 So I'm Bob Trug and I'm the director of our center for bioethics here at the medical school And I thought I'd give maybe just a little bit more orientation to what's happening here As many of you know, we've done public ethics forums for years on a regular basis And in a sense, this is one of those But it's also more than that in that this year we started a master's degree program And we have 22 full-time and part-time students And one of the courses that is being offered is contemporary books in bioethics And so as part of that we're inviting four prominent authors This semester to come and give a public forum but also talk about Their their book and so for those master students who are enrolled in this course They've had the opportunity to read Dan's book in search of the good from 2012 The class has already met for a couple of hours to discuss the book We have the session this evening and then tomorrow Dan will be meeting with the students again For a post presentation discussion and further exploration of the work Just for curiosity, we have our fellows here We've had a fellowship program since about 1990 under Millie Solomon Our new master's degree program Maybe if you're a part of either of those programs could you raise your hand and you could get a look Oh, this is fabulous And you know, so these are all people who are interested in really Acquiring a much greater depth of knowledge in the field of bioethics and we're very excited about that To say a word about Dan The book in search of the good is a memoir And it really is an account of a career in bioethics But it's really much more than a memoir because Dan's career really Coincides with the field of bioethics as one of those who who really founded the field And so in the book he talks about really the whole range of ethical issues that the field has been concerned with For the past 50 years or so And so when you read the book you get to know a lot more about Dan But you also get to learn quite a bit about bioethics Then also spend some time talking about his experience at Harvard in a Somewhat less than positive way And I thought I thought I would mention it. It's obviously no secret But Dan got his PhD in philosophy at Harvard and as he writes in the book he was disillusioned By the total absence of interest in how we should shape and live our lives And I thought that there was one telling moment in the book where he describes How a philosopher that he admired was criticized by somebody here at Harvard Who commented that this person was a very good philosopher Until he got interested in wisdom And Dan quipped that no one on the Harvard faculty of my student error could have era could have been accused of that error And so without telling any of his mentors in the philosophy department He went over to the divinity school to see if they had something better to offer And here I thought his observation was also very interesting. He wrote I thought that the theologians had all the interesting questions about life But no methodology of any great value in answering them And that the philosophers had great methodologies to answer uninteresting questions So you can imagine why Dan ended up leaving academia to found the Hastings Center And he became really one of the most prominent secular thinkers in the field And I liked his comment about wisdom and about the importance of wisdom and he writes that In his view the idea of wisdom means taking account of the full range of human knowledge and experience history the physical and social sciences Religion philosophy literature and cultural studies among others And I think that really is a wonderful summary of of his approach to the field and also the success of his career So Dan, thank you for coming. We're really looking forward to your reflections This evening about the past present and future of bioethics and And are so grateful that you were able to make the time in the effort to come and visit us Thank you very much This is actually 50th anniversary of my phd Which seems like a long long time ago My wife and I just love coming back to Cambridge remember what life was like in the old days and it was a very much quieter Place than is now the situation at Harvard's a very busy place Harvard Square has totally changed Had one restaurant nowadays and that was it where you took your parents when they came to visit And now it's really blossom. Of course, there was no such thing as bioethics and not not surely no interest or Possibility of interest within the philosophy department I came to Harvard in great part because I had been a swimmer in college. I was on the Yale swimming team I swam middle distance All my teammates were breaking world records. I was not breaking world records I was invited. I swam the Yale Harvard swimming meet up here In Hemingway gym, I think and there were 2,000 people showed up Uh, and I swam the 420 yard 440 So it was in yards in those days and was asked to uh When I stood up at this block you stand up awaiting And I was they announced my and they announced my name and everybody booed Oh, I said, um, what's going on and and anyway, I got stopped After one hour said they came here to speed it Here see the people breaking the world records Not me that were bluing the fact that they put me in and I remember saying my god, I'll show them and they came in last so But I I said that I learned by swimming with world-class people whom I could never Never beat up doing in anything that what was like to lose And it's a very good lesson to learn how to lose And I really found what you have to do is you start competing against yourself I couldn't beat any other people so I only could beat me And I quit swimming because by the time I was my junior year my times were going backwards and I said, okay Well, what else is going on at college and uh, so here we are Let me the way I want to get at the today I'm going to give you my This is a by grandiose vision of the future of bioethics sort of working up to it very