 We've got to get Mark talking at 5 o'clock, so that's our overall goal. And it's really my pleasure to introduce these terrific speakers. I'll introduce all of them at once on this panel, ethical issues in surgery and organ transplantation. The first speaker who's here to my right is Dr. C. Rowland's Hanlon, or Rolly Hanlon. And probably the best way to introduce Rolly is he was described to me as the heart and soul of the American College of Surgeons. So that's a good thing for a panel on surgical ethics. That works for me. But Rolly attended Loyola University, earning his MD from Hopkins, served with the U.S. Navy, completed his residency at Hopkins, closely associated with Dr. Blalock, and the innovative cardiac operative procedures that were developed at Hopkins, but then moved to St. Louis University where he became Chair of Surgery and was Chair of Surgery for almost two decades, I think, Rolly, before moving to become a leader, I think, the President of the American College of Surgeons, where you also stayed for a long time. And somebody told me that last night on the way home from the dinner, you still dropped by there to pick up some mail or something. So obviously, you're still animating their work. So thank you for joining us. The second speaker is going to be Peter Angelos. Peter's an MD-PhD, a Professor of Surgery and Chief of Endocrine Surgery and Associate Director of the McLean Center for Medical Ethics that you've heard of, referred to from time to time in our proceedings. He received both MD and PhD, which was in philosophy from Boston University, and he was a fellow in this program during his residency at Northwestern. Ira Codner is the Solon and Betty Gershman Professor of Surgery and Director at the Center for Cholorectal and Pelvic Floor Disorders, and he's Director of the Washington University Center for the Study of Ethics and Human Values, a past Director of the American Board of Surgery, Governor of the American College of Surgeons, and he was also a fellow here, and one of those fellows who went on to start a bioethic center himself. Charles Bosk is a great in medical sociology, one of the greatest surely in that field. I still remember when I was a fellow here on that reading course with Stephen Toolman, reading Forgiven, Remember, and it took us a while to figure out that the guy who was being described there was not Mark, but then when we found out it was New York Hospital, we knew it was somebody else, and that was really a very, very fundamental piece. Just raise your hand if you've read that book. Just look at that, Charles. It's amazing. In your spare time, you're a Professor of Sociology at the University of Pennsylvania, the author of Forgiven Remember, as I mentioned. You got your PhD, though, from here at the University of Chicago, and since 2003, you've been a Professor in the Department of Medical Ethics at Penn in the School of Medicine and a Steering Committee member on the Robert Wood Johnson Health and Society Scholars Program. So, we've introduced all our very distinguished panelists who are highly qualified to talk to us. Enrollee, will you lead us along? Thank you. Thank you, Peter. It's a great privilege, and I want to thank everyone associated with this meeting for the opportunity to be here and participate in it. I must confess to a certain amount of envy at the fact that I haven't been a fellow at the McLean Center, and I'm seriously considering being the first known veterinarian to apply, but less Mark takes me up on that. I want to show you that I'm not really serious, Mark. I'm not up to it, and besides, like your application for tenure, I might be turned down. But the four of us, our final four here, are usually in the position, as the last people on a program, you're ambivalent about that. You don't know whether it's going to keep everyone glued to his seat on the one hand or in a taxi heading for O'Hare as the last part, but we're sheltered from that by the fact that Mark is here, and he's going to be the clean-up person. I think Peter came to me at lunch, and he said to me, how long are you going to talk? 15 minutes, 14, 12, 13. I felt that this was an accommodation on my part almost instantaneously. And I'll take my cue from the town drunk who was brought into court, and the judge spoke to him very sternly and said, you've been brought here for public intoxication. The fellow said, fine, let's get started. So I think I want to get started. I got started with Mark about 20 years ago when he was beginning this great venture. And at that time, Bob Moser and I were both recruited to be on a committee, which was, I don't think they needed us, but I have subsequently realized that Mark had broader ideas about why we were on that committee. The committee was to evaluate some of the people who are now in this audience as distinguished members of the fraternity and sorority of experts in ethics and ethics teaching. So we had a certain amount of discussion as to who would discuss what, and I think we'll have to take a chance on the fact that we'll step on each other's lines. But as I said before, this is a great privilege and I'm happy to be here doing this. The picture that you see here is the front of a postgraduate course 12 years ago in San Francisco. And Mark Siegler was a prominent part of that proceedings as you see practical issues in surgical ethics at the article subsequently appeared in the Journal of the Bulletin of the American College of Surgeons in 1996. And at that time, there was a sort of simplified way of doing the above line and the below line, which is subsequently popularized in six and soon to be seven editions of clinical ethics. The medical indications had been from about 60 to 90, the 1960 to 1990, had been the dominant issue and below line, which were the items that the physicians would pay attention to. The so-called external factors at that time were subsequently regularized into two sections below the line so that we had the four topics that are classically associated with. In addition to those four topics, we had the three central aspects of surgical practice, clinical competence, respect for the patient's decisions, and primacy of the patient's needs. Clinical competence meant not only knowing what you were doing as a clinician, but also having the competence to incorporate in that the essential part, the interpenetrating aspects of surgical ethics or any other kind of ethics, depending on your specialty, that interpenetrated, as I say, and presented competence in clinical work. The Oslerian idea granted that some people say the sort of example that we're giving at the bedside is poor and one of the ways to improve clinical ethical teaching would be to have less of it, but I don't think that was said in seriousness. I think here is the third edition when I came across clinical ethics as Johnson, Siegler, and Winslade. And on the second page of the third edition introduction, you see this vital statement here. Our hope is that every clinician will acknowledge that ethics is an inherent aspect of good clinical medicine and that ideally every clinician will become a clinical ethicist. I think we've come a long way toward reifying that and actually making it a condition which obtains in a very large part of this country and the world as well. Now, when I heard the discussion today about the details of this book and its successors, I began to wonder because of the profound differences of opinion that were being addressed and the talk that chapter two was going to be written that possibly Albert Johnson might be, the fact he didn't come here, I might exclude him from the next book. But I don't think that seriously was considered, but it will provide a good deal of activity, I think, between now and the appearance of the seventh edition. The four topics method, as you see, are medical indications, patient preferences, those are the two above the line, and regularized into just a simple group below in one sign, quality of life and contextual features. And I want you to pay no attention to the next four slides because Peter has told me I have to do this in a hurry and I never intended to go through all these. What I intended to do was to show that these four topics are amplified in the book, if you're not familiar with it, this way. Here's the first one, medical indications with six sections, patient preferences with seven sections, quality of life with six sections, and finally the contextual features nine sections. That is 23, perhaps 28, but it's a lot of them. And it seems to me that it's hard to put that book in your pocket. I can do it, but it can damage your suit. And they've made it a good thing by there's a tip in, and here it is, a slick piece of cardboard, which you can pull out of the back of that book, fifth edition, sixth edition, and perhaps in the seventh edition as well. And it says all those six, 13, 19, 28, 28 different items that you can keep and sort of look at the way a quarterback will, you know, flip back that thing and sort of see what he's supposed to do next. At least that's my idea of how I might work it. Here they are. This is my version of it streamlined down. If you can't, if you look