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The pediatrician as a model of integrity: C. Everett Koop

It is not enough for pediatric radiologists to be highly knowledgeable, technically proficient, and thoroughly experienced. To develop fully as professionals and human beings, we must also embody excellences of character, as embodied in the virtue of integrity. Persons of integrity remain true to their vision no matter where they are or who they happen to be with, scrupulously avoiding the chameleonism of those who seem to change their beliefs to fit in, please others, and advance their own interests. Simply put, persons of integrity refuse to trim their consciences to fit the fashion of the moment. One inspirational example of such integrity is the pediatric surgeon C. Everett Koop (1916–2013), who remained steadfastly loyal to a professional ideal that both endeared and alienated supporters on both sides of the political aisle. His story offers insight and inspiration to all pediatric radiologists. The only child of descendants of Dutch immigrants who settled New York, Koop grew up surrounded by extended family [1]. As a boy, he developed a fascination with the instruments and skills of his family’s physicians, as well as the idea that he could use his mind and his hands to heal someone. To develop his own dexterity, he practiced cutting pictures out of magazines and tying knots with both hands. Having witnessed surgical procedures at Columbia, he began performing operations on stray cats and rabbits, recruiting his mother as anesthetist. As a teenager, he volunteered at hospitals, including one for “crippled children” on Long Island, near his family’s vacation home. During his undergraduate years at Dartmouth, where he majored in zoology, he met Betty Flanagan, who would become his wife for more than six decades. He also acquired the nickname, Chick, for chicken coop. During medical school at Cornell, he and Betty married. She supported them by working as a secretary at the hospital, and their family soon grew to include four children. Koop interned at the Pennsylvania Hospital in Philadelphia, the nation’s first hospital, co-founded by Benjamin Franklin, and then completed surgical residency at Penn. He finished his training in half the required nine years, later recalling that “My happiest hours were in the operating room” [2]. In 1945, at the age of 29, Koop was offered an appointment as the first surgeon-in-chief at Children’s Hospital of Philadelphia, a daunting challenge because pediatric surgery was not recognized as a distinct field. He completed a 1-year fellowship in Boston, and after returning to Children’s Hospital of Philadelphia, soon won over his initially skeptical colleagues. He served in that capacity for a total of 35 years, only leaving in 1981 to become U.S. Surgeon General. As a surgeon, Koop was both a master and a pioneer. He developed a device to prevent anesthetic overdoses. He improved one of the most common pediatric surgical procedures, herniorrhaphy. He developed techniques to correct congenital conditions once assumed to be hopeless, including hydrocephalus and diaphragmatic hernia. Once while operating on a child with esophageal atresia, he was surprised to discover that the atretic segment was too long to permit the standard anastomosis, so he engineered the colonic interposition graft. Perhaps his most dramatic surgical successes involved the separation of conjoined twins. In 1956, he founded the nation’s first neonatal surgical intensive care unit. In 1966, Koop also became the first editor of the Journal of Pediatric Surgery. Describing his role as a pioneer in the field, Koop wrote:

It is not enough for pediatric radiologists to be highly knowledgeable, technically proficient, and thoroughly experienced. To develop fully as professionals and human beings, we must also embody excellences of character, as embodied in the virtue of integrity. Persons of integrity remain true to their vision no matter where they are or who they happen to be with, scrupulously avoiding the chameleonism of those who seem to change their beliefs to fit in, please others, and advance their own interests. Simply put, persons of integrity refuse to trim their consciences to fit the fashion of the moment. One inspirational example of such integrity is the pediatric surgeon C. Everett Koop (1916Koop ( -2013, who remained steadfastly loyal to a professional ideal that both endeared and alienated supporters on both sides of the political aisle. His story offers insight and inspiration to all pediatric radiologists.
The only child of descendants of Dutch immigrants who settled New York, Koop grew up surrounded by extended family [1]. As a boy, he developed a fascination with the instruments and skills of his family's physicians, as well as the idea that he could use his mind and his hands to heal someone. To develop his own dexterity, he practiced cutting pictures out of magazines and tying knots with both hands. Having witnessed surgical procedures at Columbia, he began performing operations on stray cats and rabbits, recruiting his mother as anesthetist. As a teenager, he volunteered at hospitals, including one for "crippled children" on Long Island, near his family's vacation home. During his undergraduate years at Dartmouth, where he majored in zoology, he met Betty Flanagan, who would become his wife for more than six decades. He also acquired the nickname, Chick, for chicken coop.
During medical school at Cornell, he and Betty married. She supported them by working as a secretary at the hospital, and their family soon grew to include four children. Koop interned at the Pennsylvania Hospital in Philadelphia, the nation's first hospital, co-founded by Benjamin Franklin, and then completed surgical residency at Penn. He finished his training in half the required nine years, later recalling that "My happiest hours were in the operating room" [2]. In 1945, at the age of 29, Koop was offered an appointment as the first surgeon-in-chief at Children's Hospital of Philadelphia, a daunting challenge because pediatric surgery was not recognized as a distinct field. He completed a 1-year fellowship in Boston, and after returning to Children's Hospital of Philadelphia, soon won over his initially skeptical colleagues. He served in that capacity for a total of 35 years, only leaving in 1981 to become U.S. Surgeon General.