gradually break it down into very various components And see if it's it is I don't totally have this totally straight in my own head, but uh, I will at least See if I can make some sense of it in a way that will make sense to you Uh, I think I'd want to talk firstly about different levels of analysis in bioethics But I have a cobalt philosophical intellectual level Where are you really asking what what is it? What is bioethics as a discipline or a particular way of thinking about the world and healthcare What what what do we mean by the field and what what do we think is the scope of the field secondly? What is the sociological level namely where does bioethics fit into the other forms of human knowledge and pursuit of wisdom even if you will What is our status? and and finally What is what is the place of bioethics in the world of medicine and health policy? Now I think each of those levels is important and rather different and let me say a little bit about the Way we fit into the medical and policy world I think there again different levels. There's a clinic the clinical level Where you really talk about patient care and doctor-patient relationships and things of that sort the research level where you try to Think about the new medical technologies coming along how to assess them how to regulate them how to think about them And then finally the level of health policy Where you ask how we don't organize the health care system in a way to serve the goals of medicine and to do so in a sensible and fair and affordable way now All of those those are different levels. They interact with each other, of course But but I think most of us in the field usually pick one or the other We specialize or more interested in one rather than the other, but but they all come together and finally A question I found very interesting goes back to my philosophical days What kind of a person should you be to do bioethics? Well Now I found there was no the surest way of getting an argument going among my fellow For students at my harbor days was to say do you have to be a good person to do think about good ethics? The unanimous answer was absolutely not no Thinking about ethics is this is the day of analytic philosophy to be good in ethics was to be be smart quick on your feet Very good with a counter argument. It was very much a game of Like chess you're moving around the kind of person you are was absolutely irrelevant You could be an absolute rat and have all sorts of wonderful good things to say Uh, I think that may be true in some areas of of medicine health care But by and large, I do think it matters what kind of a person you are and they said to be What even philosophy called virtue ethics has been very fundamental. How can you think about ethics at all? Unless you're also thinking about what it is to be a person living living a good life and fitting that in um Now the overarching question which really grew on me this year when all on this To really ask A very basic question as about this the whole enterprise of bioethics But to ask questions about the enterprise of bioethics is overly to ask What in the world is medicine and health care? What are they all about? Uh, how do we how should we understand the health care system? How should we understand the? Goals of medicine historically and uh contemporarily And what ought to be the goals of medicine? I've sometimes been called the father of bioethics And and I and I thought well, I'll play that line out a little bit and say think of one as the father First of all, you could have debates about are you really the father? You know a lot of other people They think there's other claims That that there are other other fathers there and have you really can you really be sure about the That particular background, uh And by and large then the question is what what do you who are the who are your siblings in this field? Who are you working with? How do you bring people together who work in this the kind of collectivity like a family? And what did you aspire with with the children in your family? and So from there one one can really have a sort of interesting If you were metaphor on thinking about a field and thinking about life in short How do you want your children to turn out? What kind of an atmosphere do you want to create for your children? What kind of outside influences ought you to watch out for when you're as your children are going up and stop them from getting influenced by them? All of that works pretty well in thinking about bioethics as a matter of fact now Let me very quickly skim some other things which Build up on this picture Let me say something about the bioethics as a field and as a discipline First of all, most of you know the The long predecessor back going all the way back to Hippocrates But for the most part after the greek era Ethics Medical ethics was in the hands mainly of various religious groups all the religious traditions Thought about the ethical problems of health care and not of health care so much but of medicine And it really was not until the 1960s I think that the field that's the more secular field of bioethics began to emerge and that field Emerged in great part because of the advances in medicine during and after the second world war unfortunately large wars Do terrible kill and do kill people and do terrible things to people They also are a great way to generate lots of new knowledge And of course one of the great advances during and after the war was the development of the NIH in this country Which is a kind of symbol of all the commitment in this country to the whole medical enterprise And bioethics came along in great part Because of the Enormous developments particularly technological you had IVF organ transplants contraceptive pills end of life care shifting doctor patient relationships medicine as a Market economy the comp commodity genetic engineering And and all sorts of research Dilemmas of one kind or another as well as the problems of human subject research