The MacNeil/Lehrer NewsHour

Intro JIM LEHRER: Good evening. On this Christmas day evening the lead stories are the celebration of Christmas around the world, including in a tense place called Bethlehem. There was more action in the Persian Gulf war, and escaped presidential assailant Lynnette Squeaky Fromme was recaptured. We'll have the details in a moment, and then comes a documentary update on famine and death in Ethiopia, Robert MacNeil leads a discussion about setting limits on the length of life. John Merrow continues his chronicle of the world of two new teachers, and Roger Mudd reflects on Christmas in Washington. News Summary LEHRER: The Christians of the world celebrated Christmas today, a day that marks the birth of Jesus Christ in Bethlehem one thousand, nine hundred and eighty seven years ago. At the Vatican, Pope John Paul II delivered a Christmas message. He spoke of peace and joy and urged the world to turn to Christ. He sent greetings to 47 nations in 52 different languages, including English.

POPE JOHN PAUL II: Happy Christmas. May the peace of Jesus Christ, the savior of the world, be ever with you. LEHRER: The birth of Christ was marked peacefully in Bethlehem by tourists and others. More than 2000 people attended midnight mass at the Church of the Nativity. The church is built on the site where tradition says Jesus was born. The crowd was significantly smaller than last year's; Bethlehem is on Jordan's West Bank, the scene of violent clashes the last two weeks between Israeli troops and arabs protesting Israeli occupation. Israeli soldiers maintained heavy security in and around Bethlehem last night, but most had withdrawn by Christmas morning. There were no incidents reported. Matters were not as quiet today in the Persian Gulf. Iranian forces attacked a Saudi tanker, the ship was reported to be on fire. In other action, U. S. and British helicopters went to the rescue of a Korean cargo ship after the ship was set on fire by Iranian gunboats. The crew was reported safe. Both ship attacks took place near the coast of the United Arab Emirates. There was some dispute about whether a Christmas truce in the Nicaraguan war was holding. The Sandinista government's defense ministry accused the U. S. backed Contras of breaking the two day cease fire. There were reports of fighting in several locations around the country. The government said the Contra attacks were aimed at provoking a response from the Sandinistas. A spokesman for the Contras in Washington denied their troops had breached the truce. And back in this country, Lynnette Squeaky Fromme was back in custody. She was captured without incident this morning walking out of some woods near the federal prison for women at Alderson, West Virginia. The 39 year old follower of mass murderer Charles Manson escaped from the prison Wednesday night. She is serving a life sentence for attempting to assassinate then president Ford in 1975. And that is the news on this Christmas day. Now the famine in Ethiopia, setting limits for life, the continuing story of two new teachers, and Christmas in Washington. Ethiopian Famine LEHRER: Ethiopia is first tonight. It has been awhile since it has been first, here or elsewhere in the news. The African nation was the wrenching center of a worldwide relief effort three years ago, when drought and civil war set off mass starvation. But the crisis receded and world attention moved on. Now everything has come again, the drought, the civil war, the starvation and the attention. We have a report from Don Murray of the CBC.

DON MURRAY, CBC: Like some vast, pathetic army in retreat, they come out of the Tigre highlands. They have been defeated again by lack of rain, by dust and drought, and they come leading tribute exacted by the enemy: their animals, oxen, sheep and cattle, to be sold in the market in McKelly for derisory prices. They cannot feed them. They cannot feed themselves. And so, they're selling not only all they own, they're selling the ir future. Tedessa Hargay, farmer. TEDESSA HARGAY, Ethiopian Farmer: I have to sell them to buy food. If the rains come next year, I'll have nothing to plow or plant with, but I have no choice. MURRAY: In Tigre, they come again to the camps. They have walked two, three and four days from Sirkent, out of a land burned dead by the sun. Their faces are masks of stoic suffering and their children speak of illness and ordeal and fear. Cees Iberahu, 12 years old. CEES IBERAHU, Ethiopian Child: My parents and I have walked for two days, but there are already five in the village too ill to move. Three years ago, we survived in the camps, but now conditions are worse, and we are afraid. MURRAY: Beerhan Gabramdjiv, four children, all under ten. BEERHAN GABRAMDJIV, Ethiopian Woman: My three brothers starved to death in 1984. Already this year our six cows have died. We have nothing now. Only the government can help. MURRAY: This month they will get help, in this camp at Queehad they will receive grain, Canadian wheat, 15 kilograms per person. Enough to live, carefully, for four weeks. They will strap the bags on their donkeys, on their carts, on their backs, and walk home. And tomorrow, 3000, 4000 more people will arrive to wait here for their gift of food. This is only the beginning. In the province of Tigre alone one and a half million people will have to be fed this way, month after month, until next December, if enough grain is donated to assure even these meager monthly supplies of rations. It could be worse. Dreadfully, disastrously worse. At this very time, three years ago, thousands of Ethiopians were already starving, dying in camps of famine on this sinister plateau of Korub on the southern edge of Tigre. That the worst has so far been averted is a minor miracle of international planning and cooperation. As the crisis gathered, food was pledged, 400,000 tons, 150,000 from Canada. Planes were dispatched. Four burly Hercules transports now operate a daily food lift into Tigre, flying over twisting roads and treacherous territory, disputed by government troops and guerilla rebels. But far more will be needed, and as needs mount, so do fears. MICHAEL PRIESTLY, U. N. : And with a combination of wars and too few vehicles and maybe not enough food, we are looking at a very, very, very tragic situation. MURRAY: For now, there is grain to be given. It's the desperate imperative of this emergency relief program not to allow these distribution points to become, as in 1984, magnets of despair, camps of hunger, dysentery? and death. And so the Tigreans are urged to return home to wait until next