 Dorothy J. McClain Fellows Conference and the Fest Drift for Mark Siegler. Our first session this morning promises to be a waker-upper. We have three distinguished speakers, Richard Epstein, Ed Laumann, and Ed Lawler talking about the McClain Center as part of the University of Chicago. Unfortunately, Arthur Rubenstein could not make it. Richard Epstein is the James Parker Hall Distinguished Service Professor of Law at the University of Chicago. He's been here almost as long as Dr. Siegler since 1972. He's been a senior fellow at the Hoover Institute. He taught law at University of Southern California, where he served as interim... No, here he served as interim dean. Where were you interim dean? Fellow of the American Academy of Arts and Sciences, he and Dr. Siegler have collaborated for many years on numerous studies, and he's one of the best-known liberal thinkers in America. Richard Epstein. I want to read from the same CV that he was reading from. Who is this well-known liberal thinker that I do a talking about? I mean, I want to thank John for telling me what the topic was, something about 14 seconds ago. And I will actually get to the topic now that I've had some time to think about what I want to say. But I think first what one has to do is to explain this as a... The center is a projection and an extension of Mark's personality. And in order to understand Mark's personality, what you have to do is to go back to some basic legal and economic conceptions. The title of this particular talk, in fact, is known as the multiplier effect. And the effort is to explain how the concept of leverage starts with physics, goes into finance, and ends up in its highest and most perfect incarnation in Mark Siegler. The way in which one starts, of course, the situation with leverage is it tells us something about the way in which language actually works and explains why it is that we really do have to be interdisciplinary. A lever or levers, whatever we call it, is of course something which allows you to find a folk room, put a heavy weight at one end and a lightweight at the other end and use the length of the rod in order to project the heavier weight. And so what it does in effect is if you can do this, you can be like Archimedes or Siegler and move the world. And the whole problem about this is the question is in physics, are levers all to the good or are they not to the bad? And those of us who've ever studied economics or law or medicine or any area in which we've had trade-offs would quickly recognize that our friend Archimedes got it wrong when he said you can do this, move the world with a lever if you stand far enough away because he never asked himself the question of what's this lever going to be made of? And here is the problem. The further you move back on the lever, no matter what the substance or material you use in, the more likely it is when you put pressure on it, this thing is going to be subject to some kind of pressure and it could possibly break. And so you therefore have to worry about when you design these kinds of institutions, is to go far enough out so that you can actually get some leverage out of it, but not so far out that the whole thing will start to collapse. The term leverage, of course, then has another incarnation and this turns out to be a financial term. I hope most of you've heard of the idea of leverage and now the idea of deleveraging, which is the, shall we say, the range du jour. And the whole theory about leverage in this particular market is that what you do is you find a situation in which people can borrow money, put in a little money of their own, and then in effect make their profits fall greater by virtue of the fact that when the value of the underlying asset increases, they pay off the debt and keep all the appreciation for themselves. So to give you a very simple kind of numerical example, if you buy an asset for $100 and buy $90, the great news is if it goes up by 10%, you double your money because it's now worth $110. You pay back your debt, you've got 20 after 10. But this lever can also break as well. And so what happens is if the thing goes down $10, it turns out you're wiped out because it have no equity cushion. And we've discovered that things that go up often do go down and the painful process of deleveraging is the desperate effort to try and sell off your debts before you find yourself into bankruptcy. And we've seen a large number of investment bankhouses that haven't been able to do it. So what does this have to do with Mark? Well, Mark is essentially a leveraged man. It is actually, I've thought back, I've known him now, I guess I have to tell you, since 1973 where our first acquaintance was on an airplane where Mark was leveraging himself. Again, Anna was taking care of two twins. Mark was sitting in front of us reading a newspaper. And my wife wanted to hit him over the head for not helping his wife do this. And this of course ties in with what we heard yesterday. The only dinner, the best line of the dinner, of course, was from Stan Goldblatt. He says that Anna Sigler was a single woman with five children at that particular point. It turned out that she had three. It turned out we were behind. But anyhow, that's what we met and so forth. And in the 35 years that I've known Mark, I've tried to reflect on the following question. Apart from medical issues, when was the last time I'd ever asked him for a favor? And I can't think of a single time. Then I put the question in the opposite direction. I said, when was the last time that he asked me for the favor? And the first time. And the time before that. And essentially the way in which life works with Mark is that it's always the low-key approach. Buddy, I need a favor, is the very line. And so I reach into my pocket and I hope that a dime will satisfy him. But almost invariably it turns out, do I have the dime mark? No, it's a nickel, but that's okay. I always try to figure out exactly what it is that he wants. And essentially his great ability as an academic, I think, and also in some many ways as an internist, is to enlist the labor of other individuals in order to increase his own and the institution's productive capacity. I did say that he constantly asked you to do things. I didn't say he asked you to do silly or foolish things. I didn't even say that he asked you to do things that were down to his benefit or to that of the public at large to the cost of yourself. The real genius about Mark and the ability to do this particular thing well is every time you ask for a favor, it turns out it's a very good idea for you to do. So what happens is he has mastered the art of a listening cooperation by generating mutual gains for the people who happen to be on his radar scheme at any given time. And I think if we did an FOM chart, the friend of Mark chart, it would show an enormous amount of influence precisely because he's always in the position of asking people to do favors for him, which turn out to be favors for everybody else. And that's the multiplier effect. That's the kind of leverage that it has. Now the question we then have to ask and I have no idea how much time I'm supposed to speak is how does this relate to the organization of the McLean Center? And that's an interesting question. I actually thought of the answers. I was tripping my way up the steps a moment ago, which is if you want to figure out what is distinctive about the McLean Center over the years, it has been the ability to have in a single room people who are drawn from all walks of life who would normally have no particular reason to talk to one another. But each of them has been embagled by Mark in order to come to the meeting on the assumption that somebody else they'd like to talk to would come to the meeting as well. And so over the years, it's been really quite an extraordinary assemblage of individuals who've flitted in and out of these centers live. And it seems to me that this is actually something which has immense importance. It certainly tells us a great deal about how the University of Chicago has been organized. For people who do not understand universities, architecture is destiny. If you have a university which is reasonably close together where people are constantly bumping into one another, these incidental contexts will translate themselves into academic collaborations and the university will therefore be the home of interdisciplinary behavior not because there is somebody at the top who's organizing this, but because there are a lot of little maestros like Mark organizing this thing from the bottom so that essentially what we do is we show that decentralized institutions in the good Hayekian tradition which is not the modern liberal tradition, Mr. Lantos, can outperform all those command and control economies with respect to the way in which ideas and operations go. And I would think over the years Mark and I have probably collaborated on, I don't know, eight or 10 conferences I think I must have given over there probably a workshop or two every year. The topics are a dizzying array of subjects and the only qualification that I have to speak on any of them is a willingness to put my head underneath the guillotine and hope that I could talk fast enough so as the wind will keep the blade from falling down. But that's exactly what you want to do inside a university. I think one of the really major flaws of the modern academic model which Mark is I think living proof of its unsoundness is that we try to train people now to become deeper and deeper which means they become narrow and narrow and more and more specialized. And so what they become is essentially much too much risk averse in the way in which they start to think about scholarship. It's okay at least at a conference to make a fool of yourself from time to time. Because if you don't take the sorts of chances with ideas that link together things that may or may not hold together what's going to happen is you will get yourself into this kind of profile in which you're going to be an unleveraged academic person. You're not going to borrow. You're not going to take chances. You're always going to be safe. You'll never go bankrupt and you'll never get rich. And in terms of a business what we really want to do in universities is to encourage kind of risk taking behavior by academics. And we are perfectly happy if they have 10 bad ideas which die and most deserve a death so long as they can generate one idea which actually has some real traction and ability to it. What we do in life as you sort of sum up the total of who