So you had a whole bunch of things suddenly coming into the pipeline so to speak or into into the family system Very rapidly and people began to say my gosh, you know, these are raising raising some interesting questions Uh, and the Hastings I did the Hastings center Which I say well, I think we weren't the first in the field were various individuals interested But we institutionalized the field we created an institution and that's the way we've heard it Uh, I was founded by a colleague of mine will willard gaolin and neighbor and Hastings on Hudson, New York a psychiatrist psychoanalyst uh And he was just a person who brought few professional articles but wrote on every other possible social subject And it was the perfect partner for me. It was a natural hustler like me. We were both We had never raised any money and we had to learn how to do that much less start us a center We had to learn how to do that too. Although we did discover at the time that the uh, early 70s In late 60s was a big time for starting think tanks all over the place Somebody did a doctoral research in sociology on think tanks and there was all there we were As I say, you know, we thought we were doing something new. We're saying doing something new as like all the others are doing something new um Now what was sort of interesting is when we began uh There really was a mixed reaction to the field There were a number of people I would say one of the main interests came from a group of scientists In the 1960s who really asked the question. Where are Where's that where all of these medical advances going to take us in particularly interested in the biological question and genetic possibilities? And it was not people from the humanities much less religion or philosophy But he came from a group of scientists who held a number of conferences that I heard about those I got interested and uh Hung it was hanging head at medical libraries writing a book out of borscht and began to see the issues myself And that's why the idea came along for me Now the reaction though Among many within the field of medicine at least was uh was suspicion There was a nervousness that outsiders That yes the standard line was yes We have ethical problems within medicine, but we sure don't need people like philosophers and lawyers meddling in In in medicine And secondly it was a time when many of the physicians were sort of uh very much in the throes of behaviorism in psychology Emotivism for those who have a philosopher Namely that ethics is nothing but the expression of emotions. That's about the end of it So there was no substance those substances to feel but but in effect uh saying that that There should be no if there are ethical problems there should be no outsiders Fortunately, there were a number of scientists and others who thought you needed outsiders These were public matters and they needed a broad wide discussion And and it occurred to me over the years that ethics is a kind of odd field where they've had Something like six or seven national commissions on on bioethics Most of which all of which have had only a minority of pedestrians are people with trained in ethics Otherwise, they're just generally smart people from a variety of backgrounds They're being an assumption Which I think is quite correct that anybody recently tells and willing to read and think can can make Have something useful to say about matters of ethics in the great part because we all have to make ethical decisions in our old life And people can understand this and in a peculiar way Uh an awful lot of really good ethics comes down to it seems to sort of good old common sense Somebody's got it knows how to sort of think straight as a really decent person trying to think things through And then you can get a very Fairly good number of people of citizens together and probably make some progress with these issues Now it's very striking. Some of you may know the name of steven pinker one of your more celebrated notoriously celebrated Harvard faculty colleagues Who wrote an article a clop headpiece that's a long ago in the boston globe Of saying ethicists get out of the way because a group of ethicists raise some questions about a debate in human subject research And basically the story was this this ethics crowd is just screwing up medicine and research and they should stop bothering us I thought well, that's wonderful. That's just like the old good old days Anyway, and I and interesting about the same time of various conservative women sally satel attack bioethics So we're getting it from the left from thinker and this woman satel from the right. I said Well, that usually that's taking me a pretty good sign if everybody if nobody likes she's probably they're probably doing something right So I would say the next fundamental question we had to think about is what is indeed is bioethics And and what fields should have the dominance? And there were a variety there were two main contenders early in the late in the 60s early in the 70s one was a number of People from them in medicine argued that medicine medical ethics. It was called medical ethics not bioethics Should be built on the traditions of medicine itself It should come from the substance of the work of the physician The other view when the philosophers began streaming in a little bit later in the 70s Was that what bioethics should be built on the basis of moral philosophy as understood within the field of moral philosophy And I would say Early on that came to be the dominant theme The great earliest struggle I had at the hasty center Was that the philosophers they came in were by and large of a very secular kind they by Had no many of them had no use whatever for religion or theologians I had to constantly say but you know some of those people of religion They're actually pretty smart and have something useful to say But a lot of them just we don't want people like that And I just had to override red conference and I said I I'm going to have I run