As a surgeon, Koop was both a master and a pioneer. He developed a device to prevent anesthetic overdoses. He improved one of the most common pediatric surgical procedures, herniorrhaphy. He developed techniques to correct congenital conditions once assumed to be hopeless, including hydrocephalus and diaphragmatic hernia. Once while operating on a child with esophageal atresia, he was surprised to discover that the atretic segment was too long to permit the standard anastomosis, so he engineered the colonic interposition graft. Perhaps his most dramatic surgical successes involved the separation of conjoined twins. In 1956, he founded the nation's first neonatal surgical intensive care unit. In 1966, Koop also became the first editor of the Journal of Pediatric Surgery. Describing his role as a pioneer in the field, Koop wrote: Each day of those early years in pediatric surgery I felt I was on the cutting edge. Some of the surgical problems that landed on the operating table at Children's had not even been named. Many of the operations I performed had never been done before. It was an exuberant feeling, but also a little scary. At times I was troubled by fears that I wasn't doing things the right way, that I would have regrets, or that someone else had performed a certain procedure successfully but had never bothered to write it up for the medical journals, or if they had I couldn't find it [2].
Koop was renowned not only for his surgical prowess but also for his compassion, often spending long hours at the bedsides of seriously ill and dying patients and their families. Koop's empathy for children and families was grounded in part in his own family's experience of loss. During his junior year at Dartmouth, his youngest son, David, died in a rock climbing accident. Koop later described his expectation that he: might be better able to help parents of dying children, but for quite a while I felt less able, too emotionally involved. And from that time on, I could rarely discuss the death of a child without tears welling up in my eyes [2].
Koop expressed regret that he did not have the words to provide comfort, but one of his colleagues told him that the tears in his eyes did more to let families know that he cared and foster their trust than any words he could have offered.
A man of deep personal faith, Koop gained national attention for his belief that human life is sacred, which led him to oppose abortion, advocate for saving the lives of newborns with congenital defects, and oppose euthanasia. This brought him to the attention of conservatives and anti-abortion activists, who promoted him to newly elected President Ronald Reagan in 1981. Although Koop recalled turning down the position of surgeon general three times, he eventually accepted the nomination. His confirmation hearings were highly contentious, and he faced both strong criticism for his stance on abortion and sharp questioning over whether his career had adequately prepared him to serve as the nation's chief public health officer.
It was widely expected that Koop would toe the line of Reagan administration policies on such fractious issues as abortion, tobacco, and human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), but Koop showed that he would ground his work not in politics but in science and his commitment to patients. Tobacco interests pressured the administration to mute criticism of smoking, but Koop produced a report that compared the addictive potential of nicotine to controlled substances such as heroin. He was especially dedicated to protecting children from cigarette smoke. He pushed for warning labels on cigarette packs and produced the first report on the dangers of second-hand smoke, seeking to create a "smoke-free society" by the year 2000. While the nation did not achieve this goal, smoking rates declined substantially. Even after he left office, Koop continued to press for higher taxes on cigarettes.
The Reagan administration was slow to take action on HIV/AIDS, the first reports of which were published during Koop's confirmation hearings. Yet Koop was not deterred. He offended both gay rights activists and religious conservatives by frankly describing the sexual practices associated with the highest risk of transmission. He pushed for sex education in schools, arguing that the proper use of condoms was one of the most effective steps individuals could take to protect themselves and one another. His office produced and mailed an AIDS education pamphlet to all 117 million households in the United States. In words that ring with prescience in the era of the coronavirus 2019 (COVID-19) pandemic, Koop wrote.
We are fighting a disease, not people. Those who are already afflicted are sick people and need our care as do all sick patients. The country must face this epidemic as a unified society. We must prevent the spread of AIDS while at the same time preserving our humanity and intimacy [3].
Koop was also a staunch advocate for newborns with congenital anomalies. In 1982, a baby was born in Bloomington, IN, with both Down syndrome and esophageal atresia. The obstetrician told the parents that "Baby Doe" would never be normal and recommended against corrective surgery, to which the parents agreed. Within days, the case began making its way up through the court system, but on day 11 the baby died. Koop, who performed 500 surgeries to correct such defects, became actively involved in the passage of the so-called Baby Doe Amendment, which amended the 1974 Child Abuse Prevention and Treatment Act, setting forth specific guidelines for the treatment of newborns with congenital defects. Thanks in large part to Koop, it is now unthinkable to withhold life-saving care from a newborn simply because of a condition such as Down syndrome.
Koop cut a distinctive figure. Standing 6 feet 1 inch tall, he sported a biblical beard and re-introduced the practice of wearing his surgeon general's uniform. He did not look like anyone else in the government. Still more impressive, however, were his words and the conviction that underlay them. People might not agree with him, but they knew where he stood, and they had confidence that he would remain true to his principles. Even the editors at The New York Times, who initially opposed Koop, developed a grudging admiration for him, writing.
The skeptics and cynics, this page included, were wrong to fear that Surgeon General C. Everett Koop would use his office only as a pulpit for his anti-abortion views. Throughout he has put medical integrity above personal value judgments and has been, indeed, the nation's First Doctor [4].
To foster such integrity in ourselves and our colleagues, pediatric radiologists would be well-advised to reflect long and hard on our core convictions, our sense of what makes life most worth living and what is most worth dedicating our lives to. Also, we need to foster robust conversation in the field, welcoming spirited debate and seeking to enlighten instead of to intimidate. We need to highlight professional and personal integrity as a key focus of education in the field, not only during residency and fellowship but throughout every career. If the seeds of integrity are not planted in fertile soil and well cultivated after they germinate, they will die on the vine. Koop is a shining example of a pediatrician who put loyalty to higher things first. Instead of dooming him, that integrity enabled him to contribute far more than would have been possible otherwise.