The Twin Brothers Who Brought America EMTs, 9-11 Dispatchers, and Saved Millions of Lives

This is Lee Habib, and this is Our American Stories, the show where America is the star and the American people, and we love to hear your story. Send them to ouramericanstories.com. About your family, about the town you live in, about the country you love. Your stories are some of our favorites. Up next, the story of how identical twin brothers, a doctor and a lawyer, collaborated with scores of unsung heroes to modernize emergency medical services, help create the physician assistant profession, help write the model law for organ donation, and develop other programs that save thousands of lives every year. Here’s Alfred and Blair Sadler with their story.

Thank you very much.
It’s a pleasure for you are Blair and me to have an opportunity to be with you today and tell our story. I’m Alfred Sadler; I go by Fred, and my identical twin brother, who was born four minutes after me in New York City in 1941, is Blair.
And I’m a physician, and Blair is a lawyer.
Blair and I were medical student and law student respectively in Philadelphia in our early twenties, and this led to the idea that we might actually collaborate together. The first issue that we addressed was the Good Samaritan problem. And what I’m referring to is that Christianity and the American Bible talk about the Good Samaritan who is encouraged to stop at the scene of an accident and help someone who is injured, even if it’s someone of another persuasion. But the law may have a different view of the matter. If, for example, we stop and the patient doesn’t do well or dies, the family in our litigious society might be encouraged to sue us. So, we looked into the laws relating to this. There were different in different states, and that is what launched our collaborative career.

When I reflect back on, how did we get started? How did this idea actually take off to collaborate? We talked in the book about four green lights: four things that happened that had they not been giving us a green signal, we never would have done this. Fred’s already mentioned the first one of those, which was a joint presentation we did at Mass General Hospital as part of his surgical rotation on the Good Samaritan—the legal and ethical issues in stopping to render aid in an accident—and the Chair of the Department of Surgery afterwards saying, “This is one of the best presentations we have had.” That really led us spark, and we decided to pursue the idea of collaborating in law and medicine. We developed a paper describing a variety of medical-legal issues such as informed consent, human experimentation, euthanasia, organ transplantation, and definition of death. I called Anthony Amsterdam, a leading Pen Law professor and a mentor of mine who frequently argued cases before the Supreme Court. I asked if we could meet with him about our idea, and he said, “Sure, let’s have dinner.” Fred and I came to the dinner with two questions. First, did our medical-legal collaboration idea make any sense? And second, should we pursue such collaboration now, or should we wait until we’re further along in our careers? He reviewed the paper and said, “You know, this is a great idea.” Even more important, he thought we should pursue it immediately. That provided a major booster shot to proceed. But where and how? We were aware that the U.S. Public Health Service had opportunities to become commissioned officers, but they were typically for M.D.s and Ph.D.s in science, so Fred took a chance. He called Dr. Luther Terry, the former Surgeon General, who had become well known by fighting the tobacco industry over cancer risks and placing the warning on every pack of cigarettes: “Smoking may be hazardous to your health.” Fortunately, he was now dean of the medical school at the University of Pennsylvania, of all places. He agreed to meet with us and reviewed our position paper. He exclaimed, “You know, this is a great idea!” “I wish I had had a doctor-lawyer team working with me on the tobacco issues.” He put us in touch with the current Surgeon General and the current Director of NIH. We soon arranged for three days of interviews in Bethesda and Washington and received invitations to apply for jobs. We did, but just four months had passed with no response, and I was running out of time. My judicial clerkship in Philadelphia was ending in July, and I had to decide whether to accept an offer from a Philadelphia law firm. So, I called the office of the Associate Director of NIH, who agreed to meet with me. Just a month later, on March 28th, our 26th birthdays, we received telegrams offering U.S. commissions in the U.S. Public Health Service, stationed at NIH in the Director’s Office in Bethesda. We enthusiastically act began work on July 1st.

When Blair and I arrived on day one, on July 1st of 1967, in the Director’s Office of the NIH, we met with Mr. Joseph Murty, who is the outstanding leader of the planning office for Dr. Shannon of the NIH, and he was our boss. And he said, “Gentlemen, we have a problem,” and put two newspaper clippings in front of us, one from the L.A. Times and one from Minneapolis where pituitary glands were being taken from cadavers who were being examined by the medical examiner to determine the cause of death. And the medical examiner in every state has the authority to do that when they’re suspected homicide or foul play, or if there’s a pandemic, for example, and he has authority to do that, whether the family objects or not. But there is no authority as part of that statute in any of the states which allows him or his assistance to take other tissues that have no relevance to the cause of death, in this case, pituitary glass.