the place that I'm going to have them That's how they got that's how they got invited But I always found that Something a mark against that attitude since one really can never know where you're going to get some wisdom from what feels But certainly there are a lot of the religion as much to say about these issues As as any sacred issues In any case it was early on decided by us others that the field had to be interdisparing No one field should be able to claim dominance And the philosophers who said this is our field or the doctors who said I feel no The very nature of the issues required a mixture of disciplines Now I think all of you know Universities a lot people in universities love to talk about interdisciplinary work Unfortunately, that's not the way universities are really run. You don't get your You usually don't get your tenure from messing around in other people's fields You get from moving good in your own on your own field and getting in the peer review journals and the like So this is for all the talk about interdisciplinary stuff. There's not that much goes on and Again and again our early days when we were in this very We would have people come from universities and they were Meeting physicians meeting lawyers who were colleagues in their own university, but they never met they said yeah People in the medical school We don't talk about the law school for god's sake, but they would have a great time at our bees just by virtue of of that possibility so it so became Anyway, it became very interdisciplinary now to me the questions that Recently began to emerge There are a variety of very specific issues. I'll mention some of them later But to me the fundamental question that kept coming out more gradually over the years Would be really asking three fundamental questions What impact will the medical and scientific developments have on the role and meaning of medicine itself? In short how all these development particularly since the Second World War were to change the way We practice medicine. We think about it. We pay for it And we make it part of our lives Secondly, what impact will these developments have on the way we think about health? I think there is a very interesting Obsession almost with health in our society these days I'm sure a number of you read the new york times If you read the science section the science section is now almost two-thirds health stuff You get some physics once in a while some chemistry, but it's more and more health And I I think that's That's interesting But also disturbing in a way as in a funny sense as health improves we spend more money on it You at the same time people get more and more obsessed obsessed with it at the same time in any case To me the interesting question is How where do we want to put health and where do we put health medicine and where do we put our own lives in this package together Now then one can move. I will next move what I call the layers of analysis um Now I think one very common way bioethics is Talked about is to talk about moral rules and principles and those of you who Are familiar with the field know that principalism the idea that they're basically four principles, which is Autonomy or respect for persons non-maleficence Justice and do no harm And those those principles Developed by philosophers have been very important in the field. I think they've been overdone They've got a lot of problems But but everybody likes to think you need rules you need principles and that serves serves They served that purpose But they what's left out by principalism is as a is excessively oriented toward autonomy On the one hand and it has nothing about what I would call virtue ethics on the other It doesn't ask what kind of a person ought you to be to If you're going to be an autonomous person making moral decisions What kind of person should you be as a patient or if you're a physician trying to make a A decision using the principles What kind of a person wants you to be in order to help someone else At what house should your autonomy be able to help somebody else's autonomy or in which or the cases where The issue fades over the patient needs not just autonomy But the patient needs paternalism and then how does that change the kind of person might be if you have to be paternalistic on occasion I've been struck also by I say by the end of the 80s that a bit very sharp division Which had reflected itself earlier in the attitude toward the theologians and in bioethics A very strong split our field is ideologically divided. It's by and large a liberal field The Hastings Center says we are nonpartisan, but anybody reading it for In three or four issues will out our journal will say Basically, this is as like this new york times. So you're written up in bioethics talk Or something of it's not quite hillary clinton sort of thing, but you know And the interesting thing with big struggles with the conservatives Because there are a number of obviously conservative by by by and large the big distinction by a larger sector That the uh, the conservatives are more in the religious fold but by and large and they tend to be rather uh A parochial and they they prefer to talk with each other rather than engage that found in the major dialogues You find them being rather separate just even in the field of bioethics and for the most part They believe that the great western traditions of whether literature history Religion that that's where you find the answer to these large bioethics questions Not in issues and principles and rules and stuff of that sort Anyway, that's been a kind of interesting struggle along the way over the years. So Now the question that It's all of the I began think trying to put all of these and deal with them day to day in the running the center was Really more and more of a concern is what exactly are the goals of medicine? What is this institutional about? Uh, and I began writing about this. I suppose but in the in the 1980s Race of money to have a project on