month, burdened with food and fueled, faintly, with hope. But if the pipeline should fail for as little as a week, and, privately, aid officials worry that it will fail under the peak pressure of demand in March, then food will dwindle, and famine will devastate these people once again. If drought, and a harvest of hay instead of maize, is ordained by God, man's quarrels magnify its effects here. In the countryside near Imberte, just 35 kilometers from the provincial capitol of Asmara, government militiamen appear on every ridge. The town itself is government controlled and militia patrolled by day. But by night a haven for Aratraian guerillas fighting for independence from Addis Ababa. Many in the town secretly support the rebels, but 90% of the people here depend on emergency food aid to live, and supplies, in what amounts to a war zone, are precarious. The central government has spent precious money and resources in a vain effort to try to contain the rebels. But in this region they still roam at will, and their presence all but paralyzes the delivery by road of emergency food aid in this season of drought. The rebels are well armed and well equipped, and in time of drought, they, too, supply food to hungry Aratraians. Several thousand tons a month, brought from Sudan. They say government planes bomb their food depots. But they've also attacked a U. N. convoy bearing food to Tigre. 26 trucks destroyed. The effect this fall was chilling, and Michael Priestly, the U. N. representative in Ethiopia, warns of the consequences of any repetition. Mr. PRIESTLY: So, if the same thing were to happen now, it would be an amazing catastrophe. MURRAY: The consequences, in fact, are already seen and felt. The few food trucks available continue to be loaded, but they seldom leave, and when they do move, they move in packs, protected by troops. In the tragic tangle of drought, division and fatalistic submission, brutal underdevelopment is the inevitable result. And yet, in a valley in Tigre, a scene of biblical breadth and power unfolds. Ethiopians use the oxen to break the ground, use strips of grain sacks to carry the dirt, use the sheer force of their numbers to move the earth to build a dam to irrigate the land. In this manner, 26 dams have been built here in two years, all by people working only for food. Three kilograms of grain a day. Feet pound the ground when no machine can be found. Backs bear the burden of construction. In a corner of this plagued country, human will measures itself against the scourge of nature, and determines that it shall prevail. Setting Limits LEHRER: Next a look at the newest tough question about health care. Americans spend more on health care than any other nation in the world, most of it goes to care for the elderly. But recently the skyrocketing costs involved have forced into the open, for the first time, the question of possibly setting some limits. Before he went on vacation, Robert MacNeil considered such an idea. MacNEIL: What is society's medical responsibility to the elderly. Should it include the latest life saving technology? Should society set a fair age limit on health care spending? These questions are considered in a new book, called ''Setting Limits,'' by ethicist Daniel Callahan. The book has attracted much attention, comment and criticism in recent weeks. We'll hear from the author and two critics in a moment. But first, our essayist, Roger Rosenblatt, weighs the issues. ROGER ROSENBLATT: The riddle of the sphinx: What walks on four legs in the morning, two legs in the afternoon and three legs at night? Oedipus answered, Man, and the sphinx and its silly riddle fell to pieces. As if Man were an answer, and not a question, involving all the stages of life. A criticism is also implied: two legs, or four legs --the way a baby crawls --are wholly one's own. But three legs, old age, means that a cane is in use. Three legs at night. Weird. Unnatural. The mere thought of growing old gives us the willies, as if, with every shaky three legged step, we were creaking toward death's door, and so we're disengaging ourselves from all the rights and privileges of those with different legs: thought, feeling, humor, fury, life. Life. Daniel Callahan, in his thoughtful, sympathetic, deliberately unsettling book, ''Setting Limits,'' sees both the life and the death of old age. Callahan would have society accept its aging as a normal consequence of birth. Paradoxically, he would also have us acknowledge that there is a time to love and a time to die, and he would have us set limits on aging by means of legal restrictions on medical procedures that would insist on keeping the old alive beyond what Callahan perceives as a full and natural life span. The double thesis is both generous and severe. The walk toward death may have a fascinating itinerary, but don't prolong the journey. Two objections off the bat, which Callahan undoubtedly anticipated. The first, something of a sophistic quibble is, how does one define natural? If the natural mind is capable of coming up with respirators, bypasses, antibiotics and kidney dialyses, why should such inventions not be applied to the vision of a full and natural life span? But the more troubling question is one that Callahan raises outright: How many years do we need to have a reasonable, decent life, to raise a family, to work, to love? How many years, indeed. If one cannot answer Callahan's question, including Callahan, it is impossible to determine, to set limits on, when a life has covered its full and natural span. Everyone accords Keats and Mozart full lives, because although they both died young, they wrote miracles. But if Wallace Stevens and Robert Frost had died in their 20's, no one would know their work. It would not have been done. Full lives reached late. The list is vast. Winston Churchill, Golda Meir, Gandhi, Verdi, Cezanne. Not to mention your life, with all its Johnny come lately awakenings of common sense, uncommon sense, changes of direction, brainstorms, quests. Social science programs try to depend on humanistic truths, but in fact, they usually ignore them. If society really sets limits on those who walk on three legs, how will it ever discover what Callahan, too, would wish it to discover: The stages of old age. The glories. For all we know, Oedipus got the riddle wrong. Four legs, two legs, three legs. What if three legs applies to all three stages of life, and in old age we are supposed to lead our lives all over again, a circle, not an arc. Walter Kaiser of Harvard, writing of the last works of great artists, shows that the artists