contributed what at the end of the day is that people who hit home runs are remembered and people who sort of tried to bunt their way onto first base are not. And what Mark has always been able to do is to encourage people to be free swingers. Now how does this in fact apply when we're dealing with respect to medicine? I've now got a two-minute thing and I will say it. What happens is it encourages people to sort of learn things outside of their field. One of the things that actually amazes and pleads and disappoints me all at once is that I have been involved not only with the McLean Center with respect to its workshops but also in teaching the various fellows who come through each year in this number of summer programs. And what distresses me about the state of modern medical education in the United States is they spend too much time on medicine. And what I mean by that is if you're trying to figure out how a system of medicine fits into a system of healthcare the knowledge of collateral disciplines becomes absolutely essential. And what happens is to put it in the simplest possible terms medicine is much too important to be left to doctors. It's okay to let them treat patients on an individual basis but when you're trying to put together systems and to develop incentive structures to deal with problems of moral hazard, adverse selection trying to figure out on the margin how much you invest in specialist, how much you invest in generalist, how you put the whole ball of wax together, what you do with immigration policy and so forth. What is so clear to me is that the standard form of medical education today does not give doctors the tools to handle these kinds of questions but it often gives them the confidence to believe that they can and the overconfidence coupled with the lack of information is I think an extremely dangerous and potent thing. What is useful about the center is that Mark is able to get large numbers of people from throughout the university fairly intensive fashion to talk about these issues to a group of people who actually seem to be receptive to learn about it. So my hope and effect is that there will be less medical and less clinical in the ethics and a little bit more by way of economics, a little bit more by way of moral theory, a little bit more by way of law and everything else. And in fact that can be done. Oftentimes you have to understand what it is you need to know to do medical ethics as opposed to what it is you know to be a doctor and I'm going to end on this note. I would never presume to be a physician because the two things I can't do, one of them is procedures and the other is dosage and everything else that seems to me doesn't really matter. But what you can do in effect is you can understand people telling you how a procedure is done and what the difficulties are. So that in many ways when you're dealing with medical ethical problems the things that you have to understand is that the stuff which is easiest to learn is the stuff which is internal to the medical discipline and the stuff which is harder to learn is the collateral materials on decision theory and everything else under the sun which you bring to bear in order to exercise it. So my sense of what the mission of the McLean Center is going forward which I think is a very important is to be very conscious about that level of integration and as people become ever more meddlesome in the way in which they wish to argue for healthcare what we have to remember is that the good liberal of the 21st century Dr. Lantos is in fact the good liberal of the 19th century. It's a small government, wise, decentralized institutions who respect property rights and so therefore in their speeches on time. Thank you. Thank you for keeping everything in the simplest possible terms. Next speaker, Ed Laumann, has probably the greatest disparity between what his biosketch says and what he actually does. His biosketch is he's the George Herbert Mead Distinguished Service Professor of Sociology at the College. He's been Chair of Sociology, Dean of the Division of Social Sciences, Provost of the University and currently directs the Augburn Stofer Center for Population and Social Organization. What he actually does is study sex and knows more about who's sleeping with whom in what positions in every country in the world than anybody else in the world. You've just heard a masterful extemporaneous speak which was not misrepresenting himself that he just did it on the fly. It was a wonderful tour de force. I'm going to give you a potted speech which because it gave me a chance to think about these things and what's going to be amazing is how similar we diagnose what his mark has been doing for the university and the Center for Clinical Medical Ethics. I very much appreciate this opportunity to make some informal remarks recalling marks in my collaboration to help develop an interdisciplinary community of scholars at the university over the past 30-some years. This community is interested in clinical medical ethics and more broadly in interdisciplinary collaboration among the humanities, arts, social sciences and medicine. Mark has obviously played an absolutely critical role in fostering these developments at Chicago through his multifaceted talents, relentless energy and drive and remarkable skills as an intellectual leader, agenda setter and networker extraordinaire. Perhaps not surprisingly I first met Mark on a squash court in the mid-70s shortly after I arrived here. As you may know, Mark has had an enormous passion for the game as I do and it was almost inevitable that we would have found one another in that way. My professional interests in sociology have from the beginning of my career been in the study of informal social networks in all their guises including friend and kid ties, professional ties, ties among community and national leaders and sexual networks in order to understand their role in facilitating the exchange of information, social support, social control, resources like money and favors and pathogens. But in Mark I found a true grandmaster of networking who had much to teach me by example and instruction and how to use networks to advance one's larger agenda. One need only look at the letterhead stationary of the Center for Medical Ethics that lists no less than 68 names drawn from the most diverse of institutional and intellectual pedigrees to make this point manifest. In fairly short order, Mark recruited me to be an assistant director in the Nations Center and I found myself having to think of clinical medical ethics from the vantage point of the social sciences, a topic for which I had originally had no interest whatsoever or perhaps more correctly put had no conscious awareness of being an interest of mine. I was pressed to identify potential fellow travelers in the social sciences who could be recruited on a continuing basis to participate in bi-weekly symposia devoted to examining a year-long overarching theme. Mark is truly remarkable in his ability to elicit and formulate cross-cutting interests and concerns across a diverse array of fields including usually themselves bunkered down in the respective silos of intellectual preoccupations and concerns. I recall many at luncheon meeting at the Quad Club where a group of us were asked to wrestle with identifying a thematic focus for the year's topic that would appeal to our respective constituencies and then to identify who among our own faculty are from the national pool of intellectual leaders, those that should be invited to make presentations in the symposia. These meetings were themselves intellectually exhilarating because they involved discussing important topics with fascinating people whom you would never have met under normal circumstances of academic life. These get-togethers brought into context such diverse thinkers as Stephen Tolman in the Committee on Social Thought and Philosophy, Richard Epstein, Leon Kass, Richard Swader at Human Development, James Coleman in Sociology, Gene and John Comeroff in Anthropology, Arthur Rubenstein, Ralph Muller, Robert Michael in Economic Demography in the NRC, John Lantos, William Meadow, Sam Hellman, Norman Bradburn, Laney Boros, Eddie Lawler, Elizabeth Helsinger who is in English literature and languages and art history and many more two-numbers to mention in these brief remarks. Early in our evolving relationship, sometime in the early 80s, Mark and I found ourselves in a strategic alliance. The medical school had invited me as a social scientist and chair of the department to participate in the selection of fellows for the highly competitive MSTP program, the MD-PhD Joint Program. Apparently, the powers that be were receiving pressure from NIH to open the program to persons who wanted to pursue PhDs in the non-hard sciences. As a newcomer to the selection committee, I was clueless about what was entailed in selecting the most promising candidates. Mark was of course quite familiar with the reigning protocols for selection. Together we identified a candidate who of all things wanted to pursue a PhD in the Committee on Social Thought, a highly prestigious program that was notorious for its lengthy time to completion and was a degree program as far afield from the pool of usual suspects in the medical school as could be imagined. Talk about pushing the envelope. We finally managed to persuade the selection committee on the merits of the candidate and he went on to a distinguished career. He is Richard Gunderman, currently professor of Radiology, Pediatrics, Medical Education, Philosophy, Liberal Arts, and Philanthropy. Honestly, that is the title of his professorship and Vice Chairman of Radiology and Director of Pediatric Radiology at Indiana University School of Medicine. A final war story. In 1985, I was appointed Dean of the Social Science Division. Because of these collaborations with Mark in the Center, I'd become much more interested in encouraging the formation of more social intellectual ties across different units of the university and particularly the medical school. In the spring of 1986, Mark and I began to discuss the planning for a year-long workshop on AIDS and society that would bring together social science and medical school faculty to discuss the diverse challenges arising from an epidemic that was at the time doubling every 10 months. In the course of a riveting series of talks presented by leading authorities from such diverse backgrounds as the chief of principal, AIDS Ward in San Francisco, an ethicist from the Hastings Institute, key section chiefs supporting