the goals of medicine and what in people from all over the world Uh, and had a great discussions It's a publishing on the subject would and you got published in Five or six different languages the study we did a number of conferences in other countries But practically no response in this country at all to that issue Uh, because it seemed to me I would want to say what what we're trying to do here If you can't decide how you're going to handle treat patients or how you're going to treat research Unless you we're pretty clear what you're trying to do Uh, and I found the assumption was look, we know what we're supposed to do It's really if you're talking about questions of means and ends We all know what the ends are. We don't have to talk about that now It's this question of how do you get to where you want to go? I said, well, you better know where you want to go and try to understand that But I I didn't get a response in this country, which was which I found interesting and so it's made me all the more um nurses pushing to Get that question taken seriously and I I think If one asks what is the contemporary model of medicine That underlies the way we think about healthcare patient care clinical medicine policy medicine The the present model would be this may be oversimplified a death is the enemy There are always to be more and more research There's uh Things should always be better in our lives medicine can handle all problems physical and psychological and And by and large we modern medicine bought the Enlightenment model of the future Starting back in the 18th century and it's embodied it almost perfectly This always moved forward There's never there's no stopping place and And particularly in the attitude toward death despite all the talk about end of life care and Positions of suicide and stopping the enterprise as a whole Doesn't like death and wants to do something about it and it shows no sign of Stopping that at all and that's where when the you look at the research agenda The research agenda is trying to find more ways to keep people alive Whereas the clinician is trying to find more ways to have allow people to time more peacefully Then these things are not always working in the in tandem at all in any case And the thing that I was drove me all the more to ask about the question goes to medicine is that in my own interest in health policy Uh, I think it's well known in this country that we've had a it's been a financial struggle It's getting tougher and tougher is with an aging population to pay for health care Uh The projections down the road of the cost of health care are just astronomical in terms of percentage of gdp And what's interesting is I spent a lot of time in europe over the past 20 years 30 years And looking at other every health care system in the world faces this one They're all having financial problems because all have bought into the model of constant progress The problem is that constant progress costs a lot of money And in a curious way As we've gotten more and more successful in fighting off death We're finding more and more Basically, I put it this way finding more and more ways to expensively keep very sick old people alive longer and longer They may in the end go into hospice. They may in the ends. They know more But before they they they get there they can't spend an awful lot of money So when I began seeing that regardless of health health care systems are organized You can't solve that they're a problem by a managerial solution Everybody thinks that we just did the europeans. Interestingly when they're face pressures They said maybe we should go to more of a market model put them more in private hands Now, of course the other in this country have I'm take out of private hands to make it public But that many of the europeans looked at the market to solve their problem It doesn't solve their problem that justice hadn't solved our problem so they really uh Ended with the situation where I think the future of medicine itself as an enterprise Needs to be called into question And I finally wrote an article a couple of years ago where I Came in with an utterly utopian view of all of this which summed up a lot of what I've been saying here Which I talked about the concept of a sustainable medicine what we need for the future sustainable medicine here I borrow the concept from the environmental movement and by sustainable medicine. I mean a medicine that is a affordable in the long run Secondly is equitable and and thirdly has good public participation and public acceptance of willingness to to pay for And and by and large that means you need to come up with a notion of medicine itself Which has some built-in limits of one kind another what are the limits of this enterprise? And here when you get in what I call the para the the progress paradox I've often used the malice and look Pursuit of a better health is Is the same is almost the same as trying to explore outer space No matter how far you go with outer space you can still go for there's just more and more out there And I'm sure that if we got everybody living to be age 150 The doctors also be for the people say suffering my god can't you do something for me? That's the way it's going to be forever Now one might say well Maybe there are some things in life That that you will never basically win But you just do the best you can for your time and and move on and so too with medical progress I want to take to you Yes, you can do that and say yes, it'll be a lot of trouble having the progress But we need it we deserve it people are getting sick good That you every big thing of bad cases things we should spend more money on and so forth and so on And I said no, we've got to find a way us. I I believe we have to find some way to find the limit So here are some of my ingredients for finding a limit First of all Device a fresh concept of medical progress. What do we mean by progress? Is it really progress to keep a lot of old people indefinitely alive