Book Review

Let's Talk: An Honest Conversation on Critical Issues: Abortion, Euthanasia, AIDS, Health Care

N Engl J Med 1993; 328:363-364February 4, 1993

Article

Let's Talk: An Honest Conversation on Critical Issues: Abortion, Euthanasia, AIDS, Health Care
By C. Everett Koop and Timothy Johnson. 138 pp. Grand Rapids, Mich., Zondervan, 1992. $8.99. ISBN: 0-310-59781-1

Dear Lara,

Here's a book I'd like you to read -- in between completing your applications to medical school. It consists of an exchange of letters between C. Everett Koop (“Dear Chick”), the former surgeon general, and Timothy Johnson (“Dear Tim”), the television doctor, on four issues of great importance to the public as well as to the medical profession: abortion, euthanasia, AIDS, and health care. It goes down very easily; you won't want to put it down, and you can read it in two or three hours. But although the book is fast and easily digested, it's nutritious. Koop and Johnson touch on nearly all the important moral and social aspects of their four issues, and they do so engagingly and with intelligence and subtlety.

Writing the book as an exchange of letters is, of course, a contrivance, and occasionally it's distracting, as when the authors address each other by name in the body of a letter -- like this, Lara -- to remind the reader who is writing which letter, or when they implausibly provide background information for each other. But by and large the method is remarkably successful, and I think I know the voices of both men well enough to find that they ring true.

As for the content, the authors engage in friendly but intense debates about whether women should have the right to choose an abortion, whether a doctor should ever help a patient to end his or her life, the degree to which infection with the human immunodeficiency virus is a matter of individual responsibility, and the merits of a national health program. They begin with certain common philosophical stances: both men are deeply religious, and both are compassionate., and both believe that medical care should be a fundamental right. The strongest (and longest) section of the book is the one dealing with health care. Here Koop and Johnson discuss the merits of attempting to improve our present health care system (Koop) versus those of trying to establish a fundamentally new one (Johnson).

The issues discussed in this book are rapidly growing problems in our society. They will increasingly affect all of us, but perhaps they will most directly affect those just entering medicine. Since you, Lara, will be in medical school next year and I am long out (as are Koop and Johnson), I would like to hear your views of this book. What do you think of it?

Love, Mom

Dear Mom,

Thanks for the book. I enjoyed it very much. Although these topics are well worked over elsewhere, there were many new, interesting insights here. I agree that the section about health care reform is the strongest. It manages to describe clearly some extremely complex problems.

I think you are right that the four topics discussed in this book will greatly affect those of us now entering medicine. I am also optimistic that the next generation of physicians will address these problems thoughtfully. In my year-long premedical program, you will remember, students organized themselves to meet several times to discuss two of these four topics (AIDS and the health care system). Their concern belied the widespread cynicism about doctors.

I found the debate between Koop and Johnson to be especially interesting because it clearly illustrates an underlying difference in philosophy. Although both men rely heavily on Christianity for their arguments, each has a different emphasis. Koop is primarily concerned with the sanctity of life, whereas Johnson is primarily concerned with the quality of life. This is not to say that Koop is not compassionate or that Johnson does not believe that life is sacred -- far from it. As you say, both men are deeply religious, and both are compassionate. But they have a fundamental conflict between placing a metaphysical value on life apart from its quality and valuing it according to its quality, and I think that this conflict shows up in almost every debate about abortion or euthanasia. In the face of the conflict between belief in the sanctity of life and concern for its quality, the authors often detour to surrounding issues in order to find common ground or areas for discussion. For example, they agree that better education about contraception could prevent abortions, and that improved comfort care could diminish the call for euthanasia.

Johnson is particularly eager to find common ground and often goes through intellectual contortions to do so. For instance, he claims to be both “anti-abortion” and “pro-choice,” finding abortion personally offensive but respecting the rights of others to make their own choices. According to him, “there are circumstances in which abortion may be the `best' of a list of very bad choices.” Similarly, he believes that euthanasia should not be legalized, but that it should be “allowed” under informal guidelines. Koop often seems baffled and frustrated by Johnson's attempts to have it both ways (“You sound schizophrenic”). “If you're pro-life, you're pro life,” he writes. “Life is life.”

I like the fact that the authors are brave enough to push themselves to the brink of this irresolvable conflict between fundamental principles. In my generation, these issues have become so emotionally charged that discussing them frankly with anyone except close friends is considered bad manners -- it is “insensitive” to ask someone directly whether or not he or she is pro-choice. At the end of an hour-long discussion about abortion in an ethics and philosophy course I took at college, I realized I did not know for certain who was pro-choice and who was pro-life. Such discussions are often carefully framed around peripheral issues, such as who makes the decision, rather than the morality of the decision itself.

This desire to avoid giving offense effectively removes most people from the debate, turning it over to the militant extremists whom Koop and Johnson both denounce. In addition, the absence of forthright discussion allows the opposing sides to view each other as arrogant and unthinking, since neither really hears the other's arguments. One thing that was clear in this book was that neither Johnson nor Koop is arrogant or unthinking. At one point in the abortion section, Koop writes that he has been reminded that decent and thoughtful people make a distinction between life before birth and life after birth, because “you are decent and thoughtful, and you make that distinction.” Although I think these differences are irresolvable, it is important to understand and respect the paths by which people reach their positions. As you know, I agree with almost all Johnson's views on these issues (and it was satisfying to have my opinions so ably represented by him). However, this book did help me to understand and respect Koop's approach.

Love, Lara

Marcia Angell, M.D.
New England Journal of Medicine, Boston, MA 02115

Lara Goitein
Washington, DC 20008