alone seem to have a sense of what constituted their full and natural life spans. Shakespeare, enduring his ''Tempest'' in his 40's. Titian, doing his best work in his 90's. Kaiser tells of the nephews of Sophocles, who dragged their aged uncle to court to prove his senility, to gain his estate. To unprove his senility, Sophocles wrote ''Oedipus at Colonus. '' Three legs at night. Some night. MacNEIL: And now we hear from the author of ''Setting Limits. '' Daniel Callahan is Director and co founder of the Hastings Center, an institution devoted to the study of ethical issues in medicine. He is also the author of ''Abortion: Law, Choice and Morality'' Dr. Callahan, first of all, before we address some of the points Roger raised there, your basic premise: Why do we need to change our thinking about the health care of the elderly. Dr. DANIEL CALLAHAN, Medical Ethicist: Let me say right off that I don't think we need any change right away. What I'm looking for is a kind of long term change in out thinking, the kind of change that would apply to, say, my generation. I'm 57, and I'm really interested in what's going to happen 20 or 30 years from now. Right now we can continue muddling through. I think medicine, in its care of the elderly, has reached a kind of open, endless frontier. First of all, we don't provide the elderly with adequate health care right now. We have an enormous bias toward acute critical care in medicine. We neglect long term care, home care, a variety of other things the elderly need. More importantly, as we look down the road to the great number of elderly who are coming, and the rising health costs, we look 20 or 30 years ahead, it seems to me it's just going to be impossible, or at least extraordinarily difficult to provide health care on the scale we're providing it now, particularly if one factors in constantly developing technology. So I think we have to begin asking the question, Where is the whole enterprise going? Medicine is, has been an enormous miracle in sustaining lives, and finding ingenious ways to keep our bodies going, but I think if one really asks a kind of hard question, What's the purpose of all this? What is the ultimate end? What is aging to be, given all the new medical technology? That, I think, in the light of the cost, in the light of other things we are not doing for the elderly, I think we're going to have to say that some limits have to be set somewhere by some means. MacNEIL: But is the premise, looking at it ethically, is the premise because we can't afford it, or won't be able to afford it as a society without giving up other things that are valued, or because we shouldn't be prolonging the lives of the elderly beyond a certain point? CALLAHAN: I want to say a little of both. I think what we're really doing now with medicine is a kind of, we're almost trying for a kind of bodily immortality. We don't admit limits, we push on and we push on. And I don't think this is really giving us a decent and deep sense of what old age ought to be. We're really kind of prolonging life, and I think this is not really helpful for the elderly. In addition, it's costing us a very large amount of money. Even if we had the money, I think we have to ask these questions. Where do we want to go? But I think, given the financial pressure that's quite foreseeable in the next few decades, we have an added incentive to ask these questions. MacNEIL: Okay. If those premises are correct, explain your idea of limiting some care by age. CALLAHAN: I start, in trying to puzzle this out, how would we set some limits, what is a reasonable way of doing this? I started with the question of how long a life, as Roger Rosenblatt pointed out, how long a life do we need to live a happy life? And I tried to look at the things that the elderly seem to want, that people historically seem to want, that the religious cultures and customs seem to want, which is a life long enough to raise a family, to have a job, to think, to work, to read, to enjoy nature --a variety of things that people want. And it seems to me that probably by the late 70's and early 80's, we've achieved most of the things, not all, because we could live 150 and not achieve all, but we achieve most of the things that a human life gives us. So I started thinking that way. And here I used my own experience with the elderly, asking what do they want. The experience of going to funerals, by and large we see funerals of people who are, say beyond the age of 80, we don't see that as the kind of tragedy that we see with a younger person dying. I try to think what the elderly themselves seem to want. They don't seem to want more life per se, they want security, they want respect, they want dignity. All of this leads me to the idea of what is a kind of reasonable, tolerable, natural life span, and I come out somewhere in the late 70's, early 80's. We could argue about that. It might be 85. But it's somewhere probably less than the biological possibility. I'm sure biologically, with enough medical effort and billions of dollars we could probably push the average life expectancy to 85 or 90. . . MacNEIL: So what you're proposing is taking an age, whatever that age is, and saying, at least for medicare patients, beyond that age, certain procedures to prolong their lives would not be applied. CALLAHAN: I think that's, Let me make clear that I'm saying this for my generation, not the present generation. The medicaid, we'd say the following procedures are not acceptable. We might say that certain forms of open heart surgery could not be performed, certain extended stays in an intensive care unit would not be eligible for reimbursement. It would simply have a list of things you could not get. I would always want to relieve pain and suffering, and I would always want to provide good long term home care. The limitation would be on life extending high technology care primarily. And, beyond a certain point, you simply could not get reimbursed. That's the only way I could see it working in any feasible way. MacNEIL: I know that's only the bare bones of your ideas, but we'll come back in a moment. We turn now to two experts on health care and aging, Dr. Robert Butler is chairman of the department of geriatrics and adult development at Mount Sinai Medical School. Dr. Butler was the first head of the national institute on aging. Also, joining us from Washington is Anne Somers, adjunct professor of the university of medicine and dentistry of New Jersey, Robert Wood Johnson Medical School. She is a nationally recognized expert on geriatrics and long term care. Dr. Butler, do