expensively or indefinitely alive? I'm very interested in the question of a life extension of there are a lot of people that they're putting them Lots of money these days and to find radical ways to extend life So well, how much how long in life do you need to have in order to have a decent life? I once set the age of around 80 I'm now 85. I think 80 is pretty good If you can make it to 80 You've probably have done most of the things you can do in a life and you ought to be satisfied I reached 85. I'm still prepared to do so But it would not it might have been a loss to my family and my wife, of course Still weeping to this day if I died at 80, but uh, but but but society would have said well Oh, Cali. I remember him. He's a nice guy. He did something to do with bioethics. Okay. What else is new? That's the way that's the way life is, unfortunately So in any case the first uh So so I I want a model of progress, which is a limited model and that's certainly what we're looking for Say with the whole debate of global warming. How do we get people to set some limits to our? Desire to have continued economic growth Can we have continued economic growth at the same time? That we're not polluting our environment and we have not figured out exactly how to do that one But nonetheless the model is there of of looking for those limits and boundaries So that's the first the first problem deal with what do you mean by progress itself? And ask that question everybody time somebody comes along with a new scheme We need money to work the brain we need money to work on possible cancer blah Ask those questions, uh Secondly set research priorities the national institutes of health spends a lot of money comes up a lot of money for research So it's the private sector I would argue we need more money on For research on prevention The research on helping people who are sick put up and live with their illness particularly the elderly Who need more home care put up lots of things that are not directly of a strictly medical kind What better conducive to health so you can you can with you can easily think of a different set of priorities and the prior one a thirdly Change health care delivery priorities. What do we want to pay for? How much do we think is ought to be spent on the young versus how or the old? And how should we deal with that question putting together a medicare program? And setting the medicare program against programs for Education childhood development of one kind or another all sorts of other social needs Change the education and the cultural racism physicians Right now I think the reality is the medical school curriculum It's heavily dominated by science and and the assumption has been that science is the way to Really get people well and to fight the great good fight against death. Well the question is uh how do you move back to A much better balance between caring for people and curing people One of the great problems end of life care is finding finding physician Ways for a physician to learn how to deal with their dying patient and not see that just just themselves as having failed because the patient is dying How do we change industry incentives? toughest thing of all Unfortunately people make a lot of money off health care in this country How do how do we change that because we love we love to make anything good can be turned into something bad When people enter the arena and decide there's there's there's profit to be made there And it's a good thing because why not? and I think one of the Main things that happened to physicians with medicare particularly as medicare began was one of the things that began seeing helping physicians Income to rise What was very very simply a change in attitude is well i'm doing good And I ought to do well That's a big interesting to see between doing good and doing well But that the idea that why shouldn't I be well paid? And I began thinking about this because I would give lectures in the 1980s and over a period of time I'd usually be picked up by the chairman of some department And I was the only that was the way I got introduction introduced to every expensive car on the market The only one I didn't see with the Rolls Royce But every other one I said that's really interesting interesting little trend, but uh, but I found a very disturbing one In any case What do we do about the market that to me is one of the is one of the big enemies. So I would end up finally The need for healthcare system. I won't make the argument here your role for me I think you need a universal healthcare system We think national defense is is good to preserve lives. Well healthcare systems are good to preserve lives too Uh, and I I think our present system The mixture of medicine market is is basically a disaster So in any case we need to And so that those are my quote solutions Now how you go at changing them? I'll leave that to you all because I've gotten too old to do that kind of thing But uh, you I've given you the blueprint just quite there Just quite there and do it Okay, thank you. That's All right, well, thank you so much Dan you've given us lots to think about and also to talk about because we have some time to do that Um and lots of people that I'm sure will have many things to say I'll go ahead and start as the moderator um You talked about uh inter interdisciplinary work And I'd like you to uh comment on whether bioethics actually is a discipline because As you brought up the people who are attracted to bioethics often come from fields That uh have a coherent methodology and a way of evaluating the quality of the work So if you're in moral philosophy, you know two moral philosophers can look at each other's work and they can say You know, this one's good. This one isn't so much same sociology anthropology you name it and There's huge value of bringing people like that together So is bioethics really just you know, the greek agora where we bring people with real disciplines To talk to each other or is it a