 Well, good morning everybody. I'm delighted that you have all been able to join us and this is obviously a very wonderful occasion. I've been enjoying the terrific discussion and now we have the opportunity to recognize Mark Siegler as the recipient of the McLean Center Prize in Clinical Medical Ethics for 2020. So this is a recognition not just for Mark but also for the Center and for the leadership that Mark has provided for the Center and the leadership that the Center has provided in the field of clinical medical ethics. Mark, as you know, is a professor in the Department of Medicine at the University of Chicago. He is the Linda Bergman Professor and he became the founding director of the McLean Center in 1984. The Center was started with support from the late Dorothy Jean McLean, a generous philanthropist and grateful patient of Dr. Siegler's and after Dorothy Jean's passing some years later, her son Barry and his late wife, Mary Ann McLean, continued to support the Center which was very successful in raising additional foundation and philanthropic support. And under Mark's leadership the Center has had a profound impact on the role of clinical medical ethics in the practice of medicine, not just at the University of Chicago but nationally and internationally and notable accomplishments include the following. So I think that Mark and the Center really pioneered, named and then developed this concept of a clinical field of medical ethics that transformed what was prior to that sort of theoretical non-clinical work of bioethicists, obviously very substantial work, into applications for clinical practice that are now used broadly by practicing physicians. Clinical medical ethics aims as we all know to improve the clinical and ethical quality of care and should be practiced routinely by clinicians in their daily encounters with patients. And I think that in significant measure Mark made a disproportionate contribution and the McLean Center made a disproportionate contribution. I think that this is you know something that is broadly achieved across many clinical fields. Now in addition to that the Center with Mark as the leader developed practical clinical medical ethics guidelines on issues such as truth-telling, informed consent, confidentiality, shared decision making and end-of-life care. These guidelines have made important contributions to the current legal and professional standard of care in the United States. Another really critical innovation was the extremely successful clinical medical ethics fellowship training program that since 1984 has trained more than 450 fellows and we currently have 39 additional fellows in this year's class. In recognition of this Dr. Siegler recently received the Harvey M. Meyerhoff leadership in bioethics award from Johns Hopkins University and the award stated the fellowship training program established by the McLean Center has had a greater impact than any other clinical ethics program in the world. And the impact is obviously enormous because many of the former fellows and many of you are on this call today and faculty are leaders of ethics programs worldwide and have contributed more than 200 books and thousands of peer-reviewed journal publications. Currently fellow service directors of clinical ethics programs in the US, Canada, South America, Europe, the Middle East, Africa, Australia and China. In 2013 the McLean Center received the prestigious Cornerstone award from the American Society for Bioethics and Humanities for outstanding contributions from an institution that has helped shape the direction of the field of bioethics. Now in addition to that Mark pioneered the development of an ethics consultation service and since 1984 in our hospital this service has advised our physicians on about 3,000 complicated cases involving difficult ethical issues. In addition the center and Mark have been at the forefront of the field of surgical ethics in close cooperation with the American College of Surgeons and serves on the Ethics Committee of the American College of Surgeons from 1993 until the present time. Mark also established this conference, the McLean Conference, more recently the annual McLean Center Prize, the annual McLean Lecture Series and the unparalleled 80 lecture summer intensive course. So these educational programs have allowed us to invite former fellows and leading scholars to visit the University of Chicago and to recognize their vitally important contributions to the field of clinical medical ethics. Mark has written more than 300 journal articles and book chapters and eight books and his textbook co-authored with Al Johnson and William Winslade Clinical Ethics, a practical approach to ethical decisions in clinical medicine was originally published in 1982. It's currently in its eighth edition and has been translated into 11 languages and a ninth edition is in the works. Mark was elected master of the American College of Physicians and is an outstanding physician and teacher who's taken care of countless members of our faculty, staff, members of our boards of trustees and we're truly fortunate to have benefited from such a visionary physician as a member