures I saw something close to 500,000 patients for example removed in any given year between nursing homes and acute hospitals around specific medical needs and some of those might be more efficiently. Matt in the nursing home. So I think we need some major structural reforms given the Contemporary climate with regard to spending in this country. I'm not very hopeful that we will have a long-term care policy in the near future. I do think that when the Baby Boomers catch on and they make up 20% of the population in about 35% of the vote. No one's going to be elected dogcatcher this not responsive to what the Baby Boomers want. And I think they're going to want a decent Humane long-term care program, but I have to say I'm not very optimistic. It will see this in the very near future. Since at the end of life if someone is becoming increasingly weak, you think there would be some way in which they could have went when they were in clear mind with approval of attorney or doctors give some indication so that if they weren't able to either a doctor a family member someone could be authorized to assist at the point that they clearly indicated. They were ready. Yeah. I I I'm not totally sure what you mean and it may be the state you're from it many states. Now you can do this through the health proxy an individual can speak on your behalf and terms of first precluding the introduction of an intervention such as a ventilator tube or whatever or I can call upon with withdrawal. But as a Supreme Court decision in the cruise on versus the state of Illinois, or maybe have It reversed ruling stated. It had to be something that was clearly stated and I did mean to mention when I was talking earlier that I think Pays for each of us to be extremely comprehensive in detailing what it is. We do want so that there no questions and I would even suggest they being re-signed every year. So so that the judge doesn't say well, maybe that's what James Smith said in 1992, but would he feel that way in 1998? Would you see any provisions not just for withdrawal of care, but for assisted end-of-life if the person again and made that decision, but then was getting to a point where they were so weak that they would not be able to do that. Well, as you know that you the Oregon law physician-assisted suicide is not euthanasia. It is not the direct injection of elite agent into the individual one gives or prescribes the medications in the person takes them. That's quite different and I don't foresee in our country. I don't think the development of active euthanasia the Roman Catholic church has accepted for example, passive euthanasia. Most of the Judea stick Faith. Most of the Protestant religions churches have as well. But the Step across that jump from passive euthanasia is been called to active euthanasia. I do not think is going to happen in the Supreme Court judgement made last summer indicated that they did not agree with some of the I don't remember the name of the lawyers who brought it to their attention, but they did not accept the notion that these are really the same they indicated. These are very distinctly different processes rehnquist. For example, the Supreme Court Justice of the United States distinguish between active and passive. It did not accept the concept of active. euthanasia dementia possibility that we should be aware of. Could you mention some of those that may be the average person doesn't think about it when dying at home, you know, it's dying is not an easy business. I'm sorry to say to all of us and try to say it to myself too. But you know, there's a lot that happens including very disturbing symptoms nausea vomiting bleeding coughing. It's very difficult to demand up on the family for nursing is fantastic and not all families are quite aware of that despite their love and affection for the individual is the how exhausting it can be in the Contemporary American Family course with 60% of women in the work force. And with the busy lives of people lead, it becomes even more profound. So in the absence of extensive Long-Term Care Program where it's easy to have round-the-clock nursing or whatever. Just consider the patient who toilet team is required and you need to help them or who met at night be quite frightening Disturbed and you don't get any sleep. So it's a very courageous act to help people to die at home. Unless you have considerable resources either formal caregiving resources or have some other than your family the capacity to do it. So people should be warned of that not all dying is that bad? So I don't want to overstate this either and scare everybody off. I prefer to die at home also, but I just think we do need to remove the romance and it look white realistically had what one can expect and the future belongs to those who prepare for it can work out much better if you keep in mind some of the possible difficulties Are these living wills advance directives portable from state-to-state prep him accident in one part of the United States or the world. And the other thing I want to know is if people sometimes ran into problems with Hospital Administration or committees when there are advance directives that are understood by family and the position but someone else in Risk may may have to say about it. You know, that's a very good question. I don't really know if all the 50 states how transferable so I would think it wanted moved one might want to find out if in a particular State the health proxy is operative whether you should re-sign it or not Hospital Administrations. Are supposed to be very responsive to this one. Otherwise are not I don't know. There is the patient self-determination act which is a congressional act which even requires that hospitals and nursing homes make available to patients information about the control. They have over the end of their lives. I personally think that should have been required a doctor's offices and hmos as well because once you're in the hospital you have enough be worried and fearful about to be suddenly asked how you want to handle the end of your life. But in very I think the administration's of hospitals unless it's just a bureaucratic failures should be responsive and receptive to advance directives and health proxies. I have a two-part question