discipline in itself? And if so then How well if you mean by a discipline, uh, a does it have a A known methodology to which you are introduced when you come into the field This is what you have to learn if you have to learn to be a physician or a psychologist or a historian There are certain things you have to learn in order to claim that you are one of one of those No, we don't I don't think there is a method and it's a bit like the old saying What's bad pornography? I think those in the field know we know we know the good stuff and we see it though We can't tell you we have no criteria. We can Show you as to just why it's good. So I think if you think The problem is disciplines are narrow and and the question is the issues are narrow So you've got to have a work across the disciplines even if you don't have a methodology And it seemed to be the old and but it seems to me Let me put it this way. I guess partly I come in with a certain vision of what philosophy ought to be all about And that is a tradition I draw from looking back the hard philosophy department in the late 19th early 20th century particularly with time era of william james Royce santiana Things were very striking in that era. First of all The the philosophers those years looked at every distance at all fields religion culture Literature history was all just for the middle to be a philosopher Secondly, they wrote for the general public and not for a professional audience And there's a wonderful book called the rise american philosophy Which is basically it turns out the history of the harvard philosophy department And the history shows it's a beginning in that very broad way Particularly james went moved back and forth between philosophy and psychology Of but increasingly yes the 20th century came it came narrower and narrower So in the end philosophers basically were ended up as I found analytic Philosophy talking to each other and and making it a discipline and the way you make a discipline is you set rigorous criteria for what's counted as good stuff And then you make people and you penalize them if they don't do that good stuff and EG, you know Let them advance in the profession, but but it seems to me Uh But even this question even if you're asking a discipline, what's really good stuff in a discipline? um I'm fascinated by the question because I have a lot of literature in my own undergraduate background and reading I asked the question Can you really have a good philosophy that only other Philosophers can understand if particularly if they're dealing with questions that that are fundamental to human life and human values If you have a field where you have to be specialized to even think about those matters that we're all in trouble So very nature the case if we're raising questions that affect everybody's welfare You have to have a discipline which is able able to a make sense of everybody's welfare and communicate it to them and and now this That's didn't really answer your question. That's the that's the best we can do in the best. I think we've come up over the years Uh, you know The people that I think had the most impact in any field of the ones that learn how to how to go Effectively go public. Stephen Pinker's a pretty good example of doing this An awful lot of the leading figures and many E. O. Wilson are the ones that not only think well But they're great writers too and usually they're They have some broad education. They can bring to the way they talk about their own field That's the kind of person thing So I always tell if you want to do stuff in biology read a lot of literature read a lot of history bring in as much Read stuff in biology and bioethics at the literature, but read other things as well Good answer. Thank you Other thoughts comments questions And so we're going to have to we're going to have to use this thing here. So I apologize for that but We're lost there. I hope I have my thoughts in order So I my name is Beth. I am a bioethics student at union graduate college And I am a nurse and I have a degree in anthropology. So I Like to believe that I am well rounded and I study everything and I look at everything but at heart. I'm a nurse and I have found that medicine is not really interested in This mundane let's change the system we have and and all arrive at sort of a mediocre area we can live with But nursing in the historically Have been the people that go out and get it done We get done what someone else has seen what someone else's vision is And we are more about bringing it to the masses Can you speak at all to the nurse's role in moving this agenda forward? Well, I think in the I mean nursing the balance between caring caring for people and curing people That's the nurses are very much on the caring side and that's their great contribution I think it's a neglected field the question is it's neglected in part because the great Actions seem to begin with the doctors and the new technologies and the new ways to Keep people alive long enough in the hospitals that the nurses can treat them You know, that's the the nurses are the ones you take care of After the after the big operations and then the life-saving things that the nurse comes along to Take care of the patient thereafter So I I I'm utterly sympathetic to Your bias toward nursing and I think it's absolutely important and I wish that every physician would spend about a year or so Being a nurse But that ain't gonna happen I'd love to hear your thoughts on About informed consent because it's it's changing and it's been such an essential Concept within bioethics over the years and it's kind of evolved in kind of in real time now with Biospecimens and big data at all. So I just love to hear your thoughts on that Well, I'd say when As the field of bioethics was beginning to emerge in the 1960s the I would say the The standard model of the doctor was the doctor was the doctor My colleague will give you follow your doctor's orders and your patients and your lawyers Your lawyer's