of our faculty who not only has had an impact on direct administration of patient care but also in his contribution to this field of clinical medical ethics. Among Mark's distinguished awards are a lifetime achievement award from the American Society of Bioethics and Humanities and the distinguished educator and mentor award from the University of Chicago Medicine and Biological Sciences Division. He was chosen to serve as a member of Princeton Board of Trustees. So please join me in recognizing and congratulating Dr. Siegler on his extraordinary accomplishments and in thanking him for his many contributions not just to the university but to American and international medicine and for the impact that he has had on this field and on the careers of so many of us who are here today. So congratulations Mark it's a great pleasure to be here to welcome you to this virtual podium and we are looking forward to your remarks. Congratulations. I can't thank you enough. In fact you've said so many wonderful things that I could just skip my talk right now and conclude our meeting but I thank you for honoring me with this year's McLean Prize for your warm and kind introduction. All of us are deeply grateful for your superb leadership especially in the midst of the current pandemic and also for your continued support of the McLean Center and of the field of clinical medical ethics. And John Lantos who is the Associate Director of the McLean Center for almost 20 years. I earlier was deeply moved by your praise of the work that I've been trying to do during the 50 years of my career and the 36 or 37 years that I've directed the McLean Center. Good morning to everyone. I'm thrilled to be with you all although this is the first McLean conference in 32 years to be a virtual one. I'm enormously proud and humbled to contemplate the amazing community of clinicians and scholars and board members that make up our McLean Center. I want to express my deep thanks to Kimberly Connor, Yolanda Yu and Renana Dine for their invaluable assistance throughout the year and for helping to organize this weekend's virtual conference. Yolanda you have a future in video production. You work tirelessly along with the video producer Eric Lindholm and with his company Vantage AV. In accepting the McLean Prize I must thank all of you. Dean Polanski, Barry McLean, Rachel Kohler, the McLean Center faculty colleagues and especially my dedicated associate and assistant directors of the Center and the more than 500 current fellows. Or maybe as Ken says it's 450 plus 39, almost 500 fellows but today we have helped to create and build the field of clinical medical ethics. That field would not exist today without clinicians who over the past 50 years have embraced the central principle of clinical medical ethics which is here is the central principle that every routine encounter between a doctor and a patient involves practical, clinical, ethical issues. Kenneth mentioned most of them. There are many such issues like truth telling, informed consent, confidentiality, surrogate decision making, the risks, benefits and alternatives to surgical and medical procedures and sadly end of life care. As clinical medical ethicists we are committed to personal humane and compassionate care through active listening and communication and mutual respect between the doctor and the patient. I'm deeply proud of the way clinical medical ethics has helped change and strengthen clinical medicine in the United States and how clinical medical ethics has improved the clinical and ethical quality of care and patient outcomes. Today I'm going to discuss four topics during my talk. The first is the origin of the field of clinical medical ethics. The second is the goal and methods of clinical medical ethics. The third is the contribution of the McLean Center at the university in extending the field of clinical medical ethics and finally fourth how the field of clinical medical ethics has improved all fields of medical practice, medicine, surgery, pediatrics, obstetrics and gynecology, psychiatry and others. Let me begin with the first part. What were the origins of clinical medical ethics? In 1972 when I joined the University of Chicago faculty the chair of medicine Dr. Al Tarloff asked me if I would establish and direct our hospital's first medical intensive care unit, a MICU. In those days there were very few MICUs in Chicago or in the country largely because there were very few effective ventilators and the specialty of critical care medicine did not yet exist. In fact the first American board of certification exam in critical care medicine did not occur until 1987, 15 years after we had opened our MICU. In time MICUs became one of the great medical and technological advances that saved and prolonged lives and in the process of intensive care raised new and unaddressed ethical questions that clinicians had never before encountered. Serving as the only MICU attending and I served for 12 months of the year from 1972 to 1977 changed my career directions. Let me explain that. Our seven bed MICU received the sickest adult patients in the hospital. We didn't have the effective volume vents that we have