silly pulling this thing out of your pocket when you're at bedside, I think you can memorize this a little better. Medical indications, patient preferences, and the medical indications, they use the principles here, beneficence and novel absence. You've got, when you approach the patient, you have to know the diagnosis, the treatment, what the prospects are for success. If they're not going to be successful, what is your exit strategy? And finally, above all, the safety of the patient. Premam non-noture is not just a Latin phrase. It is above all what you intend to do. The last thing you want to do is to make the patient worse. So respect for autonomy. Autonomy has gotten a bad name not only for the physician but also for the patient. We've heard a lot of discussion about that. And those of us who've been practicing for many years are well aware of the fact that at times autonomy will trump everything else. If the patient says absolutely and can come to no accommodation with you, the way the patient has decided he or she is going to be managed is the way it's going to be. And the first thing you need to do is determine that the patient is competent and is not non-compassed, that what the patient's wishes are, that the patient is informed and the whole question of information has to be received, it has to be comprehended. At times a surrogate will do the job for giving the permission. Advanced directives also complicate things, whether the patient is willing to cooperate, can cooperate, and does cooperate. And finally, the rights are respected in law and in ethics. And below the line, the items that dominate, since the 90s have dominated, the quality of life and the contextual features are there. Beneficence, nominal absence in autonomy, what the prospects are, what the risks are, what the biases that you and the nurses and the other people in the health care team bring, what a poor life would be in your opinion, in the patient's opinion, in the family's opinion. And finally, the decision that you might make to forego therapy and to get into palliation, which of course is now a recognized specialty. Contextual features are broad. They have loyalty, which is what your idea is of loyalty to the patient on the one hand and to the fairness doctrine, the test between individual treatment of the patient and the public health aspects of the entire situation. The family, the MD and the RNs bring something to this. You bring monetary considerations, you've got religious considerations, you've got confidentiality situations, law, teaching, research, resources, and finally conflicts. I think there is the sixth addition. As I say, it will fit in your pocket with a stretch. But I think that having this handy dandy abstract, and so what we've got here in our discussion of these two papers is we've got a book, which is a modus operandi and the whole philosophy that's in there. And we've got this, which is the paper, which exemplifies the approach to that. And this is, I'm not a liver transplanter, but I've looked into this. And here is the, here is where Mark and his colleagues did an amazing thing. They wrote this paper and put it out as a thing which is lightly called occasional notes in the New England Journal of Medicine, two pages with some references on top of that. And it provided in two pages lightly styled as occasional notes. It provided the record of an amazing year plus of work and that work consisted of identifying the key ethical aspects of this problem, which was the question that was being addressed was whether you were going to do a partial liver resection and use that for a child as a liver transplant. And maybe this is an old story and everybody knows it, but the way in which that was done and the way in which I will run through quickly, they did this and then encapsulated it in this two-page paper has been a hallmark of how you should approach these things. Happily, the way in which it worked out was that both patient and donor did extremely well. And that's the way you want to start with anything that you're doing for the first time. I think that what they did was over a year, they identified the key ethical aspects. They convened extended open discussions throughout the whole academic area here. They drafted the working paper. They circulated that widely for modifications. Submit that revised paper to the IRB so that rather than starting with the IRB, they had it all done well in advance with extreme limiticulous care. The ethics of the liver transplantation had to consider risks and benefits both for the recipients. And I mentioned reduced size technique because you can't start right off if you're a total orthotopic liver transplanter and do the reduced size technique. You have to have a background. The donors, your aim in the donors is to have zero mortality, is to have negligible complications. The benefits to the recipients are a better match. And you don't have the problem of waiting and losing 50% of the patients while waiting. The donors, psychological, that covers a large territory. But I think that the selection is, as Frannie Moore said at the time, this was being considered desperate remedies, a call for desperate measures. And sometimes the results are not all it should be. And therefore, the way this was done and the projection of how it was going to be done was that it would be done at leisure, that the patient would be at that time clinically well, that the survival prospects would be high, and that the selection of the donor would be, in general terms, a parent or a grandparent so that you had this team appraisal, which we'll get to in a minute, technical suitability that you'd studied. And above all, and I emphasize that with two exclamation points, a focus on safety. Safety was the key concept. The informed consent of the donor, they were very frank in presenting this, that there were limited data on the subject, that there was a complication that the surrogate decider was also the donor. And that's both good in the sense that you are motivated, you have, you know that the person is genuinely interested, but there are also negative confrontations because of the possibility of family pressure and other things. The idea that you feel, if you didn't do that, you would be a pretty poor person. That says hematologist, it means pediatric hepatologist. The informed consent of the recipient is obtained by the pediatric hepatologist, plus the surgeon, the proxy decision maker is the parent. The standard format of an informed consent document is not a single isolated issue, as we all know, it's a continuing relationship between the donor and the people that are presuming to do the procedure. So you had not only a first consent with the hepatologist and the surgeon, and then an evaluation, sort of a person that stood up for the rights of the donor and the internists and psychiatrists who were on the team, and then a second consent in which you told them all the published data you could adduce, which in those days was negligible, and your local experience with laboratory work, with other comparable work that would bear on this, a zero mortality that you were aiming for, and the fact that complications were unlikely because you were so skilled. And the one thing which would obviate the pressure of urgency, feeling that the patient will die, is that first that you would do it while the patient, the child was in pretty good shape. Secondly, that you would give the donor a two-week opportunity for changing his or her mind. And so here are the influences on the donor's decision, the internal pressure to save the life, the basic notion of selfishness versus altruism, the pressure from the family members, and the deteriorating clinical status, which is countered by a two-week wait. So that's the discussion of the modus operandi, which is in the book, the application of it to a extremely critical situation in advance in which the patient and the relatives, patient wasn't told because it was an infant, the child, they were told that this was the first time this was ever going to be done. There's a bad joke we all know about if you go to a patient with a new innovative procedure and the patient says, have you ever done this before? If you've never done it before, that's the time to be quite frank about it and to say absolutely no, this is the first time it's ever been done. If you've done two cases before, you can call it a series. If you've done three, you say it's a series of less than 100. So... After this had been done, you look, I've reviewed briefly, the literature so-called, from 1989 to 2008, as to this initial good result, what has the effect of it been? And out of the 40 articles that I reviewed, I have seen these rough categories and it doesn't mention many of the other things, it doesn't mention the Vancouver idea, it doesn't mention a number of other things like the Tavistock group and so forth, but it mentions profound differences between the east and the west, the far east and the west. The psychology after donation, the Mayo Clinic has recently studied a couple of hundred patients in the psychiatry and the psychology group and they've found that there are problems with those