age research at the NIH, deans of schools of public health, health policy specialists, and so on, I became convinced that there was not going to be anytime soon a magic bullet that would stop the spread of the epidemic through immunization. The answer appeared to lie in behavioral interventions and here we lack critical information on the sexual practices and attitudes of the population at large that might be placing us all in jeopardy. Robert Mackle, an economic demographer and director of NRC at the time, and I began to talk and soon concluded that Chicago should undertake another Manhattan project which would pool our strengths in survey and sample design at NRC to mount a national survey of sexual practices. There's no question that the scope and ambition of this project and its capacity to tap rich interdisciplinary based empirical and theoretical resources and personnel is deeply indebted to the community of scholars that was fostered by these workshops over a number of years. It simply could not have happened without this foundation. As a sociologist, I would identify some key elements of this cross-cutting institution for which Mark has provided the critical leadership. He succeeded in fashioning a common intellectual focus and agenda that engages and stimulates the interests of those rooted in diverse disciplines and intellectual preoccupations. He has been extraordinarily successful in finding topics that grabbed the attention and commitment of a core group of participants over long periods of time. He created an environment, the biweekly luncheon meetings that permitted busy people to come together in an informal, socially supportive environment. For example, he fed us and let us become acquainted with our neighbors in a natural, unforced way. He created social sanctions, repeated reminders, personal and by email, to pester backsliders that were not coming regularly. In short, he proved to be a nudge, nag, and badgerer that helped to overcome the usual friction incurred by attendance when you have other things to do. For all these things, Mark, we are in your debt. We were all sad when Eddie Lawler left the University of Chicago to become the Dean of the School of Social Work at Wash U in 2004, but we understood the reason why. His daughter Abby, one of the finest stoppers to ever play for the Hyde Park Red Dogs, was being recruited to the better leagues in St. Louis and so they had to find a job for Eddie down there. Before that, he was Dean of the School of Social Service Administration here, the professor in the Irving B. Harris School of Policy Studies and a senior scholar at the McLean Center, and I worked with Eddie a lot as core faculty member of the Robert Wood Johnson Clinical Scholars Program. He's one of the leading national scholars on Medicare policy in the history of the evolution of the Medicare program. Eddie. I had the idea that this picture would be this big. I confess it's genuinely Orwellian looking down on us for this. Well, we've been asked to talk a little bit about the McLean Center as part of the University of Chicago and I thought I would just say a few words, both from a personal perspective on this and through an institutional lens. I arrived as a new assistant professor in 1984 at the University and quite immediately Mark took me out to lunch and this is, I think, interesting in its own right because at the time I was not doing health policy work. I just finished graduate school working on labor market behavior of old men but I'd actually been trained in health policy and Mark somehow knew this and took me out which was unusual, I will say, as a new assistant professor upon arrival and he had many ideas. He had many ideas about things not only that I could do but also ways that we could work together. We talked about teaching. He made available rounds for me to observe and attend the opportunity to work with fellows to present at workshops. It was an extraordinary thing for, as I say, for a new assistant professor on this campus and that generous outreach really launched a whole program of work for me and as Ed described, a set of relationships that have been unparalleled actually in my life. In the midst of that, Mark was particularly interested in the connections between ethics and policy and in fact we ended up teaching a seminar together with John Lantos and others over several years that drew students from all over the campus to work in this area. I too have been struggling as Richard and Ed have to sort of quite capture the imagery of this center and the best example I could come up with is Mark's World which I think of as quite analogous to Wayne's World although the academic version of it. So in Wayne's World and Saturday Night Live it has its own reality in some ways and its own community of people and in the early years, actually I think John would call this SIGS World if I remember correctly, that this was, as Ed Laum had described, a collection of extraordinarily talented, interesting and academically diverse individuals who came across to have lunch together, to have seminars and the discussions were unusual and extraordinary. I thought I would tell one story about this because in the midst of this and as we built these thematic approaches year to year, one year Mark developed this theme in which we would try to come up with empirical understandings of the doctor-patient relationship and work groups were assembled. Very interesting, small clusters of faculty to work on and to try to think through how you would actually measure and estimate the value of the doctor-patient relationship and I was in a small group of economists and others trying to sort of think through what's the economic value of the doctor-patient relationship and so this is just to give you a sense of the theater of Mark's World. We met at 6.30 in the morning in Mike Royzen's office and those of you who know Mike will probably appreciate this story more. Mike at the time was the head of critical care and anesthesiology and in the midst at 6.30 and we had Bob Michael was there and David Dranoff and Michael Kading just a terrific group and Mike has just cases rolling in that he's managing on the floor. He also has his broker who is calling up and he's doing a ferocious amount of trading in the middle of this meeting and in the middle of it, not in the middle of it, 15 minutes, he jumps up with great fanfare and says he's been measuring, I'll never forget this, he's been measuring and monitoring his caffeine intake in the morning and he has exceeded doses of caffeine that any human should be able to absorb better and it was just a fantastic, not only intellectual experience but also some great fun. I think part of the genius of this interdisciplinary approach is that I've come to believe that Mark was also great at marketing, something that not everybody has mentioned this morning and I'll give you one example of this. This was a seminar that I gave in 1986 at the center and I thought the title was over the top. This was the Winds of Creative Destruction Hospital of Closers in Chicago but Mark loved this title. He was like gleeful, he was jumping over, he thought this was great. This is what we should do and in fact I had, this was a time in the marketplace when DRGs had come in, hospitals were closing in Chicago. There was the Michael Reese University of Chicago merger discussions were afoot. There was also the Cook County Hospital Affair and so again I treat this as an opportunity, had a chance to give this seminar and actually got some terrific comments that I still remember well from Ed Laumann as a course of this but this was, I think it's a piece of the puzzle that Mark not only assembled the right people but he communicated and marketed this work in an extraordinarily effective way. I had the chance to work directly particularly in those early years with a whole set of colleagues and this wasn't just a seminar so I thought I would just point out a couple of papers that resulted from these meetings in my own life. And this is John Lopuma and this was a paper we did for JAMA. I'll get to this in a second Richard. So John and I worked on a paper on quality adjusted life years and it was one of those exchanges that I think is at the heart of this center. We learned a great deal from each other. We argued, we fought and eventually put together I think a pretty interesting piece of work which is an exemplar or I'd like to think of it as an exemplar of this kind of collaboration which was a paper directed at the ethical implications for physicians and policy makers and I think neither of us individually would have been able to go down that trail effectively. Richard mentioned these seminars and I was the beneficiary to many of his and learned a great deal from all this and actually it's I have a line, a lead into chapter of my Medicare book which really is a direct result from those days of hearing Richard and various guys talking about the dangers of moral hazard in our system. Also got to do some teaching and I think this is an important part of the history of this and some great colleagues with Laney and John and Steve Miles, Steve Miles and I taught a course over several years on ethics and policy in AIDS. Again at a time in the early part of the epidemic we actually had truth squads in our class from the university students to make sure that we didn't say anything politically incorrect or untoward and it was a really exciting and interesting seminar that again draw students from the law school from medicine, from social work and from policy and I think this was in my mind this also was a layer of the center's contribution and creating interdisciplinary work that's quite important. So I hope I've conveyed a little bit of what a special place this kind of Marx world is particularly for me as a relative outsider somebody who's not a clinician somebody with no appointment to speak of in the medical school or any of the surrounding areas but for whom in my professional and academic career this was an extraordinary resource and I learned so much I wanted to close with really picking up on a couple of comments that Stan Goldblatt made last night and just push your prod a little bit about the future of this great place. Tom Schelling has this he used to give this talk Tom Schelling is the Nobel Prize winning game theorist, has this talk about the incredible shrinking faculty seminar and it's actually a piece of game theory and it works through kind of the logical decline of any particularly interdisciplinary group of this sort over time and part of I think