you first of all agree that society does not, if not in this generation in the next, to change its thinking on care of the elderly? DR. ROBERT BUTLER, Mount Sinai Medical School: It must change its thinking on the care of the elderly, but not in the way which Dr. Callahan suggested. For example, I see no reason for an age based rationing of health care, especially since it would apply only to the governmental program of Medicare, which would mean that those of us who are better off would always be able to get care, where those of us who perhaps are on the borderline would struggle hard to find funds for our parents or grandparents. Furthermore, his book does not have data in it. He does not report individual experiences or information with regard to the character of older people, and the kinds of thinking they have. Nor does he provide data as to, to support the notion of the high cost of dying. In fact, studies within health care financing administrations demonstrate quite the contrary. It's a myth. Furthermore, I have practiced medicine now for 35 years, and I'm not aware of this extraordinary use of high technology in frail and older people beyond 80 years of age. As a matter of fact, the health care of older people is very poor in this country, and in terms of health costs there are many other ways to deal with it. Our great neighbor to the north, Canada, has total access to health care for all Canadians, and they do this at two percent less of GNP or gross national product than we do, with our melange of confused systems and the absence of a national health plan. So that long before we move towards some type of ration, which, it seems to me, should only occur in times of dire social necessity, that rationing, then , should be for all, all ages, based on function, not on age. Think of the profound effect upon children of seeing their grandparents denied health care, and the problems of health care of older people can be measured in one sharp example. That two out of every three persons who are below the poverty line in the United States are not eligible for Medicaid, which is the technique which is supposed to provide health care for those who are indigent. And the reason is because it's a state federal program, and they vary state to state as to the eligibility. So I must say, not a word is spoken until about two thirds through the book for the need to develop geriatrics, the proper care and diagnosis and treatment of older people. Not one word is expressed about the need for strong control of the way in which payment is made for medicine. There is now a physicians payment review commission, which I work for, which is part of Congress, intended to try to gain some control over costs. There are many ways to do it. One beautiful example is Alzheimer's disease. Painful, devastating disease. It accounts for half the people in nursing homes. If we made a major commitment of research, we could bring that to an end. And remember, this word ''natural. '' We used to think that senility was the natural outcome of aging. Now we know that's not so. So what is considered the natural life span is probably way in excess of 100. And when our great republic was founded, the average life expectancy was 35. So we have now gained nearly twice the life expectancy. It's a very relative and elastic concept. MacNEIL: What do you think of the idea that there is a sense of the natural life span in terms of a person having accomplished, or having done what he wants to do? BUTLER: That's what I meant when I said I don't think Dr. Callahan has really spent hours and hours of listening to older people. Some of them do come to the point where they want their life to end. In the absence of depression or the reality of some economic reason that may compel them. I think we have to respect that, and I very much favor the individual right to die. But that definition has to be very personal, not one that's established by government. Governments are not tobe trusted. It's a very dangerous business to have our life and death depend upon governmental reimbursements. MacNEIL: What would be the effect on this society, of having Congress declare that, at a certain age, whatever it was, the procedures Dr. Callahan outlined would not be available through Medicare? BUTLER: Well, I think that has actually happened. There are already procedures that cannot be administered under medicare. But, if it were to become even more precise, then what would happen is that those who could afford it would simply seek their care anyway, if not here then in some other country. People come from all over the world to the United States to seek health care, for example. And as I say, those who are on the borderline, who don't have a lot of money, would strain the family resources frequently, to find the care for their parent or grandparent. MacNEIL: He has a lot of reasons for disagreeing with you. First, he's not aware of the --you don't give sufficient data to support your argument, he says, on the high cost of dying. CALLAHAN: Well, first of all, I deny that the high cost of dying is the problem. Many have said that if we could get down the high cost of dying, that would solve the problem, and I very much agree with Anne Skatovsky(?) and other economists that say that's not the case. My argument is not based at all on the high cost of dying. My argument is based on the long term trend to invest more and more money in the kinds of technologies that are going to keep the elderly alive. Recently, organ transplantation was put under Medicare. We're finding very many more elaborate ways of extending life. It's not the cost of dying that's really the important thing, it's the overall investment of money in the research to keep the elderly going as a group. Not the last year in life, that's not the issue. We really now have about some 20% of the annual cost increase is really now traceable to the high intensity of technological care of the elderly. Not just in the last year of life. So my argument is not turning on that point at all. MacNEIL: But he says that lots of, I could let you make your own arguments, but Dr. Butler says that he isn't aware of high tech treatments being used to a very large degree. . . BUTLER: People over 80, which is the group he's referring to. CALLAHAN: I would absolutely agree, that's the minority of people. But it seems to me, what I'm looking at, again, I'm talking about 20 or 30 years from now. What's happening is we're seeing more and more technologies used on older and older people, and it's the trend that interests me, not right now. What's going