Read part one

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The provision of life-saving surgery to a handicapped child was not a subject on which C. Everett Koop could ever remain silent. Baby Doe, a boy, was born in Bloomington, Indiana, on Good Friday, April 9, 1982. Koop had been Surgeon General for five months. The boy had Down syndrome as well as a fixable condition known as esophageal atresia, a blockage to any intake of food and water. The doctor who delivered Baby Doe told the parents that if the surgery were successful, he would end up being a “blob.” Other medical personnel in Bloomington disagreed sharply with this judgment. Baby Doe was set aside without care or nutrition of any kind as local litigation began. Five days later, the baby died. What ensued was an intense battle over the application of federal law, beginning with Section 504 of the Rehabilitation Act of 1973 and the Child Abuse Prevention and Treatment Act amendments of 1984.

Koop’s actions in this extended drama — whether cognitive impairments should be generally permitted as a basis for withholding treatment of newborns and whether the federal role should be limited or extensive — were primarily protective of these children at risk. The courts generally were skeptical of a strong federal role on procedural or parental rights or medical grounds. The result of the battle, Koop says in Cameron’s account of his remarks at a Wheaton College event likely held in the early 1990s, was that most of the infant protections survived and became customary with their embrace by hospitals and medical societies. Koop told his Wheaton audience, “Certain pro-life leaders wanted 100%. ... I thought 97% was better than risking getting nothing.”

During this period ,a shift was occurring that reinforced Koop’s evident belief that pro-life issues were largely local ones, questions of morals and ethics and good medical practice, not public policy. Two major pro-life initiatives, a congressional Human Life Bill and the Hatch Human life Amendment, failed in the Senate in late 1982 and early 1983. The spearhead for their defeat in the not yet politically polarized Congress was Senator Bob Packwood, an Oregon Republican. Further Congressional consideration of legality seemed debarred. The pro-life movement, chief among them Rev. Young’s Christian Action Council, responded to the federal disappointment by offering persuasive writings and sponsoring the development of nonprofit pregnancy help centers in or via evangelical churches. The CAC ultimately changed its name to the National Institute of Family and Life Advocates (NIFLA) and made this mission its sole focus.

Despite the dim prospects for Congressional action and the agonizing wait for news about Reagan’s Supreme Court appointments, which proved disappointing, federal activity on life issues did not altogether cease. Reagan, for one, deepened his stream of statements and concern about the issue, as he had done in instructing HHS to act on behalf of Baby Doe. In 1983, he published “Abortion and the Conscience of the Nation,” a plea for protection of the unborn based on their human right to life that discussed the new medical science of the day, ultrasonography, and the need for pregnancy help centers. Koop, while largely relieved on the policy front, made a variety of pro-life speeches during this era, which Cameron dutifully records.

The next hitch in Koop’s term occurred over another request Reagan made of him. “Many Lives” does a masterful job of retelling Koop’s often artful exercise of his office. His staff was small and the literal power and scope of his office, which dated nearly to the founding of the Republic, had been circumscribed under the Lyndon B. Johnson administration. Koop wore the military uniforms of the office proudly and smartly. He deftly steered statements on key issues, most notably a major initiative on smoking cessation, through his office. Though he seldom spoke or met with Reagan, he found a way to deliver communiques through what Cameron calls the “White House mailroom” directly into Reagan’s reading sample. The restless Reagan plainly wanted more in the way of messaging on the sanctity of human life. In July 1987, he requested that the Surgeon General prepare and publish a report on the physical and mental health effects of abortion on women.

Here is where Koop’s response did, in fact, disappoint a range of pro-life leaders and policymakers. His response came in January 1989, and in substance, despite the passage of 17 months, his conclusion was that there was insufficient information in the medical literature to justify assertions about the health impact of abortion. Reagan and others had no doubt been impressed by the revolutionary impact of Koop’s landmark report on smoking. The 1980s marked a clear turning point in public understanding of the grave health harms of smoking. Cameron’s account of the statistical impact of Koop’s persuasive powers in reaction to the tobacco industry is compelling.