these days. Our mortality rate was over 60%. Each day my team and I confronted ethical issues such as how to allocate our limited number of beds, how to negotiate informed consent, when to seek surrogate consent, how to decide whether or not it was ethically acceptable to withdraw a treatment after we had started it and how to communicate a truthful often painful prognosis to the patient or to the family. My previous training in medicine had not prepared me for this problem, problems that arose every day in the MICU. Faced with these complicated situations my house staff and students and I discovered that there was no easy place to turn to to find answers to these kinds of difficult questions on behalf of patients and families and of the medical team. The medical literature and textbook did not discuss these matters. There was a new literature in biomedical ethics that had started around 1965. This body of bioethics scholarship was written largely by brilliant non-clinician bioethicists, that is by philosophers, theologians, legal scholars, social scientists. Bioethics literature and the theoretical language of bioethics rarely focused on or addressed the practical concerns that clinicians generally faced or the specific concerns that we faced in the MICU, our students, residents, nurses and attendings while caring for critically ill patients. Bioethical theory in those days was rarely applied clinically to resolve the practical dilemmas clinicians faced in caring for patients. One frequent clinical ethical challenge in our seven bed MICU involved when if ever was it clinically and ethically appropriate to move a patient who was already in the MICU out of the unit because a new patient had a better chance of benefiting and surviving. Because MICUs was so new at the time, there was little advanced clinical guidance for such daily clinical ethical challenges. Furthermore, in the early 1970s, very few clinicians were even aware of the bioethics movement that as I say had begun seven or eight years earlier in 1965. At that time in 1972, I first realized that if we were to improve the care of patients, not only MICU patients, but throughout the hospital and even in outpatient care, it was essential that doctors, nurses, other health professionals, patients and families become more closely involved in discussions about these new and difficult clinical and ethical questions. In addition to caring for patients, which I now have done for 53 years since I started my internship in 1967, I also committed myself around 1972 to devote my academic career to develop and expand the field of clinical medical ethics. In the 1970s, I was awarded the earliest NIH award in clinical ethics, a grant application I wrote. I wrote the first paper in a medical journal JAMA under the title of clinical ethics and became the first AMA editor of a section of a journal in the archives of internal medicine on clinical ethics. I came to realize throughout the 70s that clinical medical ethics should not be an elective area of study for physicians, surgeons, nurses, and other health professionals. Rather, it was an essential field that clinicians had to learn in order to practice good medicine. The central point I'm trying to make here is that not only intensive care unit physicians, but physicians in general encounter clinical ethical issues in their everyday routine care of patients and that dealing with these clinical ethical issues is an intrinsic, even an essential part of reaching clinical decisions and providing good clinical care. And I realized that clinical medical ethics was far more aligned to clinical practice than it was in those days to bioethics theory. For this reason, it was imperative that we create, develop, and expand the new field of clinical medical ethics, a field that assisted practicing clinicians who cared for patients and who made clinical ethical decisions every day in their ordinary practice. The second section I'll talk about is what are the goals and methods of clinical medical ethics? The doctor-patient relationship, as you know, is at the heart of clinical medical ethics. Its central focus is individual patient-physician decision making. Clinical medical ethics helps patients and their families, helps physicians and other health professionals reach good decisions by taking into account the four factors that we call the four box model in the book that Ken referred to. This was the book, Clinical Ethics, that I and my co-authors Al Johnson and William Winslade first published in 1982. The four box model examined the elements that go into sound clinical decision making and we thought in order of importance. First, the medical details and facts of the situation, including the differential diagnosis, the proposed diagnostic and therapeutic interventions, alternative possibilities, and treatment choices. Secondly, we took into account the patient's personal preferences regarding the medical details of the situation and the patient's values in reaching decisions about diagnostic approaches, therapeutic management, and overall their patient care. Third, we emphasized an awareness and commitment to address and improve the