that achieve donation, as well as those who have been rejected as unsuitable for one reason or another. Chris Broch, who was with that article that we discussed at length, that first one, is now in Essen and they have studied and acted, operated on 200 patients and their results validate what we saw as the ideal way to approach this. Confounders of voluntariness, there's no choice on the one hand, fear as a group from Grunigen, the potential donor survey at Washington University, they started, they were evaluating what the situation would be in a generic approach to a group of people at random and 730 to start and we finally came down to the 19 final of each, about a half a dozen were actually used in transplantation. Naturally the government is getting into this and the New York state, there's a regulation, independent donor advisory team is required. You've got the one thing which you don't wanna do, speaking of New York, is to have a donor death because that puts a pall and an almost instant repression on the project and on the program. Mark and others have studied the orphan Oregon situation if you have the misfortune that you have decided on a donor and indeed if you've gone as far as to have the organ retrieved and then the question is the person that you were expecting to put it in dies, that poses a neat problem and that has been addressed very thoroughly both by Mark and others. Expansion the Milan criteria and so forth is happen to a failure and the final comment is about two weeks ago there was another festrift for a surgical transplanter that Ben coasted me and at that time it was my understanding, I didn't attend but I've spoken to a number of people who were there, it was my understanding that the paper that we saw that the occasional notes that were done 19 years ago which indicated how you should approach this thing has become such a standard that indeed over the next 19 years we have come to the stage where it has been implemented and people like John DeGerion, Andy Warsaw and others at the MGH tell me that their care when focusing on the safety of the donor is so extreme and I'll leave this as a thought, maybe a paper that Mark might write with someone that nobody in Minnesota has a donor organ removed except that that's a highly skilled attending. We don't have residents, we don't have fellows do this. The emphasis on safety is such that it is done only by extremely expert individuals and that seems to me to be potentially at least in conflict with the idea of graduating in surgery people to graduated responsibility under supervision and it poses a nice issue as to whether you're excluding the residents and fellows from an operative procedure because the insistence on safety is such that it understandably conflicts with the premium non-notes rate ocean of extreme safety for the donor and with that I hope Peter's not getting a hook for me. Thank you very much, Roli. Mark sounds like you owe Roli a new suit. Peter, you're next, far away, thank you. So I will try to keep within the time constraints because Peter has told me that speaking over my time would be unethical. So I have a few things to... Time is super arbitrary. Ah, okay, well, there's a challenge. All right, so I'm gonna talk a little bit about Mark Siegler surgeons and the surgical ethics program. So this is gonna be a little bit personal, a little bit general and a little bit specific about the University of Chicago. So I'm gonna talk very briefly about something about history, ethics, and surgeons. I wanna talk about Siegler insurgents and as I mentioned the surgical ethics program here at the University of Chicago. So we've heard a lot of great talks over the last day and a half about the context of ethics and what was happening and all of the great things that Mark has done and pioneered. I think it's valuable for me to point out that in the 80s and early 90s, medical ethics courses were thought to be very innovative in medical schools. In fact, most of the people who wrote about medical ethics were philosophers and clergy. There were a few physicians, but there were no ethicists yet. The concept of an ethicist wasn't really known at the time. And in fact, I've spoken to people, one gentleman who told me he had spent some time in a medical school. He as original training was as a chaplain, but he had spent some time and he had on his new white coat and he was gonna go out to be the ethicist. But at the time, he didn't know what to call himself. He called himself an athician, much like a physician. And so he said he went to a patient's room and had his white coat on and talked to them and then thought that it went very well. And then later on in the day, he heard the patient saying, who was that nice beautician that came into my room to talk to me? So there were some problems with the terminology. But for the physicians who were involved were generally internists and pediatricians and some psychiatrists. There really were not a lot of surgeons. So what about this concept of surgeons and ethics? Well, although I would hope that few would argue that surgeons are unethical, there were in fact few surgeons writing about ethics at the time. And surgeons were viewed by some as purely technicians. And there may be some in the audience who still believe that, although we try to convince people otherwise. Certainly surgeons were thought to be non cerebral by many as really, it doesn't matter as long as you can cut. That was sort of the adage about surgeons. And I remember vividly when I was going to my dean for my letter to apply to residencies. And he said, so what are you going into after having studied philosophy and taken this time out and all? And I said surgery and he started laughing out loud which again I think says something about the tenor at the time. And so some people at the time thought surgical ethics is an oxymoron like military intelligence. This is just to actually, just to give you again a sense of perspective, since we're all about data, empirical data, and I don't know if, I guess I don't really have a pointer, but what I want to point out here is this is looking at ethics education reported in the literature, and this is based on work, oh thank you, based on work from Eric Grossman, who is one of the ethics fellows, a surgeon this year. And so we looked at over the past few decades what's been reported in the medical literature. And so as you can see it's really been pretty good in internal medicine and medical subspecialties, pediatrics is pretty good, family medicine also pretty good, but you look pre-1980 there was nothing in surgery. And so again, this is really just to give you a sense of the context. So with that context in mind, in the spring of 1991, I was a second year surgical resident at Northwestern University who was interested in medical ethics, who had written a PhD dissertation in philosophy that had been turned down by my committee. And so I naively thought I was just gonna rewrite it during my residency because surgical residency is you know, you got a lot of free time. So anyway, it's great to be young and naive. And so I needed a research year so that I could rewrite my dissertation. And my chair of surgery at Northwestern, David Narwald, who I owe an awful lot to, said well, we've gotta get you to finish this dissertation and we'll figure out a way, you know, you gotta go into the lab to do it. That was the concept, you go into the lab, spend a year or two. And so I'm not sure about the discussion that occurred between Dr. Narwald and Dr. Siegler, but next thing I knew, I was doing an ethics fellowship here at the University of Chicago. Now a surgeon as an ethics fellow at the time, I think was fairly novel. I think I was the first. I'm not sure that it matters. Certainly there weren't a lot of us. And I remember vividly when we read Forgiven Remember, I was the first to pass. Oh, thank you, Mark. When we read Forgiven Remember, my colleagues, the other fellows, all sort of were shaking their head and said, so is that really true? And I said, yes, it really is. So let me give you a little bit of perspective then about Mark Siegler and surgery in general. I think Mark has expressed to me, to many others, I'm sure his sincere belief that surgeons, perhaps more than any other physicians, embody the essence of the doctor-patient relationship. Now, there may be several reasons why this is the case. Maybe it is the intimacy of the physical relationship. Maybe it is from the sense of personal responsibility that surgeons feel for their patient's clinical outcomes. Perhaps it is this sort of thing that Charles Bask wrote about in Forgiven Remember, when the patient of an internist dies, the natural question his colleagues ask is, what happened? But when the patient of a surgeon dies, his colleagues ask, what did you do? And that's something that's very, very serious. Surgeons, we don't question that. That's assumed that that is the level of responsibility. I think it's important that with respect to surgeons and patients, there's been a fair amount of attention on the physician and that relationship with an individual patient. For individual surgeons, there's really only one patient