And you’re listening to the unlikely collaboration of identical twins, want a lawyer and want a doctor, who forever changed how we view certain things about the medical and legal professions and the intersection of both. When we come back, more of the story of Alfred and Blair Sadler here on Our American Stories. Here at Our American Stories, we bring you inspiring stories of history, sports, business, faith, and love. Stories from a great and beautiful country that need to be told. But we can’t do it without you. Our stories are free to listen to, but they’re not free to make. If you love our stories in America like we do, please go to ouramericanstories.com and click the donate button. Give a little, give a lot; help us keep the great American stories coming. That’s ouramericanstories.com. And we’re back with Our American Stories, and we’ve been listening to the story from Fred and Blair Sadler, identical twin brothers, a doctor and a lawyer, who helped innovate and change American emergency medical services. We last left off with Fred sharing the story of how pituitary glands were being taken without consent from cadavers by medical examiners in California and Minnesota. Let’s return to Fred and Blair.

That had happened in those two states.
The press had found out about it, where assistance to the pathologists were taking pituitary glands and sending them back to Baltimore, Maryland, which is where the headquarters of something the NIH was funding called the National Pituitary Agency was located. And they were doing this because although at only $2 per gland, if you send enough of these, and the NIH was collecting 72,000 pituitary glands from cadavers from around the country, you can make some money. The reason that the NPA, the National Pituitary Agency, was established, was very straightforward. We’re all familiar with unfortunate children who are born with a pituitary tumor or a pituitary problem which prevents them from making adequate human growth hormone that we all need to grow to our full height, and if we don’t, we end up being very short. So, by grinding up the cadaver pituitary glands and obtaining human growth hormone, then enough could be administered to the dwarfs by injection over a crucial period of time in their growth.

A noble purpose, to be sure, but it seemed clear that some people in at least some coroner’s offices were not following the law. We were complete rookies on this issue, whether it’s medicine or law. When you were confronted with a new issue, step one is due research. We went to the Georgetown Law Library, and we read everything available on the variety of state laws dealing with autopsies and organ donation. We also got advice from the leading authorities on this topic: the eye banks, the Kidney Foundation, the Heart Association, the tissue banks, even the funeral directors. During our research, we discovered that the Commissioners on Uniform State Laws (now the Uniform Law Commission) had actually created a committee that had been at work for a year on drafting a model state organ donor law. Amazing. We met with Professor Blythe Stasen, the former Dean of the Michigan Law School, who chaired the committee. We reviewed the many connections we had already made to healthcare organizations and that we had a mandate from NIH to explore these issues in depth. He asked us to serve as official consultants to the Commissioners. What an opportunity! And then, just two months later, Dr. Christiaan Barnard performed the first human heart transplant in South Africa, front-page news, Time magazine’s Man of the Year. There was tremendous public interest and concern. A Gallup poll showed 70% of people, if asked, would be an organ donor. But two New Yorker magazine cartoons sent a different message: one of a patient in a hospital bed with a large sign on top of him reading, “Patient asleep, not a heart donor,” and another was a bumper sticker cartoon that read, “Dry carefully, Dr. Bernard may be watching.” While humorous, they revealed an underlying concern. Could people trust the healthcare system not to give up on them prematurely if they were sick and were a potential donor? We worked on multiple drafts over the next several weeks and reviewed them with Stasen and his committee and other experts. Ultimately, they approved it and recommended it to the Commissioners. At its core, the Uniform Act is a gift statute based on voluntary, informed consent. It provided, first, an individual could decide to donate all our part of his body for transplantation or research upon being 18 years of age. Second, if no decision had been made by the individual, the family could make the gift, and it provided a specific definition of eligible family members. Third, it stated that the donor’s position could not be this aim as the recipient’s physician, to avoid any conflict of interest. That provided permission for definition of death to include brain death, but did not include any specific definition of death, because we knew that as science evolved, medical criteria would too. In June 1968, just less than a year after arriving at NIH with Blythe Stasen, we presented the Uniform Anatomical Gift Act to the full body of the 100 Commissioners assembled for their annual meeting in Philadelphia. It was approved unanimously. The American Bar Association approved it one week later. The model law was enacted with little or no change, by 41 states in the first year and by all 50 states and the District of Columbia in three years. We testified before at least ten different state legislatures during this period, as well as before the U.S. Senate at hearings commissioned by Senator Walter Mondale. The Uniform Donor Card was another key step. The law specifically provided that a gift could be made by any written document, including a card carried on the person. But what if the cards were different and conflicting? As members of a National Academy of Sciences ad hoc committee, we convened what turned out to be a pivotal meeting of 21 organizations with just one goal: develop a donor card that could be used by all in every state. The meeting was a success and produced a simple legal document the size of a driver’s license. The streamlined that consent process and could be used by all organizations. A potential crisis of confusion and conflict had been avoided.