patient's quality of life. And fourth and finally, we had sensitivity to what we called external ethical considerations, things that included family wishes, financial concerns, limited resources such as organs for transplantation, and these days ICU beds for COVID-19 patients, legal rules, and importantly the research and teaching activities that take place in academic institutions. These four basic elements of clinical ethical decision making demonstrate that in contrast to theoretical bioethics, clinical medical ethics must be practiced and applied every day by licensed clinicians. As we stated in 1982 in the introduction to our book, Clinical Ethics, right near the beginning and I quote here, clinical ethics is inextricably linked to the physician's primary task, deciding on and carrying out the best clinical care for a particular patient in a particular set of circumstances, end quote. At this point, I'm going to digress to say a few words about how ethics consultations are only a limited part of the much larger field of clinical medical ethics. Beginning in the mid-1970s, the University of Chicago medical faculty helped to pioneer the development of ethics consultations to assist patients and families, physicians, and other members of the health team. Medical Center faculty and fellows wrote a large part of the early literature on clinical ethics consultations which included the first book on the topic of ethics consultations written by John Lapuma and David Sheedemeyer who spoke wonderfully at yesterday's conference. Since 1986, there was a famous conference held in Washington DC that included 70 non-clinician bioethicists and only six clinicians. That conference created an organization called the Society for Bioethics Consultation and claimed that the core of clinical medical ethics was performing ethics consultations. The Society for Bioethics Consultation joined the ASBH, the American Society for Bioethics and Humanities, 12 years later in 1998 and extended its view that non-clinician bioethicists should be the ones who did the majority of inpatient ethics consultations. This has actually turned out to be the case nationally. I strongly disagreed from the beginning with the view that clinical medical ethics was primarily ethics consultations done either by clinical ethicists or by non-clinician bioethicists. This perspective would be like suggesting that the core of cardiology or oncology or other medical disciplines resided principally in the consultations they did. Obviously, that's not the case. Clinical fields like oncology, cardiology, and for that matter clinical medical ethics are much larger and provide far more care than the limited number of consultations they provide. But let's consider just for a moment ethics consultations. Each year there are probably fewer than 25 to 30,000 ethics consults in the United States. That is, those who receive an ethics consultation, I want you to listen to this, make up fewer than one tenth of one percent of the 40 million inpatients cared for each year in the United States and make up virtually none of the more than 1.2 billion outpatients treated each year in the U.S. In contrast to the 25,000 or so inpatients and families who receive wonderful ethics consultations, as I say most of them perform by bioethicists, these days essentially all 40 million inpatients and all 1.2 billion outpatients routinely benefit from the application of our clinical medical ethics standards in their everyday care. The third section I'm going to talk about is how the McLean Center has contributed at the University of Chicago to developing the fields of clinical medical ethics. As discussed previously, beginning in 1972, my colleagues and I here at the University created, named, developed, and led the new field of clinical medical ethics. But during the past 36 years, the McLean Center for Clinical Medical Ethics has been a crucial program in advancing the field of clinical medical ethics in many important ways. Today I'm just going to mention four of them, Ken alluded to two or three already, but there are even more than these four. First of all, we established clinical ethics fellowship training. Second, we developed the new field of surgical ethics. Third, we strengthened the doctor-patient relationship by introducing the concept of shared decision making. And fourth, we changed ethics research from analytic research to empirical research. Let me start with the first point, and Ken has said much of this already. We established clinical ethics fellowship training as the oldest, largest, and we believe the most successful clinical ethics fellowship program in the world. And since beginning that fellowship program in 1984, we've trained close to 500 fellows, including almost 400 physicians. Graduates of the McLean fellowship have served as directors of more than 45 ethics programs in the United States, Canada, South America, Europe, the Middle East, Africa, Australia, South Korea, and China. McLean Center fellowship graduates have held faculty appointments in more than 70 university programs. More than 25 of our fellowship graduates have held endowed university professorships. McLean Center