at a time. What I do is piecework. I can only operate on one patient at a time. And it doesn't happen if I'm not there. So surgeons are forced to do what Mark Siegler has always encouraged, which is to focus on the patient. And no matter what else is going on, at least, and I'm speaking just personally, whatever else is going on, no matter how bad a day I'm having with all these deadlines that have passed and things that I'm supposed to have done the papers that I was supposed to send Lainey and all those important things, I always know that if I go to the operating room, I can just focus on this one patient. And it's actually very nice for me. I like it. So Siegler and surgeons, well, Mark Siegler, not only did he decide to take a risk on having a surgeon as an ethics fellow, but he embraced the concept of surgeons as being intimately involved in this whole endeavor of clinical ethics. And I think his embracement is, that's not the right word, his willingness to do so is exemplified by his membership on the American College of Surgeons Regents Committee on Ethics. And Mark's been a member for 20, 25 years, for a very long time. Every single one of the clinical congresses at the American College of Surgeons for at least the last 20 years, there's been an ethics colloquium and Mark's been on the panel of experts. And I like the slide of the search in the desert for the panel of experts. Mark's always on it, which is good. We saw a little bit of an exemplification from Dr. Hanlon's comment on those papers about Mark's involvement in this issue of surgical innovation and also specifically on organ transplantation. And his body of work in the transplant ethics literature is quite significant. So let me just turn for a moment and mention again, a little debt of gratitude towards Mark. Not only was he willing to take me as an ethics fellow, but then a couple years ago, I'm sure that Mark had a major role in my being recruited here. I was at Northwestern, I was very happy. And I have no doubt that the surgery department had an interest, but I think Mark pushed them. And this opportunity to work in the surgery department and in the ethics center and have both working together was tremendous as well as the commitment on both sides to support this idea of starting a program in surgical ethics. So the elements, four key elements of the surgical ethics program. Monthly ethics teaching conference for residents, fellows and faculty. And I won't spend a lot of time on this because I really do want to allow time for Mark to speak later. A weekly ethics seminar series, many of you have spoken at that. It covers a variety of topics, intermittent ethics sessions at surgical grand rounds. This is something that I think is very important. It's not enough to just have it be a case conference separate every now and then. It's critical that it be featured in surgical grand rounds. That shows its importance. And then finally the surgical ethics fellowship program, which I'll just say a couple words about. This is a graphic depiction of surgical ethics fellows through the year. The large bars are the total ethics fellows. These small pale bars are the surgical ethics fellows. And what I want to point out is that over the last two years there have been quite a few more. And we really see the surgical ethics fellowship as a new model for further education of academic surgeons. I think in the last 25 years there were nine fellows since 2007. We've had 12 that either have finished or currently enrolled in the fellowship. We actually have funding now to support one or two fellows and in conjunction with the American College of Surgeons where there's gonna be a national call for applications for the surgical ethics fellowship. So let me just say with all this and I think that this is all important. Ultimately the holy grail of surgical ethics as I see it is not intermittent ethics teaching which is what conferences and lectures at one dot are but fully integrating ethics into the residency program. That should be our goal. And so part of what we're trying to do is emphasize the ethical implications of all of the decisions that we make. We in M&M conference, the clinical decisions that we make every day. That's really the critical thing. We don't wanna be doing ethics and now surgery but we wanna be cognizant of the ethical implications of all that we do in our surgical decision making. So let me just finish with the goals of the surgical ethics program. And they're I think pretty modest. It's to improve ethics education of surgeons throughout the US to define and establish the field of surgical ethics. To provide role models for how surgical ethics can be incorporated into an academic surgeon's career and to train young people who will not only be excellent surgeons but also great doctors. I don't think it's enough these days to say my surgeon is a real jerk but boy he can cut. We wanna train people that can do both that are really good doctors. And finally I wanna say that none of this would be possible without the support and interest of Mark Siegler in engaging surgeons, welcoming surgeons and finally supporting the surgical ethics program. So thank you Mark and thank you all very much. All right, great. Charles are you next? I actually stood up so that I wouldn't be the last speaker because that would put me in the role of my least favorite person at a long faculty meeting, the person who stands up and says everything has been already said but not yet by me. I'm really honored to be here. The working title of what I have to say is Mung Fish Soup, Mark Siegler and me. Three ingredients for everyday clinical ethics. And in time I'll address Mark Siegler's centrality to recognizing the importance of surgical practice to a comprehensive view of clinical ethics but I wish to do so in a way that mirrors Anne Fateman's description of the way that Mung described making fish soup. For the Mung, any adequate account of how to make a fish soup requires first a description of where, when, how to fish, what hooks to use, what time of day to go, how to clean the fish, what kinds of fish to use and so on. What Fateman says is that among the Mung, to speak of one thing is to speak of all things. Mung culture is said to be pre-literate which seems to be a polite way of saying primitive and that's a characterization that strikes me as odd. Since speaking of all things when speaking of one is how a very long time ago, I learned to think about the social world when I lived across the street at 1126 East 59th Street. My fish soup's only gonna include three ingredients because time is short. There are three stories about Mark's but only two are about Mark Siegler. But they will help me stir the pot for the last set of points I wanna make. I first met Mark Siegler not as a leader in clinical ethics nor as an author but as a sort of stumbling graduate student. Graduate students typically don't get cared for at the University of Chicago. I guess I violated HIPAA, didn't I? Graduate students typically don't receive care from attendings at the University of Chicago but I became Mark's patient when I told I think Shep Kalamaz's horror story of what had happened to me in student health. I walked in February 1975 with a cold and a complaint of fatigue. After all, I was shadowing surgeons at this point. It must have been about 15 months into it. So I didn't think the fatigue was unusual. The physician who greeted me wanted to work me up for leukemia. I said, what are the odds of that? He said one in a million. I said, could we start more modestly? I told the story to Shep. He said, let's get you to Mark and my care with Mark was I think uneventful. I was a male in my mid-20s. My health was threatened mostly by fatigue and poor nutrition from shadowing surgical residents from Chicago winters and from extreme penury. And there was only one crisis that I recall that occurred on New Year's Eve 1975. My wife and I had been busily packing boxes for movers who were to arrive on January 2nd, 1976. We were working frantically and my trunk began to itch. I scratched and lifted my t-shirt and there was this alarming rash. Alarmed, I called Mark at eight o'clock on New Year's evening. I really did not expect a return call. Much to my surprise, I received a call back within 20 minutes. Conversation was quick and to my mind a paradigm of how Mark grounds his ethics and his care in context and relationship. The short exchange we had is one I still remember and I think of as a model of humanistic care. Charles, this is Dr. Siegler. I described my symptoms in such a way that Mark was, and I don't, I think this is both a mark, a mark of Mark as a clinician, but it may not have been too hard to hear this. I describe my symptoms in a way that my mounting hysteria and anxiety about my impending move was probably really clear. But there were no traces of impatience in Mark's response to my panic, to the really trivial nature of my complaint or the interruption of his holiday. Rather, there were a few quick diagnostic questions and then a useful recommendation that left me feeling cared for and I think that was the feeling that I most needed in the world at that