the power of this center is it's tilted against some natural forces in the academy for this to dissipate over time and I think in the future there will be this continuing challenge to really make this the kind of exciting interdisciplinary environment that I experienced here so I hope on my personal wish list is that as we think ahead that this center and this work continues to look outward continues not to be safe and I think certainly to take advantage of the amazing social science and policy resources that sit here on this campus this is an incredible moment I think for this field and for ethics this will be a period of renewed discussion and debate about healthcare reform I think there are going to be some fantastic and hard questions that really get to the heart of the doctor-patient relationship this is going to be a period where genetics and personalized medicine I think raise new and important questions in this field I think the the era of translational science has huge implications for how we think about clinical ethics and policy and on my personal wish list and even thinking through the presentations yesterday I hope and trust the center will also look outwards into the community and to think about the doctor-patient relationship as extending into neighborhoods and the health behavior that is we think 40% or so of the overall action in epidemiology so Mark congratulations it's really been a wonderful world you've created both for me and for our institution and I thank you for that and we can't let this distinguished panel go without giving you an opportunity to pepper them with your questions please make your questions brief but don't be afraid to speak really really fast Yes I do want to ask the question which I think is extremely important for the doctors around here my sense about the medical curriculum looked at from the outside speaking about the kinds of issues that you have today is that to some extent it has not kept pace with the times there was a time when medicine was concerned as I said earlier with the actual care and treatment to patients in individual cases and you didn't have to worry about larger institutional structures and arrangements and what always troubles me when I go to large numbers of meetings for example where you talk about things like universal services is that I think of them as very complex social systems I'm very worried about how you know something about the fundamentals of insurance before you try to nationalize it know something about what economists have called the theory of public choice and I could recall mentioning the phrase at several of the sessions that we had and that there's not a single doctor in the room who actually knew what it meant and I dare say most people here don't which is a theory of how it is to respond not in market environments where competitive forces may keep them in line but in political environments where coalitions can engage and win or take all types of behavior such that if you get a coalition with 51% of the votes that can dictate the agenda you may be able to commandeer 100% of the resources unless you're subject to some kind of counter pressure by either constitutional constraints or by sort of internal house rules and so forth and it seems to me that when trying to figure out what the doctors are doing today so much of the time we spill over from ethics as physician-patient relationships to ethics as kind of structural entitlement types of issues and it is troubling to me I think that the kinds of tools that we try to bring to bear on that in law and in the social sciences are often missing in the standard medical curriculum so that when you have people who come into the clinical medical ethics program the Robert Wood Johnson program I think these concepts are not familiar to them. I think it's an enormously valuable thing that this program actually tries to force feed this information but the question that I have for the medical profession at large is why do you have to have this kind of education only for a select number of individuals when in fact doctors seem to spend an enormous amount of time and are given an enormous amount of deference when they start to work and deal with this to be a little bit personal about it. I can't think of any more uninformed source of information about policy on medical care and pharmaceutical care and so forth in the New England Journal of Medicine. I'm told that the medicine in there is pretty good but the economics and the law that you see in there as far as I'm concerned is cheerleading of the worst order and the same thing I well I'm going to just say it I mean you know and the same thing I think is in many cases true in the journal is that when season these things very sharp political agendas in which aspirations count for everything and limitations on technologies and scarcity seem to count for nothing. It's just this endless cornucopia of entitlements for which there seems to be no effective counterweight and I think we will see in healthcare the kinds of implosions we'll see everywhere else and I think a large part of the blame lies on the medical education in ways that I don't think reflect the sort of fundamental difficulties associated with scarcity and with the corruptibility of political institutions. I mean it's not that you don't want to do nice things but you always have to worry about the fact that they may not be done and I think that to me in medical education is the fundamental question. How much of the mix of medical with respect to the socials going to be involved given the fact that the politicization and the ability of the healthcare issue to become a fundamental portion of national and state politics today I think it's too important to have this left sort of haphazard understanding and I think a much more detailed form of social sciences now. Arthur's not here to defend the medical profession but you know I'd like to see whether my co-panelists think that this is just some white ring crank talking about it or whether or not there's actually some serious problem here even for an extremely difficult task which is to open up access under a set of circumstances where you don't create simply impossible demands upon a system which will die under its own weight. Running a system of redistribution is not an easy task to put it mildly and it takes a great deal of sophistication to do it and you can't get that by simply dealing with exuberance and this seems to me to be one of the sort of the fundamental problems that I associate with the entire profession. Okay. Joel. Take a breath. No and I think somebody want to comment on it. Go ahead, Joel. Or most of what you commented on I do want to defend the system of medical education and I just want to say that if you believe that really nothing of importance has changed since about 1920 then we have a system of medical education that makes enormous sense I think the main problem with the system is simply that it's petrified, it's ossified, it was created in 1920 and I know there are people in the room who will tell me about all the radical changes that have been made in the curriculum but I would say that in terms of truly fundamentally rethinking the role of physicians in the profession it has not changed appreciably and if we want it to change we need to start from scratch which is unlikely to happen so there's a hopeless comment. Is Holly out here Tina there is a big curricular reform effort going on here but go ahead Dr. Binning. Well I actually think that much of the problem with medical education starts before they get to medical school if you think about our selection criteria it's how well do you go to lectures, take tests, get grades and if you're going to start having us in our profession think about these issues seriously it's too late if you wait until medical school medical school should be an extension and should build on what you learned before you got there and of course even in the new curricula that people are developing the students still know that the currency is going to lecture and taking tests and when you do things like try and implement curricula that is broader half the students don't show up if they do show up they're only doing it because they feel a little guilty and so I think we need to have a discussion about how do we select the students for medical school and how could we lead a change that would result in different criteria and rather than just having a few sciences as the pre-medical requirement that we made a much bigger look and made some basic decisions Thanks I think we are going to move on to the next panel but let's thank this panel but first Dan Salmezzi is going to give his talk I first met Dan at a bioethics summer camp where we had the opportunity to go hiking in the mountains of I think New Mexico and we had a great chat Dan and Jay Jacobson and myself and we were talking about medical ethics and autonomy and health care rationing but Dan also knew the names of most of the wild flowers we saw along the way and I was pretty impressed he's a Franciscan friar an internist he's professor of medicine and directs director of the bioethics Institute of New York Medical College in Valhalla, New York he got his BA and PhD from Cornell and a PhD in philosophy from Georgetown and he was appointed by Governor Pataki to the New York State Task Force on Life and the Law in 2005 he's also editor in chief of the journal Theoretical Medicine and Bioethics Dan Thanks I joined the legions here expressing what an honor it really is to be here celebrating all that Mark Siegeler has done for the field of medical ethics and among the papers I was asked to talk about the first one is this one Confidentiality and Medicine, a decrepit concept we heard a little bit about it yesterday it was actually published while I was an intern at that time we were calling the New England Journal of Medicine the Brown Journal because it came in brown paper and we never actually had the time to open it and read it but I did read this article and actually wound up subsequently as a chief resident copying it and handing it out as part of the education program that I initiated in ethics for our house officers I actually had the opportunity to meet Mark as a resident in about 1985 I think it was and somebody who was interested perhaps in going into the field of medical ethics I went to his lecture and talked to him and I'm coming over the course of the last day and a half or so to realize that I thought this was accepted that there was a field already I didn't realize that I was actually talking