former fellows have written more than 200 books and an untold thousands of peer-reviewed journal publications. Many of the graduates of our ethics fellowship program are leaders, scholars, and mentors, including most of the speakers at this year's McLean conference, and they advance empirical scholarship in clinical medical ethics and are dedicated to strengthening the doctor-patient relationship and to improving patient care. Ken quoted the Johns Hopkins Institute presentation of the award to the McLean Center that stated, and I'm going to repeat Ken's quote, the training programs established by the McLean Center have had a greater impact than any other clinical ethics training program in the world, end quote. Second, we developed the new field of surgical ethics after working in close association for 20 years with fabulous pediatric leaders like John Lantos and Laney Ross and Rick Kodish and many many others, and with medical leaders like Steve Miles, who was the associate director with me for the first three or four years at the McLean Center, Susan Toll, Peter Singer, and many of the speakers at the conference and leaders in psychiatry like Laura Roberts and leaders in many other fields, the McLean Center began working in close association with the American College of Surgeons which had not seen a high degree of ethics participation. The McLean Center has led a national effort to train surgeons in clinical surgical ethics and to encourage research on topics related to surgical ethics. During the past 14 years under the guidance of Dr. Peter Angelos, who is widely regarded as the leading surgical ethicist in the United States, the McLean Center has trained more than 85 surgeons in the new field of surgical ethics. The goal of the surgical ethics program is to prepare surgeons for academic careers that combine clinical surgery with scholarly studies in surgical clinical ethics. Graduates of the McLean Center's surgical ethics training program currently work in more than 40 U.S. universities in surgery departments. Since 2016, the McLean Center has sponsored a joint surgical ethics fellowship program with the American College of Surgeons, a program that has now trained 15 surgeons from institutions including Harvard, the University of Michigan, Stanford, UCLA, Duke, the University of Alabama in Birmingham, the University of Wisconsin in Madison, the University of North Carolina, Case Western University, and the University of Colorado. Also, under the auspices of the American College of Surgeons, a new textbook on surgical ethics was published in 2018 with Peter Angelos's co-editor. Interestingly, McLean Center faculty and former fellows contributed 60% of the chapters in that book on surgical ethics. A new book under preparation entitled Difficult Decisions in Surgical Ethics will be published in 2021 and is co-edited by three of our former McLean fellows, doctors Vassil, Locknia, Peggy Kelly, and Peter Angelos. The third point I want to make is that we strengthen the doctor-patient relationship by helping to introduce the concept of shared decision-making. The model of shared decision-making between patient and physician stands in contrast to the two famous earlier models. That is, the model of physician paternalism, the doctor knows best, which had existed for thousands of years and the more recent model of patient autonomy, which prevailed from the late 1950s to the mid-1980s. In the 1982 report by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical Research, the President's Commission repeatedly cited a paper that I had given two years before and published in 1981 on the doctor-patient accommodation. The President's Commission stated in its report, and here I quote, the Commission's view is intended to encompass a multitude of different realities, each one shaped by the particular medical encounter and each one subject to change, as the participants move toward Siegler's patient-physician accommodation through the process of shared decision-making. End quote. Shared decision-making has emerged as the essential model and method of the doctor-patient relationship, a method favored in several studies by 75% of patients and 80% of physicians. Believe me, this was not the case before the early 1980s. Shared decision-making reflects both the doctor's moral obligation to respect patient autonomy and at the same time to use the doctor's medical knowledge to help improve the decision-making process for the doctor's patients. And fourth, we changed ethics research from analytic research to empirical research. As Dr. Laura Roberts stated yesterday in her talk on moral injury and academic medicine, the McLean Center played a key role in advancing the empirical turn in medical ethics scholarship. Many of the talks at this conference support this empirical approach to research. Think of the last conference that we just heard on pediatric ethics and the people who presented it. This turn refers to the application of the techniques of clinical epidemiology, health services research, decision sciences, and database clinical outcomes to the study of ethical matters in clinical practice. Previously, ethics research had relied