time. Conversation went like this, Charles, when did you last sleep? I don't know, 48 or 60 hours ago. Unlike Mark, I could not help but express my irritation. When did you last change your t-shirt? I don't know, everything's in boxes. I don't know where anything is. When did you last shower? We don't have a shower. The crummy apartment only has a bathtub. Okay, when did you last wash? I don't remember, I'm just trying to pack and so I'm still panicked and irritated. And then Mark's response sort of melted all of that away. Charles, this is what you need to do. First, I want you to take a bath and wash with soap. Then I want you to change your shirt. Finally, I want you to take a nap for at least an hour. I think that'll solve the problem if it doesn't call back or take a Benadryl. Hallelujah, I was cured. I left Chicago uneventfully after that and after I left, clinical ethics flourished. Now, I think this is an example, I hope of spurious correlation from a very small sample. But I can't be sure. Now, the second ingredient in my fish soup is the next time I saw Mark, which was five years later at the University of Virginia. Forgive and remember had just appeared. This was one of the first occasions that I invited to talk about it and I didn't quite know how yet. So, but two days before my talk, an Air Virginia flight, one that happened to have the same number as the flight that I was to take in a mere 48 hours, made an unplanned landing in the tidal basin. The trip to Charlottesville was my first venture away from home since becoming a father. My wife insisted that I take Amtrak. I argued to no avail that flying to Charlottesville so soon after a crash was probably the safest thing on earth that I could do. But I lost that argument and I was on a very crowded Cardinal, that's the name of that particular train that was filled with husbands similarly advised. So I found myself next to a quite gregarious traveling salesman who was delighted to show me his entire line of promotional items. He had pens that put your name of your business here and cups and buttons and God knows what else. And he was absolutely oblivious to my obvious rudeness and disinterest. He, in fact, when I tried to escape him to the dining car, he followed me. And I, you know, so I was an unhappy camper when my very late train arrived. Tired, hungry with no hope of being fed because everything in Charlottesville had closed and stuffed only with self pity. I made my way to the hotel. Anxious about the impending grand rounds, I've never done one of these before, I spent a sleepless night. I sort of made my way the next morning to the auditorium where I was to talk and I was surprised to be greeted by Mark who was spending a sabbatical year at UVA. My surprise was the result of a fundamental attribution error. I thought of Mark much like a comic book hero of my pre-adolescence Aquaman. As I recall Aquaman, if he was out of water for either an hour or 24 hours, he perished. And all the Aquaman things revolved around getting him water within, you know, solving things on land and getting him water within this defined time period. And I sort of thought of Mark as one of those people that couldn't survive outside Hyde Park during the length of a sabbatical. And that belief I think was an index of how poorly I knew Mark and how young I was, but Mark was excited to see me. He had just recently read Forgiven Remember and his effusive praise embarrassed me. I had been a graduate student here and I was really good at managing withering criticism. But I had never experienced praise before and I didn't know what to do. So Mark told me that he was, you know, really happy to see me and he was gonna introduce me. And the first part of the introduction was so generous that I found myself looking around the stage for who this strange person was that he was describing. The second part of the introduction veered off in an alarming direction. Mark had made slides. I think we called them lantern slides back then of the last transmission of the doomed Air Virginia flight with the air traffic controllers. The transmission had been released less than 24 hours previously. If you're so young that you've only used PowerPoint, ask an old person next to you how hard it was to get slides made in less than 24 hours. I had read, we hear in this transmission panic, helplessness and terror as the co-pilot tries to let his clueless pilot know that they're both about to die. And I had read that transmission in the paper while I was failing to find sleep the night before. And I found it so disturbing that I thought, this is something I never wanna think about again. So as the slides flashed, I experienced what Margaret Mead and Gregory Bateson identified as in a way. We now call that ordinary dissociation. And I was yanked back to now by a kind of rising emotional pitch in Mark's voice. So what I am certain that Professor Boss will provide us is a key to understanding this transmission, how this kind of error occurs, what sense of professional responsibility is conveyed in the transmission and how such crashes can be avoided in the future. No, no, not what I was gonna talk about at all. I had a text and I had not yet acquired the skill to either improvise or to avoid a question while seeming to respond to it. But today, I now look back and I see those slides and see them as kind of a very important learning moment for me and a very important teaching moment. First of all, let's marvel at Mark's prescience. 20 years before the IOM, Mark saw the connection between airline safety and medical care. But more importantly, Mark was encouraging me to think about my work in a way that gifted teachers do. He was urging me to see distant implications in research that I had just completed but had not yet really understood. I don't understand the process of writing something that you don't understand yet, but it happened. Mark's challenge provided me to look at social processes that connect sense-making and associated decision-making in time-pressured situations filled with irresolvable uncertainty and a dynamic shifting balance between the costs of action and inaction. Mark helped me on that day to think about medicine not as an isolated province in which human conditions problems are faced but rather as exemplary of problems, human condition problems wherever they're faced. Now, the third ingredient in this soup that I'm about to stir is a conversation I had with another Mark, Mark Jacobs, a sociologist who was here with me who had just published a book in the mid-1990s on juvenile justice, tragic narratives and what he called the no fault society. I had invited him to pen to a colloquium and then dragged him, we were supposed to have dinner but the dinner coincided with a standing meeting that the Green Wall Society funded of social scientists, clinicians and ethicists to talk about the relationship of bioethics and social science. So it happened that that night we talked about the support study discussion I thought was terrific. I thought, God, this is pen at its very, very best. We walk out of the room and Mark turns to me and says, you know, that discussion is not possible in the realm of juvenile justice. Why not? Well, there weren't any community just representatives. It was just a bunch of academics debating with one another. What are you talking about, I protested. That's docs allowing themselves to be challenged by outsiders and academics. No, Mark insisted. You're all part of the same community. You share the same values, you talk the same language. And how can you of all people make any claim to being an outsider in medicine? You've been living among these people for 25 years. You have no idea how gentle a critic you are compared to say a community member who's been abused by the juvenile justice system. Now, I've been mulling over that criticism which was made about 13 years ago ever since. And the three stories I tell are parts of what I think makes Mark's contribution to clinical ethics so singular and so important. And I regret to say that the last comment represents a challenge to clinical ethics, all clinical ethics. Mark's included any clinical ethics that assumes that the ethics function can be internalized within an organization conducted fully by members of that organization. Because I think then those folks won't be blind to their blind spots. But the strengths of Mark's approach are what I wanna talk about today, today being what today is. And I think there are many and I think they create a Chicago School of Clinical Ethics that's every bit as influential as the Chicago School of Sociology. When we Chicago Sociologists say Chicago School of Sociology, we face the East and we bow three times. So this is sort of from a sociologist's point of view the best thing you could say about anything. Let me briefly elaborate the three strengths that I think are critical as they apply to surgical ethics and to ethics more generally because surgical ethics aren't any different from anybody else's ethics. Mark anchors the practice of clinical ethics in relationship. Moral certainty in Mark's approach is not the primary goal of ethics consultation. The goal is engagement