to somebody who was just beginning this field and I asked him what I should do and he gave the advice I think he gives everybody he said come to Chicago I didn't take his advice I went to Georgetown where I had the opportunity to study with Edmund Pellegrino which was truly an important thing for me and in my development as a philosopher and ethicist I owe a great deal to Dr. Pellegrino but you know Mark has his persistence and perhaps I'm a slow learner and this may yet change so the second paper that was in the packet is the one I'm going to concentrate on though this one called the contributions of clinical ethics to patient care and in it really Mark has raised a complaint that a lot of people have and that's that when we think about medical ethics this is the way it's typically thought about the way it's typically taught the way it typically rolls out even in clinical settings and that's that we start with our grand theory or set of theories and from these we can derive general ethical principles of some sort even if our theories disagree we might be able to converge on these principles we then specify them in terms of rules regarding clinical care, research the organizational structure of health care and the socioeconomic and political environment in which health care is delivered and then we further specify these into the rules which govern patient care our research protocols policies and procedures of hospitals and other institutions and then public policy well Mark thought there was something wrong with that picture and and in fact I agree and to sort of explain why I'm going to start with a pair of distinctions for you one for those of you who studied any formal philosophy will recognize the distinction between morality and ethics and then second a distinction between common sense reasoning or practical reasoning or phronesis versus scientific reasoning the words are used quite synonymously in ordinary language but from a technical point of view when a philosopher thinks about ethics and morality we think of them as distinct that morality is really in some ways the some sphere of activities that we think are worthy of praise or blame it would include for instance in medicine our codes those sorts of things that are unreflective in the way in which we act and ethics though is if you will a lens on that it's the systematic study of morality looking at it critically trying to to look for justifiable answers to the questions if you will the science of morality so this is so morality is is the subject ethics is really the discipline for studying that subject the second distinction is between common sense reasoning and science and this will make hopefully a little bit more sense to you as the talk goes on but whenever we do something scientifically what we're really doing is talking about the universe right we're talking about everything that we can comprehend within that universe whether it's the universe of patients whether it's the physical universe itself whether it's the biological universe and what you're doing in a scientific endeavor really is is relating data to each other in a sort of abstract way a common example from this is physics is you know force equals mass times acceleration at least at Newtonian speeds that's a rule in which we're relating the data to each other common sense reasoning is different common sense reasoning is about particulars it's not about what is true in general but what is true here and now in this particular state and what we're doing in many ways is relating the data not to each other but to us as individuals so while it may be true that f equals m a the question that the orthopedic surgeon asks in the emergency room is how much force does it take for me to reduce this dislocated shoulders that it comes back into place appropriately okay it's important to distinguish these two and we confuse them all the time Aristotle wasn't so confused in the metaphysics he writes this the doctor does not treat man except accidentally he treats callous or Socrates or someone else described this way who is accidentally man so if someone has grasped the principles of the subject without having any experience and thus knows the universal without knowing the individuals contained in it he will often fail in his treatment for it is the individual who has to be treated we didn't get it from the metaphysics Aristotle sort of repeats the same argument in the nicomachean ethics where he's actually talking about interestingly at the convergence of clinical ethics with the practice of medicine he's using the practice of the doctor to talk about moral reasoning to talk about his ethical view of moral reasoning and he says this for what the doctor appears to consider is not even health universally let alone good universally but human beings health and even more particularly than that presumably this human beings health since it is particular patients that he treats so what I want to contend at the very beginning then is that clinical medicine is a common sense practice it is a common it's relating the data to us to individuals it's a common sense practice but a practice that doesn't occur in a vacuum it's undergirded by biomedical research it occurs in an organizational structure and within social economic religious and political structures as well so I think the picture looks actually more like this that this is the field we're interested in in the end it's about the particular patient the individual practitioner or team of practitioners and the patient but we know that there are social conditions to that practice that it occurs in organizations their research that inform our clinical care toward the patient and what we're doing I think in medical ethics actually is studying this field I think it can't be divorced from from actually the philosophy of medicine and please understand these writ large I don't want to exclude any other other professions but it's the systematic study of this field that we're about and so I want to present in the next few minutes for you something I'm calling the Tractatus Philosophico Medical Morales or what Mark Siegler would say if he had studied a little too much Wittgenstein or maybe what I'm saying is that Mark Siegler should read some Wittgenstein and if he did what he would actually say and these may be bold enough in Wittgensteinian way to encourage some discussion I think we'll have hopefully some time for that so here's the Tractatus clinical ethics is a branch of the philosophy of medicine the philosophy of medicine is the philosophy of a scientifically informed common sense practice the philosophy of medicine is not a branch of the philosophy of science because medicine itself is not a science the philosophy of medicine informed the philosophy of science informs the philosophy of medicine because medicine is a scientifically informed practice. While clinical ethics is properly considered a part of the philosophy of medicine, clinical ethics is of necessity informed by general ethical theory. Clinical ethics is not the application of general ethical theory to clinical practice. All attempts to apply general ethical theory to clinical practice must assume a philosophy of medicine at least implicitly, whether or not that philosophy of medicine is insightful or correct. Many mistakes in clinical ethics are traceable to a lack of attention to the underlying philosophy of medicine. Medical ethics, though, as we know, is both a field of scholarly inquiry and a practice. As a field of scholarly inquiry, that is, as a science, it is open to the insights of many disciplines. Medical ethics is not a discipline, per se, but a field of study to which many disciplines contribute. These disciplines include, but are not limited to, philosophy, law, theology, sociology, economics, health services, research, history, and others. Normative medical ethics is the systematic critical reasoned evaluation and justification of judgments about right and wrong, good and evil in medical practice, and of the kinds of persons clinicians ought to become. Descriptive medical ethics is the use of empirical methods to study and explain the beliefs, attitudes, and behaviors of patients, practitioners, and others in medical situations of normative interest. Of the data needed to answer such questions well, and of the associated factors and effects of policy and education about normatively interesting questions in medical care. Metaethics, by contrast, is the systematic critical reasoned study and justification of fundamental questions about moral reasoning, language, and knowledge. Metaethics informs medical theory that, in turn, informs medical ethics, but metaethics is not a part of medical ethics, per se. Medical research ethics is the study of the morality of biomedical research. Medical organizational ethics is the study of the morality of local healthcare delivery systems or networks of such systems. And the social ethics of medicine is the study of the morality of healthcare systems in relationship to the social, cultural, legal, political, economic, and religious aspects of the societies in which medicine is practiced. Clinical ethics research is the study of the morality of clinical practice. The central concern of all medical ethics is the set of all normative questions concerning clinical practice. The importance of all other subjects of scholarly inquiry in medical ethics is derivative, dependent upon our concerns regarding normative clinical questions. To the extent that the ultimate concern of a scholarly endeavor is not a clinical question of normative interest, that endeavor is not medical ethics. The clinical ethics is also a practice, a common sense enterprise. Clinical ethics consultation is a common sense practice that is informed by the study of medical ethics just as clinical medicine is a common sense practice informed by medical science. Clinical ethics praxis is also concerned with clinical policy development and clinical ethics as a praxis is also concerned with teaching clinicians about how to address clinical questions of normative concern. So that's my analytic reconstruction of Mark Siegler's philosophy of medicine. What I want to end with is saying this, that I think Mark understood early on that many of the most pressing moral questions which we face in our healthcare system today are engendered by our abstraction from the patient. I'll sort of illustrate this for you. Many of you are probably familiar with this painting by Luke Fields, his painting of the doctor. I want you to pay attention to what I call the clinical