We did not really realize that at the time that we were working on the Organ Transplant Law, with the Uniform Law Commission and writing the Uniform Anatomical Gift Act, that we were essentially dealing with very important bioethical alternatives. Should we set up a system (which we did) which was voluntary, which would allow us to donate and the next of kin can also donate, or, as a pair of professors at UCLA (one of whom was a physician and one of whom was a lawyer) argued that you’ll never get enough organs through voluntary donation, and therefore we should switch to what some people call presumed consent or opting out, which says that all of us are organ donors unless we object? So, the burden is on the citizen to object to donating. And we felt that this approach went against all American values, particularly altruism, autonomy, and trust. We argued our position in law review articles and in New England Journal of Medicine articles, and this helped support the movement in all the states and in the District of Columbia to pass the Uniform Anatomical Gift Act.

And we’ve been listening to the story of Fred and Blair Sadler, want a doctor or the other a lawyer, and how they collaborated and innovated and changed all of our worlds forever—that organ donation card that we all take for granted. My goodness! Without that idea, without that work that they did, what a different world we’d have and how many less people would be alive. And by the way, what a thing to do: that dialogue about getting the citizen to opt out of organ donation. What a terrible idea. It would have ruined everything, and there would have been great resistance—assumption that we’re just giving away our organs. But to fight to do it right and to get people to voluntarily do this and make this the status quo. What a remarkable achievement by these twin brothers. And by the way, you can pick up Fred and Blair’s book, Pluck: Lessons We Learned for Improving Healthcare and the World, and you can get it at your local bookstores, at Amazon, or any place you buy your books. When we come back, more of the remarkable story of Fred and Blair Sadler, twin brothers, a doctor and a lawyer, who changed how we live and how we die. Here on Our American Stories. And we continue with Our American Stories and the story of Fred and Blair Sadler. Let’s continue when we last left off.

We’ve talked a lot about organ transplantation and bioethics, but emergency medical character as well was a similar remarkable experience. We were now at Yale running the Yale Trauma Program, and it’s remarkable to reflect on where emergency care was in 1970. As hard as it is to believe, there was no 911 number. There were no EMTs or paramedics. Ambulances were glorified station wagons, sometimes doubling as hearses. There were no residency programs in emergency medicine. There was no system of trauma centers. Every day on the battlefields of Vietnam, well-trained medics were taking wounded soldiers to well-equipped trauma centers. Their cardinal rule was the golden hour. The golden hour: get the patient to a well-equipped trauma center in one hour, and they had a chance. Ironically, no such goal existed back home in the States. It was “Scoop and Hall,” pick up the trauma patient, take them to the nearest hospital, and hope for the best. No wonder that. A 1966 study by the National Academy of Sciences is called “Accidents, the Neglected Disease of Modern Society.” We began our comprehensive study in Connecticut by learning everything we could about EMS in the state. Working with 9 MPH students, we canvassed the state. Connecticut had 35 hospitals and 179 ambulances, but there was no coordination between them. In 1968, a presidential commission had recommended a single telephone number, 911, and AT&T declared it was available, but only a few systems had been established. In Connecticut, for example, it served only 14% of the population. So, we created and co-chaired the state’s first EMS Advisory Committee and developed a 700-page report, which we distilled to a 52-page summary, submitted it to the Governor, entitled “Emergency Medical Services in Connecticut: A Blueprint for Change.” Key legislative support followed and funding, and in just five years, 6,000 ambulance personnel six completed the new 81-hour EMT course in Connecticut.

Our next problem found us, and that was that the Assistant Secretary for Health wanted someone to look into the legal issues of the fact that there were new types of health professionals called physician assistants being trained to help the problem with the acute shortage that existed at that time. This is 1969. Medicare and Medicaid had been passed in 1966, which enfranchised millions of additional Americans for health care. Be it the elderly, or be it poor people below a certain poverty line. However, there were nowhere near enough physicians and nurses to do so, and to train additional doctors would have taken seven to ten years to do so. Very bright and creative physicians and nurses decided to solve this problem. And at Duke, Professor Eugene Stead and Professor Thelma Ingalls from the Nursing School got together to teach nurses to learn a lot more about medicine and give them a certificate as specially-trained. And the plan at Duke was to this was in the late fifties and—