heavily on non-databased analytic scholarship done by brilliant philosophers, theologians, and legal scholars. Such research had less impact on modifying clinical practice than did empirical, data-driven clinical studies. And let me turn to the fourth and final point of my paper, how clinical medical ethics has changed and improved the practice of medicine in the United States. To recapitulate, in the 1960s and 70s, the early development of biomedical ethics in the U.S. was led by brilliant non-physician bioethicists. As I said, theologians, philosophers, humanists, legal scholars, social scientists, physicians, and other clinicians had remarkably minimal involvement in that development. And the impact of biomedical ethics in its early decade and beyond on medical practice and medical education was extremely limited. Clinical medical ethics, by contrast, has succeeded in changing and improving medicine in crucial ways. In contrast to the 1970s, physicians are practicing clinical ethics every day when they tell patients the truth, when they break bad news, when they negotiate informed consent for a procedure or a medication, or when they make decisions based on shared decision making, or when they decide that a patient lacks decisional capacity and turn instead to a surrogate decision maker, these and other clinical ethical considerations have become so much a part of daily routine medical practice that they've become widely accepted, frankly, as the legal and professional standard of care in our country. While very few U.S. physicians today are formally trained as clinical ethicists, all physicians regularly apply clinical medical ethics approaches in their ordinary daily work with patients. I'd go so far to say that these days clinicians can't practice good medicine, medicine that meets the U.S. standard of care, technically competent and ethically appropriate medicine without some knowledge of and ability to apply the core principles of clinical medical ethics. Since 1972, the changes brought by clinical medical ethics to medicine have been profound and have occurred without fanfare or drama. In contrast to the 70s, today almost every medical organization has a code of ethics and an ethics committee. Similarly, every large hospital 200 beds or more is required by the Joint Commission to have a mechanism, usually either a hospital ethics committee or an ethics consultation service to resolve complex clinical ethics problems on inpatients when they occur. Publications on clinical ethics appear regularly in medical journals that are widely read by clinicians. Most importantly, in contrast to the 1970s, clinical medical ethics discussions have become a part of everyday clinical discourse and of routine clinical decisions in outpatient and inpatient settings across the country. This transition was critical in clinical medicine. The physician has the special knowledge as well as the legal and professional responsibility to assist patients in curing or caring for their illness and to assist patients in dealing with the fear, pain, and suffering that often accompany ill health. Physicians and nurses are licensed by the state and are professionally, legally, and personally accountable to the patient if they fail to adequately integrate clinical ethics into their care and management of patients. The field of clinical medical ethics is now almost 50 years old and has helped to improve medicine, medical practice, and patient outcomes. As we look toward the future and recognize the emerging challenges to humane, compassionate, and personalized care, I remain confident that clinical medical ethics will remain a central focus in defending and improving clinical medical practice for the benefit of patients and of their families. Thank you for listening to me and before I say goodbye, I'd just like to take a moment before we break to thank my wife for her love and support and brilliance and to give her a chance to say hello while we're on live with you. Rich Kodish said we often depend enormously on our spouses to help us make decisions. Anna. It's wonderful to be with you virtually for this year's conference and yet I'm so sad that this pandemic keeps us from gathering in real life. Truly, these are bittersweet times. Seeing many of you on screen has been a joy, our brilliant speakers and moderators, but I miss seeing everyone, everyone in the audience, friends from over the years and over the decades. I miss the opportunity to gather for conversation during the breaks when we could hug and greet each other and catch up on family news and activities. Mark and I send our virtual hugs and love to all of you. All of you are part of the McLean Center family and very important people in our lives. We pray for your safety and for better times. Thank you, Anna. We'll take a break now and reconvene at 11.10. The final panel of the morning will be a powerful panel on surgical ethics moderated by Dr. Peter Angelo's. We look forward to having you join us again as we resume the day's presentations between 11.10 and 11.15. Thank you all so much. Bye-bye. And Ken Polanski, thank you for this fantastic award. It means so much to me. Thank you.