In a core sense, Koop was right about the medical literature. If there was a tobacco industry with captured scientists and a wealth-generating array of products, there was undoubtedly an even more monopolistic abortion industry and academy. The pro-life movement at the time was, as Koop suggested it should be, interested in maternal support and medical ethics, not health data. Prodded by attorney Thomas Glessner, who had replaced Rev. Young at the CAC, as to why Koop could not say “Abortion by pregnant woman is fatal to fetal health,” Koop’s reply was terse: “I would be laughed out of office.” There were undoubtedly more artful ways of communicating an urgent need for research on what abortion does to individual and social health, but here Koop decided to kick the can down the road.

The controversy over HIV/AIDS is far more complex, and Cameron portrays the matter thoroughly. Some of the same players at the Reagan White House were involved in an issue that was, for its first decade, mysterious and divisive. He notes the column by William F. Buckley, Jr. that called for the prominent tattooing of HIV-positive men to warn other gay men of their infected status. Another commentator, Pat Buchanan, Reagan’s communications director, stirred passions by writing that AIDS infections, nearly always fatal, represented God’s judgment on homosexuality.

Koop’s and many others’ reaction to these statements was negative. Koop rightly noted the practitioner’s duty to provide care without regard to the individual’s status — the wounded lawbreakers and law enforcement officers alike are his patient (just as should be the rule, Koop had argued, for the disabled newborn). Likewise, AIDS itself was facilitated by disease pathways that needed to be understood and countered — the child with hemophilia who was afflicted with the disease because of a transfusion was not under divine judgment.

These reactions by Koop reflected his character as a physician. But there was a need for reflection about the major issue with his role in the AIDs crisis, public education, particularly of children. The 1988 mailing of the Surgeon General’s bulletin to 107 million homes, advocating condom use, is worth historical analysis. The idea of changing behaviors dramatically among the gay population may be unrealistic, but so too was the idea that abstinence and partner reduction were not relevant calls by public authorities — and that the preservation and promotion of these values was more important than ever. Koop helped shake a conservative administration out of passivity over a health crisis involving an unpopular segment of the population, but, as he did on other occasions, he treated some values, like the sanctity of human life and marriage, as private preferences rather than bulwarks of society and human happiness.

Koop continued to labor in public life after the Reagan years. He sought consideration to be Secretary of Health and Human Services under President George H. W. Bush. Cameron offers inside information on how the Bush people gave Koop the silent treatment, leading him to submit a curt letter of resignation as Surgeon General in May 1989, several months before his four-year term expired. Cameron also reports that the 1988 Democratic presidential candidate, Michael Dukakis, had contacted Koop and indicated to him that he wanted him to stay on as Surgeon General.

Four short years later, Koop could be seen speaking at a White House event hosted by the Clintons and Gores “to showcase his support for their healthcare reform initiative.” This event, as much as any other, indicated that if Koop saw a bright line between private values and public policies, its gleam had faded as his life progressed. The Clinton health care plan, which would have guaranteed “access” to legal abortion with federal support via funding and mandates, fell of its own prescriptive weight and failed the next year.

“The Many Lives of the Surgeon General” is an impressive study of a complex man who cannot be easily appraised. His impact on public understanding of the value of the disabled and people dying of a cruel virus, among mankind’s worst enemies, cannot be overestimated. His eloquence on the beauty of every life, the child with Down syndrome or another Trisomy, his depiction of the peril of societies that embrace abortion and infanticide and dismiss the disabled and the aged like so many defective dolls on an assembly line, his and his wife’s agonizing but faith-saved account of their son David’s death climbing a mountainside in New Hampshire, his care for individual patients, overnight in their hour of need and years after through letters and appearances at life events — all these are rendered faithfully in Cameron’s work. At the same time, the travails of family and life advocacy in a vicious environment — travails as acute as ever today in our stricken world — are worth recollection and renewed conversation.

The challenges Dr. Koop faced are still with us, and no greater need exists than for men and women able and willing to build on the good he did and accept the risk of whatever criticism follows.