to happen 20 or 30 years from now. At that point, we're going to be using many more of these high technology, many procedures that were begun with the young in mind, such as dialysis, are increasingly applied to the elderly. Some 30% of people on dialysis are now over 65. We're doing that with surgery, we're doing that, eventually we're going to be doing heart transplants, eventually we're going to do artificial hearts with that group. That's what I think. . . that's the real danger. Not now. 20 years from now. MacNEIL: Dr. Butler also thinks that your basic idea of the natural life span is wrongly taken. CALLAHAN: Well, I'm going by a large number. I don't think it's all that flexible historically. I do think that there is a kind of sense of completion. Some people want to live to be 100, that's true. Some people feel their life is over at 65. I think it's somewhere in the low 80'2, upper 70's. I'm looking for an average for policy purposes. We have to look in general, it seems to me. What I've seen of the elderly, with my own family and the response I'm getting to the book itself from the elderly, the people in their 80's by and large say, We've had enough life, we're not looking for more life, per se. Some disagree, of course, but the large number don't just want to push on and on. BUTLER: If you look to data you'd find that all Americans, in surveys, want, in fact, some 45%, to be centenarians. There's always a very profound urge to live. And I think we have to respect that because it's often extraordinarily vital and contributory, as we saw in the essay. MacNEIL: Centenarians or centurions? BUTLER: And you know, this is about heart transplants, the truth is that if we calculate the availability of donor hearts nationally, it's infinitesimal, the number of individuals who would be in good health, who would have brain death and who could become the donor supply base. Moreover, we have never suggested, no one in medicine has ever suggested the utilization of heart transplants for people who have multiple problems. It's only for people who are vigorous and healthy and functional, and that's a very small number indeed. MacNEIL: Let's bring Professor Somers into this. What do you think of Dr. Callahan's approach? PROFESSOR ANNE SOMERS, Robert Wood Johnson Medical School: Well first let me say how happy I am to be here, in this discussion with two very good friends, both of whom have contributed so much to the welfare of the elderly. Also let me say, robin, that I want to speak tonight primarily not as an expert to compete with these two. I'm neither a scientist nor a professional ethicist. I want to speak simply as an older person. I'm 74 years old, a woman, I have a husband who is very severely disabled, has been at home on home care for over eight years. My children, none of them are closer than 500 miles away, so I'm pretty much on my own. I lived with these problems every day. I try to cope with them every day, ethical and medical. These are not abstractions, and I've given them a lot of thought. As far as reacting to Dr. Callahan's book, I'm about 50/50. I agree with about half of it and I disagree strongly with about half of it. MacNEIL: What do you think of his idea of setting an age beyond which certain life prolonging procedures would not be available, at least under Medicare, at least under the public, or taxpayers' expense? Prof. SOMERS: I would disagree with that completely. That's one of the points I would strongly disagree with. I would agree with Dr. Butler on that point. MacNEIL: Why would you disagree with it? Prof. SOMERS: Well, I think we already had part of the answer when we saw Roger Rosenblatt's essay, we see how much heterogeneity there is, how different older people are. Some can continue to make a big contribution, others can't. Some are very healthy, others are not. It's just a totally arbitrary and I think would be totally unacceptable ethically, medically, almost any way you look at it. I just disagree with that. MacNEIL: Let's go back to you because Dr. Butler also disagreed with that. CALLAHAN: One thing I think ought to be noted right off is, of course the system I'm describing is the system that now exists in Britain, and to some modified extent in most of the European countries. Great Britain very consciously has a policy which tries, the policy I'm really looking for, one which would greatly improve the quality of care of the elderly, but at the limitation of the life extending care, and that's exactly the kind of system they use, and I think it's a very good system and they get pretty much the same outcomes in terms of longevity that we do in this country. MacNEIL: Dr. Butler? BUTLER: Unfortunately, they don't enjoy the same life expectancy in Great Britain, which has become in many ways a very poor country, and even recently, in fact, in the New York Times reference was made to a struggle going on in which Mrs. Thatcher has stepped down because of the inequities and difficulties in the health care system. So I don't think the British model is a very handsome model to present at all. MacNEIL: Their rationing is not made explicitly and is not tied by law, not tied to a particular age, I believe. When they say there can't be kidney dialysis for certain kinds of patients. CALLAHAN: No. I think in this country, I want to promote an open debate on those issues. In Great Britain, it was done basically behind closed doors, in a paternalistic way that would be unacceptable in this country. But I think the principle, namely trying to achieve a good balance between life extending medicine and the kind of medicine to improve quality of life, that seems to me to make sense and is much wiser than ours, which is enormously biased. Right now we're enormously biased toward acute care medicine, at the expense of a lot of other things the elderly need. I want to see a better balance, and I don't think we'll ever get a better balance unless we set some limits. Prof. SOMERS: Can I say a word on that? Because there I want to agree with Dan Callahan completely, and I think he's made a big contribution in challenging us to rethink our national health priorities. In at least two or three areas, it seems to me that we are now rationing against the young, if you want to put it that way. We certainly are investing a disproportionate amount of our health care dollar in the elderly as opposed to the young. Secondly, I agree completely that we are investing a disproportionate amount in acute care as opposed to chronic care. And thirdly, and closely related to that point, in quantity as opposed to the quality of