gaze, right? The doctor's attention is focused on the patient. This is 1891 and people were saying this all changed in the 60s. I think the seeds of this started much earlier. Here's the next painting just a few years after this. Don't any of you know who the artist is on this? This is actually Picasso, that's correct. Before he started abstracting, he did Ciencia y Caridad. But notice the clinical gaze in this picture. The doctor may have his hand on the patient's pulse. The doctor is looking at his watch. And there's a divorce in this painting between the caring aspects which are done by the nurse or sister and the technical aspects which are already being done by the physician. A central task for medical ethics is to keep our focus even as we pay attention to all the other complicated social, economic, political and technical and scientific aspects of delivery of care to keep our focus on the patient. Because it gets even worse. I picked this up from an artist in Helsinki at the European Society for Philosophy of Medicine meeting where she was just observing. She just went into the wards and observed what happened and did drawings. But notice here, where's the gaze of the technician? Where is even the gaze of the pregnant woman? They're both on the monitor, not on the patient. I think Mark Siegler has repeatedly reminded us throughout his career that we need to keep our eyes focused on the patient, both to do better medicine and certainly that's the main task perhaps for medical ethics. And he also I think has repeatedly said that we have a very good role model for learning how to do this and that's William Osler. But somebody else is going to talk about Siegler and Osler later this afternoon. Thank you. We'll have an opportunity to ask Dan some questions afterwards. This next introduction is complicated so pay attention. Jim Childress could not make it. Al Johnson could not make it. Al Johnson was supposed to present a paper this afternoon. He sent his paper in. We're moving Al Johnson's paper to the current session. But because Al is not here, it's going to be read by Father John Parris. He got that? So I will introduce both of them. Al Johnson by some quirk of the publishing industry is actually the first author of Mark Siegler's book, Clinical Ethics. He's Professor Emeritus of Ethics at the University of Washington, who is Chair of the Department of Medical History and Ethics at the University of Washington for about 15 years. He also served on the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, the first big national commission from 1977 to 1981. He's currently a visiting scholar at Stanford. Father John Parris is one of the leading scholars in bioethics in the country, particularly interested in end-of-life care issues. He's written extensively in most medical and bioethics journals and has also been an expert witness in many of the key end-of-life legal cases over the last 20 years. It will be fascinating to see whether Father Parris can stick to the text since his usual approach, as you may know, is to get out in the audience and extemporaneize. It will also be interesting to see whether he takes questions as himself or as Al Johnson. Unaccustomed as I am to public speaking. And certainly unaccustomed to having a text in my hand. I don't think in 20 years I've read a paper to anybody or anything. In fact, I think the last paper I read was with Mark Siegler in the audience in New Orleans. This is how I met Mark Siegler. We met as combatants. He wrote an article called Against the Emerging Stream on Nutrition and Fluid. This is a hopelessly bad idea. I was presenting a paper to the AMA in favor of it. Mark's at the back of the room, the very end of the room, crowded room there. And at the end of this, he said, you know, you and I can make a living debating this around the country. And I've got two daughters at Yale, so we've got to go to work. Before we began this practice, we went around. And after three or four of these debates, Mark came up with the question that he always poses to everyone. Why don't you come to Chicago? That was 20 years ago, and I came every other year for 15 years. And I was quite pleased to note at this conference, this was the first conference in 20 years that I wasn't going to give a paper. So I didn't bring a tie. I came in formally thinking I can relax for the first time. So here I am as Al Johnson. Now, originally, I think it was going to be Dan, but they thought, A, he's not old enough, and B, not Jesuitical enough to read this paper. So they went to some old Jesuit. This paper is Al Johnson's Reflections on His Involvement in Experiences with Mark Segal. And I'll read it just as he wrote it, he said. I thank Dan So Maisie, as what he wrote, for taking the podium to speak my words. I begin my remarks with a paraphrase of the words of another great Mark, Mark Anthony. I come not to praise Segal, but to blame him. But in blaming him, I also blame myself, Jim Childress, and most of the other old timers in bioethics. This is why Dan could not read this. My contention is that we made a big mistake, almost from the start of bioethics. And we should admit it, take the blame, and hope that the younger bioethics will correct it. Bioethics began as a flurry of concerns about how technology was dominating the humane in the biomedical sciences in practice. As a flurry concentrated into a more disciplined inquiry into ethical problems posed within contemporary science and medicine, a search for some basic principles to set out the various harbors began. Moral philosophy, religious ethics, law, sociology, history of medicine. And those various strengths converged on a particularly compelling problem, the use of humans as subjects in medical research. The Tuskegee revelations of the 1970s shocked the nation and recall the evils of Auschwitz and Dachau. Congress initiated a regulatory process that would safeguard the rights and the welfare of human subjects. In its mandate, the National Commission for the Protection of Human Subjects ordered a commission to, quote, conduct a comprehensive investigation and study the identity and the basic ethical principles that should underlie the conduct of biomedical and behavioral research with human subjects. How rare a specimen, a congressional mandate to study ethical principles. Still, the commission obeyed as best 12 persons, only two of whom Karen LeBek and myself have studied moral philosophy could do. We engaged a distinguished academic moral philosopher, Stephen Thulman of the University of Chicago, to begin the comprehensive investigation. It turned out it wasn't easy to identify ethical principles. They can't be pulled out of an ethical grab bag. We enlisted a troupe of academics to help us, including Jim Childress and Tom Beecham. Among these, Tris Engelhardt provided the commission with a paper that he stated, respect for human persons is a logical condition for morality, not a value among other values, but rather the basis of our sense of moral responsibility. He footnoted his remarks with a reference to Emanuel Kant. It so happened that my fellow commissioner, LeBek, and I had recently read a book on Kant's ethics, entitled Respect for Persons. When Kant used this concept as a fundamental notion for all ethics, he explained it involved the treatment of persons as ends and not merely as a means of utility for others. This appeared to the commissioners as a useful expression for a very basic idea about ethical research. This idea has been strongly defended by such fine philosophers as Hans Jonas in a seminal essay on ethics of research and by Jay Katz in his monumental book on research ethics. It is on reflection a patently clear ethical imperative for the work of research and the benefits of which derived from one party flow not to that party, but to science and to society. The commissioners were quite happy with this formula. Respect for Persons worked its way into a prime place in the commission's Belmont report where it is said to incorporate at least two ethical convictions. First, that individuals should be treated as autonomous persons. And second, that persons with diminished autonomy are entitled to protection. Treating persons as autonomous men giving weight to autonomous persons considered opinions in choice while refraining from obstructing their actions unless they are clearly detrimental to others. The Belmont report goes on to state that respect for persons requires that subjects be, quote, given the opportunity to choose what shall and shall not happen to them. This opportunity is provided when adequate standards for informed consent are satisfied. The lofty principle of respect for persons thus collapsed into informed consent. The Belmont report is a monument of bioethics. The story of its making has been told in various ways, most lucidly in acrylic course in my own birth of bioethics. He learned from Sigler, this Johnson boy. But its line of argument, though suitable as a statement of research ethics, began to lead bioethics as a stray. First, the need to produce a document of public policy responsive to congressional mandate makes impossible serious philosophical reasoning. The Kantian thesis about respect is itself a huge intellectual edifice. Kantian scholars trembled before it. And so the commissioners, mostly untroubled by this philosophical intricacy and subtlety and desirous of simplicity and clarity, put Kantian complexity aside and slipped into the much simpler notion of liberty proposed by John Stuart Mill. Person's choice of action should not be obstructed unless they interfere with the liberty of others. And here begins the blame for bioethics, like Mark and myself, Bill Winslade, like Jim Childress and Tom Beecham, and many others. Childress and Beecham produced in their fine text The Principles of Biomedical Ethics in 1959. The same year the Belmont Report was issued. It structured, 1979, yep, it structured with some modifications, the principle of all bioethics around principles of research ethics, respect for autonomy, non-maleficence and beneficence, and justice. Jim had been a consultant to the commission. Tom had succeeded Toolman as its ethics advisor. Their quartet of principles became the standard throughout the growing world of biomedical scholarship. Two years later, in 1981, Mark Siegler, Bill Winslade and I sat down in my San Francisco study to begin writing clinical ethics. We were motivated to produce a book that would be acceptable to clinicians by bringing principles down to practical application. We devised our framework of medical