and dialogue. There's an implicit faith that process and dialogue is a sure path to appropriate decision making than fidelity to abstract principles that may not apply here, may not apply there. Next, clinical ethics is an activity best done by clinicians. Now limiting the practice of clinical ethics to physicians is a position Mark once took and has retreated from but the more I think about it, the more I think that the general principle that clinical ethics cannot be divorced from clinical practice is a sound one. To understand clinical ethical dilemmas in their fullness one needs to have some experience with the dimensions of clinical responsibility. Some you have to know what it means to care for another. Now there are lots of caring roles. You don't have to be a physician but I don't think you can, I have a lot of trouble with folks like me calling themselves ethicists and sitting in a room and giving recommendations. It's not to say I have nothing to offer. But I don't think the handholding that I do with graduate students is the same thing as experiencing the weight of clinical responsibility in its fullness. Folks that are trained like me can make, we can challenge, we can raise questions, we can make observations, we can challenge prevailing orthodoxies but to think where the real deal is I think a real bit of, it's a dangerous bit of hubris and nonsense. It mistakes what our special, what our trained competence is and blurs a professional boundary I think. So to complete the abbreviated list of the strengths and marks approach, I think the real focus is on the quotidian aspects of everyday practice and ethics as part of it, everyday practice. Many in bioethics focus on conflict in a spectacularly dramatic, excuse me, case. Such a focus has the defect of blinding us to the ethical dimensions of the most ordinary clinical action. Mark does not make this mistake. Clinical ethics is everyday behavior. Practice of ethics is not detachable from other aspects of clinical practice and by extension training in clinical ethics is part of training in clinical, the clinical arts more generally. Focus on the everyday, on ethics is realized in relationship and on the ways that clinical ethics is not detachable from the rest of clinical practice or the hallmarks I think of the McLean Center. They represent both the reaffirmation of traditional professional values and a radical break from priorities of the present. Some ways Mark's contribution is like his approach to clinical ethics, rooted in relationships focused on the everyday and not detachable from his identity as a person or as a mensch. Thank you. Ira, over to you. If you can finish by five after five, we'd be grateful. Give us your bottom line. I know you had 700 slides, but you're a great communicator. That communication has nothing to do with it. I'm glad to be here. I'd like to give you the assurance that I've made a career, put my kids through college, fed my family by dealing with complex ends. So here I am at the end again. I'm following on the trail of Franciscan and Jesuit Latin scholars and need to comment on this book and Mark's work on this paper. So let me complete the Latin litany. You are indeed a mensch. It's amazing that no one has mentioned the term chutzpah because you put a medical article in the surgical, the bulletin of the American College of Surgeons, which is a phenomenal undertaking. Now I'm gonna zip through a lot of slides because I didn't know what was going to be done for sure. And so if it gives you a severe headache, we've done some research recently that shows that a very rapid procto exam will get rid of that. And I can accommodate you in the hall later. So sit tight here. These are things that Mark mentioned in the office, in the book and Dr. Hamlin and Peter covered them pretty well. I think it is worth mentioning the schizophrenic experience I had this morning listening to Richard Epstein make his comments because all of us have been talking about what comes first above the double line, the medical part or the patient part and what Richard said and I sat there that is that we should be hiring medical students who are interested only in the below the line issues. He said, what is going on here? So these are all things that have come out and the issues that are the forces that pushes below the line are escalating because of the unimaginable cost of medicine in the number of Americans who lack access to our healthcare system. So Mark's conclusion of the article in the bulletin of the college, we take as very worthwhile, but these really were as if you were speaking to internist and not surgeons. We look at these issues differently. So what I'm going to try to do in just a few minutes is reflect on what this fellowship has meant to me personally and then the impact that it's had nationally and perhaps internationally. So I've gained some insight as to how this started. I was, because of our research on genetic predisposition to colorectal cancer, I was able to do a presentation on one of these expert panels with Mark at the American College of Surgeons. I didn't know about this advice that come to Chicago. So he invited me to work with SSS to create a curriculum for teaching ethics to surgery residents. And I found after being lured to Chicago that we had no comprehensive program at Washington University and there was a challenge from our medical school to go beyond just looking at medical issues but to look at all issues facing human values. I received immediate support from the chancellor to explore this issue at Washington University. So the impact of Mark and the incredible McLean Fellowship bailed me out of this because I was pretty good and I came here with tenure as a senior professor of surgery but got off that Southwest airline every Wednesday and found that I was a graduate student. So I was strong on hemorrhoids, weak on ethics and I did get this invitation to come to Chicago which I did six intensive weeks followed by weekly flights. I was on my way to becoming the Southwest airline poster child well into my 60s. So we were, this is our class, we were thrilled, sometimes astounded at what was going on. The conferences were great and all of us tried to emulate these weekly conferences. There's some things that really caused me some consternation because when I went for the first interview with Mark, at first I was apprehensive because there was nowhere for me to sit and then I became more apprehensive because I realized there was nowhere for him to sit. But I graduated. I went back to Washington University and pursued this issue that we had no comprehensive program. We did take the advice of senior medical faculty to go beyond and received support and monetary support from the chancellor. I'm going to skip through this. What we, when we began it was a time of moral uncertainty with business scandals, healthcare scandals and even clergy scandals and the challenge that we took was to look at the treasures that we had in all of the schools of the university and to put them together to really encourage the highest ethical standards and to train the next generation of scholars and to engage the community. So a good part of what we did was to reach out and we created now, we're in our sixth year of the Center for the Study of Ethics and Human Values. The mission is to create forums much like today but not ever as effective that bring all sides together for discussion and analysis of even the most difficult issues of our time to advance the knowledge of human values through practical application in real human affairs. And as always, Mark was incredibly supportive. I would point out, this is the chairman of philosophy. Mark was great. The person on the right is the provost and Mark was wonderful. He impressed the provost. I was a pushover. Professor of philosophy just, no one gets to the professor of philosophy, even you Mark, can't budge the chair of philosophy. So we've looked at our impact now and we've done a lot in education, research, giving grants. We've brought the students together, the faculty together and that last figure in the corner, we've had to put together a strategic plan and when we look at the number that we've impacted in five years, it's approaching 17,000. So we're pretty happy. And I'm sorry that Dr. Pellegrino left but we were thrilled to get this letter from him where he said, what you've accomplished in so short a time is extraordinary. You're the only program I know engaging the whole university so effectively. Washington University said an example, I hope others will follow and my quest of course is to follow my mentor Mark. If we look at the entire specialty in surgery, a lot of this has been said, we are different. This is another quote from Charles Bost you get the feeling that surgeons kind of abide by what he said, even John Cameron for too long surgeons have been considered non-caring technicians interested only in the surgical procedure and the immediate outcome. And if we really go back to castle, the salient feature of the surgical character has been decisiveness and action oriented approach to problem solving and contradiction to a reflective and contemplative response. I don't understand what he's saying. When we started the program with our surgery residents, we actually did some data gathering and found that 100% of them said they encountered ethical issues daily. Only 60% discussed them with their fellow residents and only 25% would ever think of discussing them with the surgical faculty. In general, 100% had an interest in bioethics. Only 20% felt sufficiently prepared to make decisions. 