tion. We do not tell the community which guidelines to use in making their judgments. The smail community group to which you may have had specific reference in mentioning a town in Massachusetts, may come up with a different set of circumstances than, say, a group into Seattle.

Senator KENNEDY. Where do they go? Who within HEW is spending his time just thinking about that kind of question?

Dr. DUVAL, I think that in terms of how to make the moral decision in the community about who will or will not benefit from the procedure, I would have to say there is no focal point inside the Department that attempts to make that decision.

Senator KENEDY. It's not a question of trying to make the decision. But who is saying that we need more time to work on this particular kind of problem, and therefore, we ought to fund this study here; that there is more of a demand for medical science in this area, and therefore, we need more kinds of studies here; and here are three or four different kinds of alternatives, and these are some of the things that we have found successful under these circumstances—who is there to counsel us along these lines?

Or are you saying that there is some one in the Department who can say, "Here are 15 studies, and I hear there is something that is going to be done at the University of Chicago, and when that comes in, I will send you up a copy."

Dr. DUVAL. I believe your question is directed toward the situation in which Federal funds are involved in supporting an effort in the community, usually supporting research and involving equipment, where a person might or might not be the beneficiary of an esoteric

system.

We have a peer review procedure to decide whether or not the investment should be made.

Once this has passed out of the frame of reference in which pure research is involved and it becomes a service that professional people in the community decide to make available, we do not thereafter have a focal point that serves as advice and counsel to that community as to how they should resolve that professional and moral question.

Senator KENNEDY. Where does that community of Milford go? If they call up my office, who am I supposed to send them to over in HEW? Where do they go?

Dr. MARSTON. Well, Senator, I think as you know, the attempt would be to put them in touch with those individuals with the greatest information about the specific area that they were interested in.

Senator KENNEDY. In other words, a specific area like renal dialysis? Dr. MARSTON. Yes.

Senator KENNEDY. There is some specialized unit in HEW that can respond to specific technical questions in its particular area; but that can't address the broader questions and issues which are involved. Should he just go to somebody in NIH who is an expert in terms. of kidney disease? You have the best in the world on it-I don't think anyone is questioning that-but is that all that we need? Do we need somebody who is an expert on that, or rather some kind of agency that isn't specialized on kidney disease, but also has other kinds of inputs in terms of the wide range of ethical questions involved?

I think that is what we need to address ourselves to.

Dr. MARSTON. The question you raise is one that is going-
Senator KENNEDY. Where does he get it?

Dr. MARSTON. I don't know that there is any place that one can go, to answer this question, or to get very much help on a question where you have a gross disparity between resources and the need for resources, this is the question whether it is a question of a physician or a physician assistant, a renal dialysis machine, or something of that type.

It is one of the major problems that faces us. I think one needs contact with a specialist, if there is a particular interest, as there is in many communities, and also a need for working at the broader question of allocation of scarce resources.

There is no place in NIH, or HEW that I know of that people can come to ask how to handle the health resources in the community and get at one place a single answer.

Dr. DUVAL. We might add that we don't think there is a single

answer.

Senator KENNEDY. That is right, but we need to try, I feel, to raise some of these questions in order to provide help to those who have to make decisions. I think this is all. Maybe this commission would never recommend that there be that one place. Maybe they would. At least, they would be able to guide the community in terms of some of these areas.

Senator Mondale ?

Senator MONDALE. I don't know of any issue that fascinates me more than this one, because there is generally some proportionate relationship between an action and a reaction. But in this case, the reaction is grossly disproportionate to the action.

All we are proposing here, and have been proposing for some years, is to create a measly little study commission to look at some very profound technological breakthroughs which could revolutionize human society, including such issues as behavior control, genetic engineering, vital organ transplants, kidney dialysis, experimentation on human beings, or any number of other things.

All we have said is, "Let's have a public study commission to look at it."

That is all we have asked for. But the reaction has been fantastic. In 1968, they bootlegged Christiaan Barnard in here to tell us why this would put South Africa ahead of the United States in medical science. He said, "You will have a politician in every surgical room." The major portion of the American public bought what he said. He said they didn't have any problems in South Africa on the vital organ transplant issue.

I know that a widow in South Africa recently complained that her husband's heart was taken away without consultation. She took that personally.

But they have no problems, he said, and to do anything about it would be terrible. They got Dr. Kornberg in here, who is a great scientist, and what did he say?

In 1968, he said the bicchemist who deals with molecules cannot afford any time away from them. "Today, I am not in the laboratory. I do not know what is going on at the bench. Tomorrow, I will be less able to cope with the identity and the behavior of molecules. The more

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I am estranged from the laboratory, the less competent I am to advise you regarding special problems in this field."

In other words, he asked us, "Why are you wasting my time here?" Today, your position apparently is that if we have a little study commission, it would freeze American technology. That is apparently the position taken here.

Why do we assume that if the public understands this that their reaction will be necessarily anti-science? Might it not be more supportive and, in the long run, doesn't medical science require public support, public understanding and, above all, public confidence?

My point is that we are asking to do so little, and the resistance seems to be entirely disproportionate. Everybody is getting studies these days. What is wrong with a little bit of study here?

Dr. DUVAL. Senator, my response to that would be to reiterate that we are in full accord with the objective for which these hearings are held now and as a consequence of the submission of your resolution, and that the objective you are trying to achieve is eminently desirable.

I would submit that as a consequence of the very rapid technological advance that has been made in the last 3 or 4 years in science that society, itself, has responded rather well to the number of abuses considering the extreme work that is going on in this field.

It has been very small, and I am very impressed that at the moment society has indeed responded in the way in which you have hoped and expected that they would.