about organ transplants first. There's the controversy now about whether or not organs should stay in the area where they're harvested or whether the it should be according to need anywhere in the country. And the second part has to do with your remark about prisoners and donating. I assume that the implication there was that they were the prisoner would not have a choice, but I'm wondering if they are given a chance in a way to repay Society if they're to be executed. I would think this would appeal to some prisoners and they might have valuable organs to donate. To take up the second first. They were hearings in Congress on what's happened in the People's Republic of China and which prisoners are not only have their organs removed, but they're sold and it's usually made available apparently to the elite classes in China and I even got the impression maybe from some overseas people of well could come into China and there it is clear coercion, and it's been is being dealt with in our Congress in the context of Human Rights. I think the issue is often a matter of subtle coercion. I'm sure you're right that some people might feel assuage the of their guilt for acts they may have committed if they could feel that they could give an Oregon to someone but they might also know that in the Nuremberg trials and in the decisions that Drew up and what is called the nurnberg code there had to be a different party that asks for a volunteer for example, even in medical research. It cannot be your own doctor or doctor and whom your life depends. So it's very hard to know what would happen in a prison what sort of deals might be struck. And that I think is you know is the Robb so to speak now forgive me, but I forgot the first part if you just mention the word or two other come back. Oregon, I don't know. I didn't follow well enough and I'm sorry that I can't recall well enough the recent decisions that came out of the Department of Health and Human Services secretary Shalala. It was an effort as I understand it to try to be more National rather than local because what happens on a local basis as I understand it is that It doesn't then speak to what the individual needs might be on a broader National basis so that you might I don't know the categories well enough, but you might be in a category one where you need it the most but you might be in Seattle Washington. But if it's University of Pittsburgh where they do many liver transplants, maybe people are number for might get it before the person in Seattle. So I think the idea is to make it more Broad and not as community-based now whether that's psychologically a good idea. I don't know because it may be that those communities who are encouraged to be donors might be more willing to be donors. If they know it's in fact more likely to affect their neighborhood. It's interesting in France and some other countries. We have presumed consent so that unless an individual so specifies and puts on their person and saying their wallet I do not want to have my any But my body used as transplants or I don't want my brain in my heart or you know, I was very specific everyone then. It's potentially a donor a kind of universal donor. We've not done that in the United States, but it is something that might be thought about because the shortfall in Oregon is still very profound in this country. And that might be very interesting policy issue and social ethic to consider. I have felt after the second world war in the Advent of health insurance companies and the soaring of salaries of doctors that we are over overmedicated over operated on Andover hospitalized in the United States. I read a recent article that there are more bypass operations performed in the United States as compared to Canada yet. Canada has a lower rate of heart failure deaths and I wondered I would like you to talk about that was about to practice in fee-for-service medicine have a lot to answer for 2 we ordered more than we should have. We ordered more visits of patients more medications more treatments more diagnostic test. And I don't mean that that was always function of avariciousness her delivered this but just it was easy to do and that also sometimes was a way to not take the time that one should take for a really fastidious taking of the history and a careful physical exam because somehow or other the test would magically do it for us. I think that's been very regrettable. And it's I think part of why medicine is brought down on its own head some of the turbulence which we now see in the Healthcare System. There's no question, but what We in the United States to do a lot more. However, some of the differences and health cost between nations is also a function of other matters. For example, we have so much more trauma in the United States. In our country, for example compared to Japan. We have more homicides on one day in the United States and Japan does in an entire year and entire year. So our hospital emergency rooms in the great cities of this country her burden by psychiatric problems of drug addiction trauma what you just don't see in some other countries so that when they talk about the Hi-Health cost the United States, I think it would be a good idea to distinguish social costs or those Health Crossett or consequence of differing social issues rather than just coming to conclude as some people do while we better cut costs in the United States because look how much more cheaply Japan does it or France does it or whatever? I think we better take a tough. Look at what it is our health cost go far go for and that includes your point cuz I do think that we Have too many hysterectomies the United States for example are many things which we simply need to have practice guidelines outcome studies to make sure that what we do really make sense and that the performance indices justify what we do in medicine. Thank you. Doctor Robert Butler founding director of the National Institute on Aging he spoke earlier this summer at the National Convention of the AARP in Minneapolis programming on Minnesota Public Radio is supported by Glenwood Inglewood water clean fresh pure and plenty of it home and office delivery available. 374 2253. That's it for Midday. I'm John Raby are producers Sarah Meyer, it would run.