80% wish they had more discussions about these issues and 80% are happy to have formal teaching about ethics and we have implemented the program very similar to what Peter described. It's such a big deal now because we have all stood by and let medicine become a business. Time is money, reimbursement is down. I was going to mention yesterday, one of the big challenges is to show me, give me tools, mark has created disciples. The problem is when the disciples go out, they meet the heathens. And the first question the heathens ask me is what's it worth? You know, there's the chief of surgery says, you generate income by doing surgery. What is teaching ethics worth? Help. It's frustrating in surgery because we can really do more than ever before. So we try to do it for as many people as possible. There are a lot of threats to the surgical training now, including the shift to outpatient. And we just live in suspicious times. Our mentoring system has been corrupted by the shift to outpatient and the reduction in working hours. So when we look at surgeons, I point out a few incredible things that we have to deal with that really do make us different. Very few understand the anxiety of going to bed at night and realizing what we have to do when we wake up in the morning of taking another human being, cutting them open, and perhaps losing them at our own hands. It's hard to explain to someone what it's like in the operating room when we burn the bridge. We've cut the arteries, we've de-vascularized the structure, but we really don't know how we're ever gonna get to the end of the operation. It does result sometime in strange behavior. And yet we sit by and let everyone tell us that we're only technicians. So, Mark, you have made great inroads, including your appearance and participation on the Board of Regents, but especially participating in this book, The Ethical Issues in Clinical Surgery. It's a case-based curriculum. It now is published as an instructor and trainer's format. It was commissioned by the College of Surgeons. Dr. Hanlon was instrumental in doing this. Peter is a co-author as well, and it is just one year that these have come out, the resident's version and the instructor's version, and they are treasures for any of you who are interested. And I don't think you need to limit it to surgeons. It is a great tool. It presents ethical quandaries, including the very complex ones. It provides the guidance that the trainees need in navigating these waters. It's a terrific resource, but you always need a champion to implement such a program. We have a national champion, and Mr. Par Kamengar, who's a grateful patient from San Francisco, who has provided ethics awards that buys the books, buys the pizza, helps implement the program. This last week, we had surgical educators, some of whom are here now, from 17 training programs, they successfully received the grants to share, and we are now sharing the need and mechanism for implementing this teaching of clinical ethics into the surgery training programs. We will have another round of these grants. So if anyone is interested, you can contact me, and we will send you the application for the Kamengar grant for next July. I'm thrilled that the McClain Center now has a special fellowship program for training leaders in dealing with the challenges of surgical ethics. When I came here, I was clearly the oldest fellow they ever had. I was probably one of the first surgeons they ever had. I was ready for the Wednesday Ethics Conferences when I mentioned surgical interest in ethical issues because when everyone's eyes rolled up, I knew because I had two daughters, and whenever I said anything serious to them, their eyes rolled up the same way. So it is an honor, and I can't be more thankful to you. You are a great communicator. I obviously don't have time for questions, but what we do have time is to acknowledge all the surgeons in the room who've worked in the area of ethics, and could I ask you all just to stand up and take some applause? Martin, yourself as well. And thank you very much for that terrific panel. Just a couple of transitional comments. One is Mark would like to remind everybody that immediately following his remarks, everyone is invited to celebration or reception at the DCAM, which is at 58th and Maryland, and that will be immediately following Mark's remarks. On Mark's behalf and on all of your behalf, I'd like to thank John Lantos and Lainey, especially Lainey, believe me, she did all the work. And most of all, I'd like to thank Ella and her whole team there. If you could all stand up and take our applause. You all know who you are better than I do, but thank you all very much. Just in transitioning to Mark, the main attraction here, I'd just like to make two points. One is last night, Stan Goldblatt talked about the future of the center, and it occurred to me sitting here this afternoon that the future has been staring us in the face. If you look at this map, and I don't know if you can see it from the back, and I think this correlates with a lot of the comments on health disparities, there's a whole bunch of stars in the United States and in Europe, and there's a couple of parts of the world where stars are missing, especially in Africa. So I think Mark, that gives you a signal for where you can leverage your assets and the assets of all the people in the room over the next 25 years. And then finally, just, you know, I've already expressed my appreciation for your having changed my life, but I thought maybe the best way to segue into your comments is just to ask people in the room to raise their hands if Mark's changed your life or had a significant impact on your life. Now, Mark, I'd like you to, as you come to the podium now, just to look around the room and keep your hands up just for a second. And Mark, will you just look around the room and that in addition to creating a field is your true accomplishment, and we're all very much in your debt. Thank you so much, and we look forward to hearing from you. Well, I'm overwhelmed. I did hear that wonderful comment. Was it, no, no, I think it was Rallo who said it, that everything has already been said, but not by me? Who said that? Charles? It's a day, it's a day for thanks, and I'm filled with thanks. Thanks to my family, Anna, and the four kids, and Rich M, Marita Allison, Anna's mom, Nora, Nora, where's Nora? Grandma, Nora, coming on 96 and flying around the country on her own. And of course, the little baby, he's a baby here who's got the best t-shirt of all. What is a t-shirt says? Say? Where's my favorite shirt? But it's not just the immediate family, it's the extended family. It's the extended family of Lainey and John Lantos and Peter who organizes extraordinary event today. It's the extended family of fellows who are, as you know, dear to me and as close to me as any students or colleagues can ever be. It's the thanks to the faculty, which I've always thought is the great faculty in the country and in the field of ethics. And of course, it's thanks to supporters and friends of the center. Lindy Bergman who's been with us from the very beginning is there. Lindy, raise your hand. And Kay Bucksbaum is in the back and Kay, raise your hand. And of course, thanks to my incredible teachers. I think back on my years at Chicago and I mean, the people you come in contact with here are just extraordinary. When I arrived, Leon Jacobson soon became the dean. I mean, what do you say about the first physician to have used chemotherapy to treat patients or Charlie Huggins who would won the Nobel Prize for establishing the relationship between hormones and cancer. Don Steiner who discovered Proinsulin and revolutionized the fields of diabetes and endocrinology. Gene Goldwasser who's still on the faculty was my biochemistry teacher. He collected urine from the entire class regularly. And from that urine, he isolated the hormone erythropoietin in 1977, a substance that is now used to treat anemia in more than three million people a year. Janet Rowley, teacher and colleague who has helped establish the link between cancer and genetics. And it's not just these investigators, but it's the clinical teachers, some of whom are in the audience now or have been in the audience through the day. We introduced the incomparable Joe Kersner earlier who at 99 years of age is still in, I don't think he's an emeritus faculty member. I think Joe's on the faculty. And Al Tarloff, my chairman of medicine who changed my life by directing me into general medicine, Dick Bitty, my colleague who taught me clinical medicine, a great clinician. Lou Kohn who was around last night and Shavad Hekmat, Bob Replogel, reps in the back there who let me work in his lab as a medical student. Taught