life. So in all those areas, I agree with Dan Callahan and think he's made a real contribution in provoking a national debate. I hope this is the first step in such a debate. MacNEIL: Let me come back to a point Dr. Butler raised earlier. WHat about as an ethicist, what about the ethics of the medical profession being prevented from delivering certain life prolonging procedures to one set of patients, while, for money, they could do it for another set? CALLAHAN: I agree that's a real problem with the solution I proposed. MacNEIL: And would you destroy private health insurance? CALLAHAN: No, I absolutely would not. I guess the thing is, right now I think we have an unjust health care system for the elderly because there are so many things we don't provide and we force people to impoverish themselves to get, say, nursing home care. I want to make that a more just system. After the age of 80 or 85, wherever we might set it, then I agree injustice might set in. However, it seems to me in the nature of the case, it would not be for a very long time, it would be a very small minority of the population, and it's a kind of tradeoff. I don't propose that this is the ideal, in the best of all possible worlds I surely wouldn't want to do this. But I'm looking for a situation of some severity where we have to make hard choices, and I think the hard choice of that injustice at a later age is well worth the kinds of gains we would get in a more rounded. coherent health care system. MacNEIL: Professor Somers, you say you're living with some of these problems, what would be the effect on relatives of the patient who A) could pay for such a procedure and the one who depended on medicare? Prof. SOMERS: I think it would be very unfortunate, on everybody. I mean, that would be exacerbating an injustice which already exists to some extent, but making it far worse. I think that' unacceptable. BUTLER: I think there's no doubt that we're all three of us agreed that we need to have a decent long term care policy. We need to provide home care. . . MacNEIL: And all three of you agree that we don't have it at the moment. BUTLER: And we don't have it. But I would like Dan to open the discussion which he would like to see opened to many other social choices we make, not just for medical care. For example, we spend nearly 12 billion dollars a year for one act called death, the funeral and the burial, which is more than 25% of what we spend for nursing homes over a whole year, which is 365 days a year versus a one day event, for nearly the same numbers of people. So there are some strange choices we do make. . . MacNEIL: But that's not an area that you can legislate in. BUTLER: No, it's not. But I'm saying that if we're going to raise consciousness, which is what Dr. Callahan says --he's not really talking about having this legislated this year --we're talking about our thinking in terms of choices for the future. There are so many things which we should be laying on the table for frank discussion as to how society spends our money. MacNEIL: Well, we only have a minute of so left, picking up on something you said, Professor Somers, a moment ago, what, again from an ethical point of view, is it inevitable, as some people claim, that it is going to come to one generation pitted against another generation in the allocation of medical resources? You seem to imply that it is? BUTLER: I don't know that it's inevitable, but the present figures suggest it's awfully likely. Right now we're spending a much larger proportion of at least federal money on the elderly than on. . . MacNEIL: Well, they have health problems way out of proportion to the problem of the young people. . . CALLAHAN: Well right now the number of children under the, families under the poverty line has gone up over the past five or six years. The number of elderly under the poverty line has gone down. We've seen a decline in the status of children and an increase in the status of the elderly. That's a very bad trend, it seems to me, and one that I think has to be arrested. I don't see a direct competition, I think what we lack is a really coherent view of what the young and old ought to get in our society, and how we want to compare health needs with other kinds of needs in our. . . BUTLER: We have to have a national health policy, and health insurance. We have 40 million Americans, 40 million Americans without access to health care, which is unacceptable, and certainly children do need --that trend is wrong. But on the other hand, the other trend of the better status of older people should continue. MacNEIL: Of course, lined up against that argument, we don't have them here tonight, but lined up against that argument are huge areas of the medical profession and the political --politicians in this country --and the polls show in the general public. BUTLER: The public is more and more responsive towards a national health program. MacNEIL: Professor Somers? Prof. SOMERS: I just wanted to put in so strongly that we should be emphasizing the positive rather than negative, and rather than setting limits, let's cover the young people, these 35, 40 million people who don't have adequate health care today, let's come out, all four of us, for national health insurance, or some national health policy for bringing these people in, that is the positive, the American, the innovative way, I think, to approach this terrible imbalance which we certainly have. MacNEIL: Let's leave the last word with you, then we must go. CALLAHAN: Well, my political sense is very strongly that we need national health insurance, but that politicians will not buy it unless we can show that there are going to be some limits to the care. I've provided one suggestion for a set of limits. I think we have to show that we can afford to pay for it, that national health insurance would not bankrupt us. That means that we have to have boundaries to the system or no one is going to accept it. MacNEIL: And you're saying, Let the debate begin. . . CALLAHAN: Let the debate begin. MacNEIL: All right. Well, Dr. Callahan, Dr. Butler, Professor Somers, thank you all very much for joining us. The Education of a Teacher LEHRER: Our education correspondent, John Merrow, has been following the lives of two new public school teachers. He first profiled Lynn Robbins and Susan Holst in September. They are now on Christmas break, the school year is almost half over. It's a good time to take stock of all that's happened. So here is part two of ''The Education of a Teacher. '' It begins with the two young teachers reading excerpts from their journals.