indications, patients' preference, quality of life, and contextual features. Although these features represented the empirical circumstances of clinical cases, they had to reflect ethical principles lest our book be only a cheap sociological treatise. We naturally chose the quartet of Beecham and Childress. We did not discuss or defend these principles at length, but assumed each of their four principles stood behind each of our four empirical topics. We had all been misled. We had followed a twisted path from Kantian autonomy to Milzian liberty. Belmont had taken the first misstep, reducing Kantian autonomy to a definition of liberty, and then immediately linking this principle to informed consent. Beecham and Childress, being astute scholars of moral philosophy, knew and acknowledged the distinction between Kant and Mill, even proposing that they were following Kant's doctrine of self-legislation, but softening it into a position much closer to Mill. Johnson, Siegler, and Winslade made no effort to clarify these moves, and after affirming the patient preferences, reflects moral principles for respect for autonomy, quote, a moral attitude that inclines one to refrain from interference and the other's beliefs or actions, they go immediately to the practice and problems of informed consent. So what's wrong? Is this not a philosophical picadillo? I believe it is much more. It established a line of argument that has harmed the way in which bioethics conceives of ethics of the patient- physician relationship. We not only read Kant too casually, we exceeded with little evidence to the belief that the relationship was and perhaps always had been vitiated by the evil of paternalism. We were living in those days in a culture that had become strongly anti-authoritarian. The patient- physician relationship many believed was an adversarial one. Just as in research, we had to fend off the rapacious researching grasp of the body and blood of the subjects so too in clinical ethics. We had to ward off the paternalistic physician seeking to enter the patient's body by usurping the patient's judgments and choices. Thus we seized on a formulation of a broad ethical principle in order to refute that paternalism. By refuting it, by stating that it naturally was an adversarial contact between the patient and the doctor, patients were the new superiors who gave the orders and who called the shots. And that's why I blame Mark Sligler today. In his first edition of clinical ethics we wrote, in a priority ordering, patients' preferences are the wadiest ethical category in the patient- physician encounter. Mark was unhappy with that formulation. He was uncomfortable with the adversarial view of the patient- physician relationship. He had a clinician's natural instinct that this relationship with patients was not at all adversarial. Like several pioneer bioethicist physicians such as Ed Pellegrino and Eric Cassell, he knew that people came to him hurting and looking for help. That relationship had to be from the start collaborative. Yet as Mark argued with Bill Winslay to myself, he won some concessions but it does not dislodge us from our autonomy stance. In subsequent editions, the priority ordering was abandoned but patient preferences were still supported by an inadequate interpretation of the principle of respect for persons. A more adequate interpretation can be found within the pages of Kant himself. While Kant didn't speak of respect for autonomy, he meant something a world away from John Stuart Mill's liberty. The right to choose and to live as one chooses. For Kant, respect for the dignity of all humans were capable of making themselves and others a universal law. His final formulation of the categorical imperative uses the now antiquated notion of quote, a kingdom of ends. But antiquated as it is, it is most appropriate as an ethical principle for the establishment of the alliance of the patient and the physician. When humans treat each other as ends and not as means, there arises a systematic union of rational beings under common objective law. That is a kingdom of ends. Doctor and patient, each with their own needs, desires, capabilities must find those principles that allow them to coalesce into helping, healing and an alliance to achieve a common goal to become, if not a kingdom, at least a republic of ends. So I blame Mark Siegler for not fighting hard of his collision's instincts in our collaboration. I blame myself for being too shallow in understanding the problem in the meaning of the great Prussian philosopher. I blame many of my early colleagues for failing to find a firmer ground for a collaborative healing relationship. Well, after all, what are friends for if not to pass around a little blame? Thank you for allowing my voice to be heard even when my body could not come. He's stuck to the script. You'll tell your grandchildren about that one. It's a first. It's a first. Questions or comments? Go ahead, Woody. Sorry. You want to come up on that? Yeah. To teach us in his four-step process for ethical analysis that medical indications preceded patient preferences. And so I've grasped that and run with that. And many times my colleagues have said, but the patient wants it. And I would say, but it's not going to help him. It's not medically indicated the balance of burdens to benefits as such that we shouldn't do it. And so I've stuck to the Siglerian approach on that. And Mark, I hope that leads into what you want to say. In fact, it says precisely what I was going to say. I just want to preface it by being outraged. Another set of financially remunerative debates around the college. Even though the kids are out of college. Mark has his card ready. I'm so sad that Al Johnson's not with us. As you may know, he was struck by a cop about a week or 10 days ago crossing the street in San Francisco. Thank goodness he's fitly all right. Although he's been advised not to travel. And he seriously apologizes for his not being with us. What Al doesn't say is that we heard in 80 or 81 in his San Francisco house. Is this Mike working up there? Going in and out. Try this. We gathered in Al's house in San Francisco which overlooked, as I remember, the bay. And you would leave the house and go out to the roof of the house. And you would then climb an outside staircase of about 10 or 15 steps that took you to an airy. A kind of, I mean it was the strangest room. It was the room where Al did all of his research and scholarship. So it was separate from the house itself and the roof. And you really felt you isolated because in a way you were. There was no telephone in the room and you overlooked the bay. And we sat there for two days literally doing what Woody has just said, arguing over the order of the chapters of the book. What ought to be the sequence? Should autonomy and liberty dominate as chapter one, leading into a second chapter on beneficence. And as you know, we integrated beneficence and non-maleficence into a single category which we always thought was intellectually reasonable. And rather than drafting any portion of the book, we spent the better part of two days of our meeting arguing out that point. And I still to this day, I mean there was no definitive turning point in the discussion. But I still to this day remember a case that I had dealt with and these cases then are so important. A case that I dealt with a week or 10 days before the meeting. Here at the university, I know I have colleagues in the back who look after many faculty members and this will resonate with them, not the individual but the possibility. One of these brilliant, young, aggressive associate professors who ran marathons and had a young wife and a couple of kids and who I had known for a few years had staggered into my office looking, I mean I had never seen him look so bad because he, as I say, he was healthy and vigorous. And I said, what has happened to you? And he said, well, I've hardly slept for two nights struggling with my decision, which also, I said, well, you know, I thought he was thinking about a career change leaving the university. I said, and what was that decision? What were you struggling with? And he said, whether to accept surgery or radiation therapy. Now, as far as I knew there was nothing wrong with him and so this decision that he had struggled over for two nights obviously had struggled over made little sense to me. As the story unfolded, he went on to say that he had been coughing for the better part of a week and indeed in the last two or three days his phlegm had become blood streaked and he had kind of made a series of leaps about his father who had died of lung cancer and the kind of treatment that his father had had. So he had self-diagnosed himself with lung cancer as a result of this blood streak sputum and not only that but he had stayed awake wrestling with which decision was best for him with his young family and his career and the like. I mean, I could imagine all of you in the audience. You want to, I mean it was risible and yet it was very serious because he was a man in anguish. But to step back and say, you know, I don't want to break your train of thought but you're the fourth person I've seen this morning with blood streak sputum. You know, there's a bad virus going around. I mean, everybody's got this bronchitis, whether they had the flu shot or not and I think you may be jumping the gun on self-diagnosis and needing either radiation therapy or surgery for that matter. Rather, if you listen to me, let's just give this four or five days and talk it over next week and maybe get a little bit of sleep and I think you'll be feeling better. I know it's a trivial type case and rather bizarre in its presentation but somehow somehow it resonated with Al Johnson and Bill Winslay who said, yeah, you know, it doesn't make sense in the medical context to assert the liberty claim or the autonomy claim or the anti-paternalism claim until there is at least some reasonable structure in which the decisional framework can be organized and a decision can be reached. It's, I mean, it is not exactly the same as, you know, whether you're going to live in this house or that house or this town or that town, it takes a certain, well, even that, I mean, that takes a lot of background information also. Somehow it was that case for all its bizarre quality that led to chapter one being the first chapter on beneficence prior to that powerful chapter two and we're currently, Al and Bill and I are drafting the seventh edition. We're halfway through almost and obviously, we'll take very seriously what Al