me how to operate on hearts, working in a sheep model. The late John Altman, the late George Block. I mean, these were the clinical mentors that I grew up with. So I thank all of them, all of you, my four beautiful children, Dillon and Allison and I see Richard over there and Jessica. But enough about the past. We've had a good 20 year run of conferences, 24, 23 and a half, 24 year run of the center. I wanna spend my final five minutes between me and your first glass of wine, your celebratory wine, to tell you about some visions for the future, things that excite me enormously. First of all, you've heard from several people about the vision for surgical ethics. We are committed to becoming and continuing as one of the great centers in the world in surgical ethics. I'm counting on Ira Kodner and Washington University to join us in this effort. I'm hoping that Rick Kodish at the Cleveland Clinic is gonna come along. But we are going to make sure that surgical ethics becomes a legitimate part of the entire ethics firmament. And it's timely and it's appropriate. Second, you know that we are one of 25 or 26 great institutions in this country to have won a Clinical Translational Science Award, the CTSA Award. There will be at least one more round. This is the effort to translate scientific discoveries, not just stage one from the bench to the bedside, but stage two from the clinical arena to the community. And we are fortunate in that Laney Ross, one of the associate directors of the ethics center. So far as we know, is the only ethicist in the country who's currently co-directing one of these 26 programs. So Laney, congratulations on that. I agree. And Ira, I have a message for that provost or vice chancellor who said we want you to keep operating. In the last month or so, under the guidance of this great transplant group, you heard some of their roots and foundations today in several of the discussions, especially Dr. Hanlon's discussion. Juliana Testa, raise your hand, Juliana. Mike Millis, the chief of transplant. Wait, let me tell you what we're doing. We have come up, Juliana has taken the lead, and we have come up with an idea that has the potential. If we can answer satisfactorily the proper ethical questions and clinical concerns, has the possibility of solving the worldwide shortage of abdominal organs for transplantation? Kidneys, livers, intestines, and pancreas. I can't take the time to give you the whole plan, but the concept is simple. It's simple but problematic with a lot of difficulties. Is Megan Crowley-Mitoka still with us? Megan is the anthropologist who'll be working on the project. The concept is simple. Living donors have been the one group in the United States and in Western Europe and of course in Asia who have been on the rise to try to meet the tremendous discrepancy between the need for organs and the supply of organs. And that gap exists in all countries around the world, in Africa, in Asia, in Europe, and in the United States. And the use of living donors has traditionally been the use of family donors, parents to children, husbands to wives, emotional relationships, or children to, dull children to parents. And has used the healthy person as the primary donor. The person, if you look at your next door neighbor here in the audience, who is perfectly well, healthy, and without a medical problem. The idea, the concept would be to instead of using healthy donors to rather approach patients, surgical patients who have agreed and who need elective abdominal laparoscopic surgery. There are at least a million and a half such patients a year in the United States. 900,000 elective gallbladders, 200,000 elective hernia operations, 200,000 gastric bypasses for obesity. The patients, if you just bear with me for a moment, who have accepted elective laparoscopic surgery have essentially undertaken most of the risks of being a living donor, which is to say, the primary risks are undergoing surgery, being a surgical patient, and secondly, undergoing general anesthesia. If those two are your two major risks, and they have in fact proved to be the major risks of morbidity and death in living donors for 50 years, then the slight marginal increment in going for an organ like a kidney or a portion of the liver or an intestinal segment is a small incremental difference. And indeed, if you have a million and a half elective laparoscopic operations in the United States annually, you don't need a million and a half donors. Indeed, you could get by with three to 5% of that population being willing to serve as altruistic volunteer donors. Now the ethical issues are huge because it's a vulnerable population. That is, it's not the healthy person off the street, but it's a person who's already been defined as ill by virtue of the fact that they need elective abdominal surgery. And can that be done in a non-coercive, voluntary, ethical way? For that matter, will surgeons, the surgeons who are ready to perform an elective gallbladder operation permit their patients to be approached, let alone used as a potential donor, will payers consider the idea, having agreed to pay for a gallbladder operation, will they agree now to pay for a left lateral segmentectomy that might be used to replace, to deliver an infant or child? These are really tough questions. We intend to study them all as we did in the first procedure long before implementing this, this idea as an actual pilot program. But that is one direction in which we want to go. Another area, and this picks up on Peter's comment as he pointed to this extraordinary map, is that under the direction of Fumi Olapati, distinguished oncologist who was with us yesterday, and her husband Shola, the Dean of the University of Chicago has developed in the last three months a new program in global health. And yesterday, Fumi and her husband and I announced to our advisory board of the McLean Center that we were launching a two-year project, a really long-term project, in global health and ethics. The issues in global health and ethics, as you know, are unlimited, and in fact, sitting in the front row is Peter Singer, who with his colleague, Dr. Dar, at Toronto have served as the advisors to the Gates Foundation for their work in Africa and to many other developing countries. But priority setting in developing countries, the decisions as between malaria, TB, and AIDS, international research ethics, human rights and medicine in countries around the world, women's health issues in Asia, Africa, South America, to name just a few, are extraordinary problems, and we are committed as one of our major initiatives going forward to take on the ethical issues. In the first year of doing that, we will devote 30 of our seminar sessions that you all know to be that lunchtime seminar to bringing the best people in the world, perhaps beginning with Peter and Dr. Dar, to keynote it, people like Paul Farmer from Harvard, to Chicago, to advise us on how we should go forward in launching this extraordinary new program in ethics and global health. We'll bring them from the United States, from Canada, and to the extent that we can afford them from elsewhere in the world. Shola, Olapati, and I will develop a new course for the Fellows, a quarter-long course. We're committed to doing that, using some of you in the audience in ethics and global health. We will commit ourselves at least once a month to integrating international global health issues into our Wednesday case conference. And beginning this year, in the first year medical school course, we will have at least one session, increasing to two sessions next year, co-taught by the Olapatis and by the ethics faculty on global health and ethics. These are some of the new commitments. But I can't help but ending with the fifth commitment. And the fifth commitment comes out of long-term discussions here at the university and today during our meetings. I mean, we simply have to recommit ourselves to launch new programs in advocacy for the medically underserved. We have done this on an intermittent basis. You heard we were doing it in the late 1980s, early 1990s. That book, It Just Ain't Fair, which represented the state of knowledge in 1991, must be updated and we have to go further. It may be that we'll start this new program if we find it receptive environment with our own pediatricians here at the university because there is strong commitment in leaders of the pediatric department to say that you can do pediatric ethics unless you couple it also with pediatric advocacy. So these are five areas. Five areas that I want to point to for the future, surgical ethics, clinical science, translational program, the possibility of moving ahead in creative, innovative, dangerous ways in the organ transplant business, the global health and ethics, and then the new program in advocacy for the medically underserved. With those words, I will stop being the barrier between you and a glass of wine. Please join us tonight at the DCAM, 58th and Maryland, for the most informal, happy party that I can think of. Kids are not only invited, they're encouraged, and I want as many kids as possible, and thank you all so much for coming to this wonderful.