I want to throw in with that argument the possibility that by setting up some form of central or national commission, you will be somewhat inclined to relieve local communities and local groups of some element of local responsibility.

Senator MONDALE. Just tell me why that is true?

Dr. DUVAL. I believe there is probably a natural inclination to say, "I can do this as long as group A has not told me that it isn't OK."

We think the system of defending everything you do locallywhich is what we do now-is working rather well.

Senator MONDALE. Do you have some study groups on science and ethics and so on?

Dr. DUVAL. Yes.

Senator MONDALE. Does that paralyze local initiative?

Dr. DUVAL. No, sir, it doesn't.

Senator MONDALE. In other words, if you do it on your own, it is fine, if we ask you to do it, it is not?

Dr. DUVAL. No, sir, I didn't mean to imply that.

We have a group that must examine everything that is done in this general area before it can be funded. So, among his own peers and associates and colleagues, every person involved in this work locally must present his case before a court, so to speak, that includes the same type of representatives that you have already described in your Commission.

We would not like to see that decompressed or relieved of responsibility by guidelines established by central governmental authorities. Senator MONDALE. I have great respect for what you are doing. great respect for the medical profession. In Minnesota, we have a great medical apparatus

But I sense an almost psychopathic objection to the public process, a fear that if the public gets involved, it is going to be anti-science, going to be hostile and unsupportive.

I think, in fact, the public very much wants a healthy, growing medical science. Trying to keep the public out is, actually, a greater risk than opening up the process and letting the public participate. This sort of bias shows up in several ways. I have asked several medical witnesses about how many medical schools, for example, teach these issues, regarding science and its implications for society. I think very little is being done.

How many medical schools try to train their doctors to be broadly understanding of the economic and social implications of the field? Far too little is being done. I think there is more than was true a few years ago, but it is too often considered a waste of time.

I think the medical profession suffers from trying to keep all their functions private. I think the more they would let the public in, I think the more surprised they would be of how understanding and supportive the public would be.

I think resistance to this modest little proposal underscores the inflated fear that the medical profession has.

Dr. DUVAL. Senator, I would like to respond by saying that to the extent that my colleagues are guilty of giving you the impression of privatizing in this area, I would apologize, because I firmly believe there is a very real feeling in the scientific community that the public interest with regard to this field at this time has never been more appropriate and more warmly received.

I have no explanation for such interpretations as you may have put on it in the past.

With regard to your point about instruction in this type of activity in the medical schools, it is my impression that there is a great deal going on now in the United States. In the school I started at the University of Arizona, we have a complete course which takes on the entire field.

Senator MONDALE. When was that course set up?

Dr. DUVAL. 1967.

Senator MONDALE. As I mentioned, I think there is some progress in this area, but I think it is slow and late, and that you are a leader in the field.

Dr. DUVAL. It is because you held hearings and directed our attention to this that there has been an adequate response.

Senator MONDALE. At one medical school.

How many medical schools have courses like the one you have set up?

Dr. DUVAL. More than half.

Senator MONDALE. That is quite a change.

Dr. DUVAL. There may have been less than 10 percent in 1967, Senator.

Dr. MARSTON. Senator Mondale, may I respond to your comment on behalf of NIH?

I was Associate Director at the time that Dr. Shannon made his statement in your longer hearings. I have reread those, and I think they are very positive and I agree with a statement that was made 4 years ago.

I think it is important that the position of NIH is precisely yours, that this is a question of great importance and one that must be shared

with the public. It cannot be held within the scientific community, and I would want no misunderstanding on my personal feelings on reviewing last night the statements made 4 years ago before your committee.

Senator MONDALE. Thank you very much.

Senator KENNEDY. Senator Dominick?

Senator DOMINICK. Dr. Duval, I want to start out by saying that I think that Senator Mondale and Senator Kennedy have introduced a resolution which by drawing attention to the problems here which have not been drawn attention to before in Congress, have performed a very useful service, and I really think that.

I had the opportunity of having lunch with Dr. Barnaard a couple of years ago right after his spectacular heart transplants, and raised some of these questions at that time at lunch.

As Senator Mondale said, any effort to question what he was doing in terms of legal or ethical positions were greeted as though you were attacking him personally on his skill as a doctor, and this I found a little frustrating.

I noticed in your statement here on page 9, Doctor, that you refer to the private sector and the groups who are actively investigating some of these problems now, including the National Academy of Sciences, the American College of Surgeons, the National Academy of Engineering, the American Academy of Arts and Sciences, the American Philosophical Society, IBM, and the Kennedy Foundation, amongst others.

About when did they start becoming involved in this?

Was it really after the heart transplant operations started drawing attention to these problems in a rather massive way?

Dr. DUVAL. Senator Dominick, the first entry of this kind into the field coincided with the NIH Clinical Research Center in 1952. The great impetus in the area did occur subsequent to the first heart transplant.

I might add that it has gotten a great deal of stimulation by hearings on this type of issue.

Senator DOMINICK. I am having trouble hearing you.

Dr. DUVAL. It has had further progress and impetus as a result of the focus provided by hearings in this room.

In other words, I would make the same comment, Senator Dominick, that you have already made, that these have served a great purpose in bringing these to our attention in this way.

Senator DOMINICK. In what particular fields are these people and groups you are talking about now working?

Dr. DUVAL. In the broad fields of medicine, biology, theology, but the purpose of their undertaking investigations or explorations in these broad areas is to specifically treat the issue of the local regional management of problem situations involving genetic counseling, genetic manipulation, organ transplantation, time and cause of death, et

cetera.

Senator DOMINICK. There used to be in several States, at least, and I would presume pretty much nationwide, an experimental, a human experimental scientific situation where, if a prisoner legally convicted was on death row or something, and he wanted to go through with a