LYNN ROBBINS, Teacher: I think every teacher ought to have a secretary. Already I spend ridiculous amounts of time writing down book numbers, taking attendance, collecting field trip money, etc. It's not the paper test grading I don't like, it's the nonacademic business we must attend to. Today one of the administrators seemed a little upset that I hadn't had to time to look over the 120 forms the students coded today. SUSAN HOLST, teacher: Make sure that you copy both the question and then answer it. You'll need the question when you go back to study. Tomorrow, Thursday morning, make sure you're here on time tomorrow. I'm really surprised at how much of the day I spend dealing with discipline. No wonder we only get halfway through our lesson every day. I spoke with several of the other teachers after class and they kept trying to reassure me that this is all very normal and happened to all of them. I hope it's true, because otherwise I don't see how one could make it throughout the year. JOHN MERROW: Susan Holst and Lynn Robbins are keeping journals at our request, describing their first year as teachers in Baltimore County, Maryland. Lynn Robbins teaches English at Johnnycake Middle School. Susan Holst teaches 9th grade physical science at Woodlawn High School half a mile away. Their journals reflect what they've learned in four months. At first, Susan thought students would be mature enough to discipline themselves. Seat assignments wouldn't be necessary. Now she knows differently. HOLST: Today was a monumental day for me. I had to create a seating chart for one of my classes. I remember the first day being so adamant about the fact that they were mature enough to sit where they wanted to and behave. I'm not sure that I have changed my ideals forever, because part of the behavior problem could be due to my inexperience. It's depressing to me, because I felt sometimes like all my philosophies are shattering around me. ROBBINS: Writing up interim reports, I'm beginning to get nervous. It's an awesome thing to find yourself in a position where you must judge the abilities and efforts of those you know so little about. I worry whether or not I'm giving a fair measure of my students' abilities. MERROW: Teaching is an awesome responsibility, and teachers often feel that they don't get enough support from home, from parents. To try to involve parents in their children's educations, the Baltimore County schools, like most school systems, hold parents' nights. It's an opportunity for teachers and parents to meet, form a bond of support. ROBBINS: I have a lot to learn, and the only way I'm going to learn is if people let me know when I make a mistake. And it will happen once, maybe the entire year. I don't know, maybe twice. MERROW: The turnout at Johnnycake was impressive. Before the night was over, Lynn Robbins met the parents of nearly half of her 118 students. Parents learned a little bit about their children's teachers and classes. Lynn learned that she has support at home. HOLST: What we're trying to teach mainly this year is the relation between matter and energy. MERROW: Just five minutes away, at Woodlawn High School, Susan Holst learned a very different lesson. HOLST: I was a bit disappointed at the number of parents that came. Out of approximately 95 students, I only had 11 parents come. I was really nervous to meet the parents --what will they think of me? Will they think I'm qualified, even though I'm so young? Well, now that it's over, I still haven't the answers to those questions. MERROW: One lesson that first year teachers have to learn is that they can't teach if the students aren't paying attention. Lynn Robbins meets discipline problems aggressively, but seems to be untroubled by them. Susan Holst admits she has discipline problems, and is upset by them. HOLST: My days are beginning to resemble, more and more, that short lived television series, ''The Bronx Zoo. '' In brief, I started my day bey being threatened. A student told me, ''Don't mess with me today, Mrs. Holst. Just consider that your warning. '' Sometimes I wonder about what kind of children we're raising that cause them to be so disrespectful. But at least I'm not willing to give up. I'm not throwing in the towel yet. MERROW: To keep new teachers. like Susan Holst, from throwing in the towel, Department Chairmen visit classes informally to offer encouragement and suggestions. Her school system also requires formal evaluations --four of them --by a team led by the school principal. These are nerve wracking experiences for any new teacher. For her second formal observation, Susan spent ten hours preparing a lesson on how light behaves when it strikes different objects. HOLST: Let's look at three specific substances now, in the little packet you have on your desks. Let's look at them specifically. The first object is a piece of construction paper. Just kind of hold it up to the light, and tell me what you see when you look through this piece of construction paper. What do you see, Rickie? RICKIE, Student: Nothing. HOLST: Okay, Rickie sees nothing. You do the same with this. . . MERROW: Were you nervous? HOLST: Yeah, sure. MERROW: Were you nervous the night before? HOLST: Umm Hmm. I was less nervous as I started the lesson. MERROW: Did you stay up late? HOLST: Yeah. I was up most of the night. Just nervous energy. MERROW: What's riding on this? HOLST: Whether I'm rehired, I'm sure. There are less students coming in, enrolling in the science classes and they may have to make cuts, so it's really very competitive right now. So whether or not I'm rehired depends on how I serve my first year. MERROW: The formal observation process has a second part, in which the new teacher gets feedback from the observers. Susan received compliments, but no specific suggestions that would help her do a better job. TEACHER: Your lesson plan was extremely thorough and very comprehensive. We could tell what happened the day before, and we knew exactly where you were going to be going tomorrow and the rest of the light unit. Very impressive to me were the students being, answering questions in complete sentences throughout. With the development of opaque, translucent and transparent, there's no way that the students are going to go away from that class today without a thorough understanding of what those three terms meant. And the way the you developed it, I thought, was very, very good. The one thing that I noticed at the beginning, which I think that you've improved on, and it might have been the fact that we were in there observing, was at the beginning you didn't project quite as well. But I detected then, as the lesson progressed, you got into more and were projecting more to the students. TEACHER #2: Something I really liked, when a student makes a mistake, you're able to turn that mistake around and still pat him on the shoulder and make him feel good about what he's said. HOLST: The evaluation afterwards was as interesting as before. It was still awkward to sit in there with four men and have them talk about you, but their comments were all very positive, and they seemed to feel that I was doing an excellent job, and a real asset to the department. That certainly makes me feel great. But I can't help but wonder if a lot of people get the same response, or are they lenient in their evaluation. MERROW: This is Lynn Robbins' first formal observation. Her goal in this lesson is to convince the seventh graders of the importance of using specific details in their compositions. ROBBINS: At the bottom, underneath there, I want you to write one