Drs. Speer and Pearlman respond:—Nayvin Gordon's heated response to political arguments we did not make and to ideological positions we did not assume brings to mind Alice and the White Knight: “I see nobody on the road,” said Alice. “I only wish I had such eyes,” the King remarked in a fretful tone. “To be able to see Nobody! And at that distance too!”* In the stressful atmosphere generated by vexing social, economic, legal and ethical issues, it is understandable that discussion of the proper course for geriatric medicine elicits comments across a broad distribution of opinion. The concerns about the physician's role in the prolongation of life, social costs of medicine, quality of life assessments, and a lengthy catalog of other unresolved questions encourage some people to search for villains and sinister forces. Other discussants seem content with footnoted folklore in which issues are argued in the absence of evidence, where data are conceptualized before they are mastered, where unyielding positions are taken in advance of understanding the issues, and where self-interested special pleading masquerades as scholarship. However, a substantial literature of constructive, carefully reasoned and thoroughly researched studies is also developing. It is a literature to which we hoped to make some modest contribution. It is also a literature, we believe, that Dr. Gordon's letter enriches. We would not have answered Dr. Gordon's letter had we considered it to be wildly out of order or irrational. We do hope that Dr. Gordon will have some day an opportunity to read carefully the clinical conference that occasioned his letter. But we take no offense at his quotations out of context or at his misattribution of our motives. Rather we wish to commend the passion and sincerity of his Cassandra warnings and slippery-slope concerns. Dr. Gordon's letter is not the best model for clarity of expression or for logical analysis. But we hear the alarms of conscience he sets ringing. Indeed, to a far greater extent than Dr. Gordon might suppose, we share his concerns and look anxiously to an uncertain future for the rights and well-being of the elderly and the poor. It is altogether fitting to press hard the question of why quality of life appraisals are being considered now. It is utterly relevant to remind that resource allocation decisions are political decisions, and to urge that these background concerns and agendas be brought to a level of explicit review. It is moreover urgently important that we not slip into euphemisms when we discuss withholding therapy as a medical management alternative. Our commitment in the clinical conference was to clarify the questions before giving answers or making pronouncements. Our discussion of quality of life considerations in geriatric care was not an endorsement of its capricious use. Needless to say, to reckon the social costs of medicine is not to urge the curtailment of care for the helpless and hopeless; to ponder the limits of striving too officiously on behalf of the terminally ill is not to seek a redirection of funds for war preparations. We believe that quality of life considerations can be positive and helpful when properly applied in a careful, structured framework of clinical analysis. When a quality of life assessment is reached with a patient concerning that person's subjective view of his or her own state of health and well-being it can be central to compassionate and effective medical decision-making. In this context, quality of life considerations may 1) encourage therapeutic decisions that augument or maintain quality of life, 2) avoid decisions that do harm, and 3) generally enhance patient autonomy by including their values and preferences in the determination of therapeutic goals. We would be as fearful as Dr. Gordon at an uncritical, casual application of quality of life measures. Certainly quality of life should not be used as a screen for evaluating the comparative worth of human beings. Technology has placed us on a slippery slope, however, and critical analysis rather than ideology seems to us to be a safer guide in charting our progress.