said. Those outrageous remarks you delivered, John, so that you and I could. I'd like to get some opinions on the relationship of the key concepts that were put into the Belmont report because I've always thought that it was the book of Job taken in the modern form, the Lord giveth, the Lord taketh away, blessed be the name of the Lord in the sense that first you give autonomy, then you announce that autonomy doesn't go with people who have limited competence, then you conclude that all people have limited competence and you conclude that autonomy essentially has to be handed over to an institutional review board of one kind or another. And I'm just curious, is this an unfair characterization of the way things work or is it, in fact, have some resemblance of truth in a way in which one would want to evaluate the subject? I'd simply say it's an unfair characterization of how things actually work. Does anybody want to? I do think Johnson is correct in as much as, the emphasis on autonomy gives us false understanding that in fact, the patient has choices and you say the only choice the patient has, which are in fact options that are available. So you begin with, I always tell them, we make a huge mistake in ethics beginning with what should I do? The first and much more important question is what is going on? What's happening? What is the clinical situation? And until you have that clarified, choices don't exist. Laini, do you want to speak to us? Is there just one mic and one Ella? We need one one doctor for a little bit. Okay. Oh, okay. So I think we're all missing that the concept of respect for persons has both a positive and a negative component and we're focusing on this negative component of liberty and that I have the right to make decisions and choices but there's also a positive component which is what's being missed which is that as physicians we have an obligation to help patients make the right choices which can get into the medical indication but actually goes beyond that because it really still remains focused on the patient's preferences which says that we as healthcare providers need to help educate them to make the right informed decisions and those right informed decisions really are dependent upon the medical indications and so I think we've all missed the concept and moving from respect for persons to respect for autonomy is the real error. I remember working with Jim Gustafson early on. You heard about that yesterday. Jim had come to Chicago in 7071 and it was one of the founding members of the Hastings Board had trained at the Yale Divinity School people like Al Johnson and Jim Childress and Gene Hautke, Stan Hauerwas, sort of that early generation of theological ethicists. Jim always emphasized to me exactly what Laney has just said that medical decision, this was his image so I'm not creating the image that medical decision making was very different from being offered a menu in a restaurant. That was Jim's image. That going to a restaurant and having the waiter hand you a menu it really didn't matter much if at all to the waiter whether you chose a fish entree or a meat entree whether you chose the pecan pie for dessert or the cherry pie. I mean the waiter was simply there to be of service and to be gracious. He said medicine is not like that. It does matter. It has to matter. If it doesn't matter there's something wrong with medicine that any choice is equally reasonable and acceptable because of course it's not the case that cherry pie and pecan pie are the same as choosing radiation therapy or surgery if in fact one or the other is needed. The doctor has to be committed, has to be involved, has to be structuring, has to be advising, has to be teaching. And then of course the ultimate question for Jim was but how far can the doctor go? I mean what are the limits? I mean it's just like a waiter who says you better eat the cherry pie. You don't want the cherry pie. Or else. I mean how far is legitimate? And Jim would never tell me. That's a damn take a stab at. Laney I think that Al's point historically we may disagree with this was that in the enunciation of respect for persons it was already sort of cast from the beginning as a historical matter whether that's what was intended or not as liberty. And I think he thinks that's just what happened. I think he might agree with you that respect for persons if it's taken as he's suggesting it in a Kantian sense would be a better principle. But he's also saying that that contains two things. One is Kant's sense of autonomy is not Mill's sense of liberty. That autonomy means that we act in a way that our will is determined by nothing but accordance with the moral law. That's not exactly, then you're free because you're not influenced by anything else but morality. So that's a very different notion of what it means to be an autonomous being than Mill's notion of liberty. And there's also he's I think suggesting there's a relational aspect that we miss in Kant too in the sense of the kingdom of ends that we also respect each other collectively and that we're not simply individual atoms but are connected to each other. And that is point I think well taken in this paper is that we never really think about that in terms of the doctor-patient relationship as a kingdom of ends. Is this mutual respect for persons that Kant was looking for? So I think it's interesting. Go ahead, Mark. Mark, I was struck by what seemed like a little disjunction between your enthusiasm for the seventh edition and Johnson's lament for this great failing that you guys have collectively been a part of. And I wonder, I mean it seemed to be deeper than just the ordering of the chapters, his reflections on this. And I wonder, given I think all of our experience of you has been that your intuitions, your sensibilities are not along the lines of a autonomy-driven patient sovereignty model. And yet I wonder if at this stage, say in the seventh edition or going forward, if you conceive of a way of repenting and turning back or turning at least toward a model that might sort of say wholesale, we are not just going to tweak this, but we need to start over in our conceptualization of the doctor-patient relationship. Whoa. I like the way you put the revisionist tendency in the theological language of repentance. This is available. I think there are things to be said and done in the seventh edition. And hearing Al's paper, I think opened the door to those possibilities that perhaps we've not had quite sufficient courage to do in some of the earlier versions. I have always written about three or four times more than ends up in the first chapter on the doctor-patient relationship, on the evolution of the relationship, on decision-making in the face of uncertainty, on the need for the explication and understanding of the goals of the participants in that interaction. The things that Ed Pellegrino has taught us throughout his illustrious career about the healer and the one who needs healing and how the language they use to talk to one another helps define the functions and the goals of that interaction. It's historically grounded. It's philosophically grounded. It's ethically grounded and it's clinically grounded. And I think there's more to be said about that. I would also remind Al, I'd also remind Al about a section that, again, we fought over but has remained as one of the mainstays of chapter two. Chapter two is this chapter about the tension between autonomy, liberty, preferences, it's called patient preferences and informed consent. That chapter, for those of you who have read any of the editions from the first, oh, you've memorized it, first of the sixth, that chapter on patient preferences does not start with the law, does not start with philosophy, does not start with informed consent. It starts with five or six pages entitled the importance of patient preference. Some of you will remember that and the importance is clinical importance, psychological importance, emotional, clinical, psychological, legal. There were five concepts on why respect and adherence to the preferences of individuals is important, deeply grounded, I think, in the philosophical concepts and the legal concepts but also clinically grounded. And that's an area that also, I think, is open to expansion and revision based, again, on this really elegant paper that Al sent us and that John presented. One last question from Sumacrae because she's had her hand up the longest but she's so meek that Al keeps walking past it. Thanks, Mark. I just want to say a little bit about what I heard Al say and I think that the challenge that came through was really picking up on this kingdom of ends and that the polarization of either paternalism or sort of rampant patient autonomy actually misses the point. And I think that where I get stuck in clinical ethics and where I'd like to challenge you in your next addition to think about is actually more than just a couple pages of what patients, we should think about with patients but an actual rigorous taxonomy of patient and family perspectives on clinical ethical issues. What isn't in the literature that I can find is looking at clinical ethics issues when they emerge and actually hearing how the staff have defined the issue but then going to the patient and family and understanding that same issue from the perspective of patients and family. So it's like I think your point of medical care being adequate, technologically sound, appropriate first and foremost is core to medical science and I think in clinical ethics we have to challenge ourselves like Jack Wenberg asked us to yesterday that within that context of medically appropriate options we begin to take patient choice as a primary guide for our understanding of ethical issues and medical choice. I hope others will answer but I can't agree more. Of course the person who raised the question, Sue McRae, is someone who has one of the deepest and longest experiences in the patient-centered movement in medicine, who trained as a nurse, trained here, was the head of the clinical ethics program at Toronto for a dozen years, has written and practiced exactly the kind of patient-centered medicine she raised in her question. That's a major failing. It's an evolution in the medical literature, thanks in large part to the kind of work that you and your group have done. And it ought to find its way more closely into the book on clinical ethics. I agree. You'll send me some notes about it and I will continue, I'll work on that. Let's take a 20-minute break, come back at quarter of 12 and thank our panel.