day, and then we're going to decide what to replace it with. Sarah? SARAH, Student: Saturday? ROBBINS: Okay, Saturday. That's fine. Now we have, ''Saturday, I went to the store with a friend. '' What can we do next? Mark, before you fall out of your chair? MARK, Student: Money? A dollar? ROBBINS: Money? Okay. On the way back from the store we found some money, we might want to replace money, that's a good one. MERROW: What do you have riding on this? ROBBINS: Probably more than anything else, my own confidence. I'm not so worried about my job. But I think I can come across well enough to keep that. But I'm worried about just doing the very best that I can, so that I feel assured about what I did. MERROW: After the class, Lynn met with the evaluators. They praised her teaching, and more importantly, they offered constructive criticism. STEVE JONES, Principal: The concepts today were solid. I think the area that we need to look at. . . We're going to point out a couple of things that we'd like you to think about and possibly put in place as we progress through this school year. These suggestions are suggestions so that we can see some improvement, and we all need to do that. SHARON NORMAN, Baltimore City Public Schools: We saw many good things today, and we want you to hear that. And we also saw some things that we could make suggestions about to make you the optimum teacher that you're going to become. So try and balance them that way, too. There are a couple of managerial things that I'd like to stress. This is real hard to do, but try not to repeat the student responses because it encourages kids to tune each other out, and say Ms. Robbins is the one I have to listen to. If you feel the response was not sufficiently clarified or not loud enough, as is often the case, ask another student to say it. I though you did a nice job of directing the discussion, but as you established earlier, you were more teacher directed than I think even you were happy with being. There were times when the kids could have taken some of the burden of the discussion off your shoulders, and it's the teacher's job to pull more out of them --''Tell me more, elaborate on that. '' PAUL DOUGHERTY, Chairman, English Department: Some of the things that I would like to do, after next week or so, is to give you an opportunity to get out and see some of the other teachers in the Department. I think if you get to watch Sue Lauber and see how she takes her time and gets students to provide much more of the information that they've got, and as well to get you to watch Carol and Rachel. MERROW: This is quite a day for you. How do you feel now? ROBBINS: Exhausted. I'm exhausted and I'm hoarse because I talked too much MERROW: How are you doing, do you think? ROBBINS: I think I'm doing well. I still like it, that's a good sign. I haven't changed my mind yet. I still have people saying, You wait, just wait till the first year's over. But, so far, so good. MERROW: It's possible that discipline problems, bureaucracy and paperwork may drive Lynn Robbins and Susan Holst from the classrooms someday. But now, with the year not quite half over, they remain optimistic, idealistic and caring. ROBBINS: I wonder if my students know how much I care, how much I rejoice over their successes and grieve over their failures. I wonder if they'd believe me if I told them how I cross my fingers as I calculated one student's grade, or grimaced as another missed a C by a few points. And would it make any difference to them? HOLST: This week was very normal. I enjoyed my students, I felt we accomplished a lot, and there were no major discipline problems. I really enjoyed teaching this week. It's such an interesting job. To think that just a few months ago I didn't like it at all. It's such an exciting job, when you actually get to teach. Maybe this will be a trend. Christmas in Washington LEHRER: Finally, some Christmas thoughts from our Washington man of thoughts, essayist Roger Mudd.

ROGER MUDD: Washington, D. C. has always taken a special pleasure and comfort in Christmas. So many families are on temporary duty here and have their roots elsewhere that Washington's celebration of Christmas has, over the years, helped draw the city closer together for just a few brief weeks. And nothing symbolizes so dramatically this spirit and feeling as the Christmas trees of Washington. In a city of hard white marble and unforgiving politics, the trees of Christmas seem to soften both. Their glow and warmth and glitter encourage us to suspend, if only temporarily, the harsh judgments of governing, the cruel assessments of our politicians toward one another, even the proud cynicism of the media. Each year all of us take delight in watching the national Christmas tree being raised and lighted on the ellipse. And each one of us looks forward to seeing our White House festooned in ribbons. On Capitol Hill, where eleven months a year a Christmas tree is really a tax bill, the Congress actually decorates a real tree at Christmas time, this year it's a 60 foot Norway spruce. After all, it was a tax bill, though we call it census now, that brought Joseph and Mary to Bethlehem almost two thousand years ago. Of course, nobody in Washington is likely to claim that, because this is the city where taxes and the census originate, or because this is winter, or because most of the inns are filled that we're likely to have another savior born to us. But it's hard to look down Pennsylvania Avenue toward the Capitol at night during this holiday season and not feel softened by the spirit of the nativity. Throughout the years, America's presidents have helped keep that spirit alive. In fact, a history of America could be written from the Christmas messages from our presidents. Reflecting not only the American condition, but also the depth of our leaders' faith. In the midst of the Great Depression, Herbert Hoover said, ''Christmas is the children's day, and older folk can enter into its joy only when led by their hands. '' Just a few days after Pearl Harbor, Franklin Roosevelt said, ''Our strongest weapon in this war is that conviction of dignity and brotherhood of man which Christmas Day signifies. '' In 1948, Harry Truman said, ''Of all the days of the year, Christmas is the family day. Christmas began that way. '' In 1959, Dwight Eisenhower, just back from a trip around the world said, ''I fervently hope that in this Christmas season each of you will give thought to what you can do for another human, however distant in miles and poor in worldly estate. '' And less than a year before he died, John Kennedy said, ''Christmas is truly the universal holiday of all men, when all are reminded that mercy and compassion are the enduring virtues. '' And few of us can forget the Christmas of 1979, when we prayed for the 50 American hostages in Iran, or the Christmas of 1981, when we lighted candles in our windows as a beacon of solidarity for the Polish people. So the news this week, the good news this week, is that the trees of Christmas are again beautiful, and the spirit of the nativity is again alive in Washington, D. C. Recap LEHRER: Again, the lead stories of this day were the celebration of Christmas by Christians around the world, and the recapture of Lynnette Squeaky Fromme, the 39 year old woman who attempted to assassinate then president Ford in 1975. She was apprehended without incident near the federal prison at Alderson, West Virginia, from where she has escaped Wednesday night. Have a nice holiday weekend, we'll see you on Monday night. I'm Jim Lehrer. Thank you, and good night.