suggestions and you fall on your doctor's orders. It was a very nice. It was a doctor's Decision to take the burden of decision making away from the patient because that was part of the problem and You got a paternalistic medicine So one of the major things that obviously began happening was as the profession itself was became criticized more It was demystified medicine was then ideas that People should have a choice autonomy came to the fore with the principles and And and then I'd say after a while Autonomy became so the joke got, you know, the doctor is just gives you a menu and the Doctor, here's the menu here the choices you decide patient and I think it's time is going on Or I said well that really doesn't really work very well Now we're now I think there's a movement back to find a better balance between Old-fashioned paternalistic medicine namely where the physician one way or the other has to have some that what has to say What he or she thinks ought to be done Communicate this to the patient Understand some patients are not able to make their best best judgments for themselves And I think even more understand it They said patient patients everybody should make their own choice But most of us had no experience making a lot of the hard choices in life It's not as if we've had a you know, we've lived through 10 Likely fatal illnesses. We've had to make decisions. Most of us suddenly face bigger decisions We're not in a good position to decide what might be best for us And here I think you need a physician sometimes willing to be fairly pushy about it And the question is the old paternalism was bad, but the uh, the new Autonomy uber Alice was not so great either And that's the best I can say no But that takes a lot of that's where the character thinks is how do you get a physician's get the You know really how knows how to think well about the welfare of a patient And a whole theme I left out in this I should have I think it's very important for people working in bioethics to understand the culture at from which they come Uh, not only understand know thyself, but know thy culture And and people making decisions about most things are will be we will reflect their class income Education all sorts and you better know that about yourself that that's part of it If you're going to be a more paternalistic doctor You better understand the difference between social culture between you and your patients and how that can be And and to what extent you're bringing some of your personal system values into something Where they shouldn't be in some places where they should be If I remember correctly At some time a while ago you, uh, you said that used a metaphor for how we were handling ethical issues And the metaphor was we were putting a old wine Into uh, I mean new wine into old wineskins Are we still doing that or have we come up with any new wineskins? well, um I I guess My picture is that it's all become more complicated as time has gone We've not we have not settled that a lot of people really have adopted the four principles. That's probably been the leading System if you will that's been used in bioethics, but that's had its critics over the years You know feminist bioethics you have people have very specialized that uh, and uh, I I At the moment if somebody I said what would be the dominant principles values that are Ethical or intellectual that Are shaping the field I did very hard to say because an awful lot of movement people moving into different areas Of medicine health care, which weren't explored before so you're getting and people having to find new ways of talking about these issues Uh, a lot of things that interest me there aren't any very good ways about How do you talk about allocating resources between the young and the old? Well, okay, you say what should be done justly. Well, how in the world what how do you decide what's a just Solution to that sort of problem Somebody once said to me 90 years old 90 days old you treat everybody equally Yeah, I said well the 90 minute old has to compete with an Or even playing field the night. You know that was well, that doesn't sound quite right But trying to what kind of principles do you bring to bear on that? I'm struck by the fact that the more difficult problems these days Involve so many overlapping areas that it's very difficult to disentangle them to have any single This is to come back to the question about is it a discipline any single Known ways that's the best way to deal with the problem If it's a really serious problem, and you're really sensitive you ought to be confused as hell Dan you've been a leader in Probing the question of what's the purpose of medicine? What is health? We're meeting in the context of the ethics center here, and you're meeting with students What are your thoughts about the purpose of ethics education? Well, I guess what I consider good ethics education is to Um Well, let me ask in general Distinguishing from ethics education For work in health care versus a general education ethics. Well, let me leave aside the question general Uh, it seems to me what you want to do is to equip somebody with a Fairly rich view of life itself Drawing from a lot a lot of sources that you can bring to bear In the in the making of this decisions if I'm sorry Yeah, that's That's the way I I think I sense they would sum it up And your effort should be to Open people's eyes that old expression to all sorts of different angles And this is where the cultural comes in when somebody said well, I think we should do x y z was a wait a minute I I decided after working at four years and five years in bioethics that if you told me your age educational background Income level I could make predict 90 percent of every View you had in bioethics And I asked is it whether it's supposed to be rationalistic. It can't be that simple But unfortunately that's the way the way it is and It's not surprising that Uh, a lot more people in favor of You know, Bernie Sanders and vermont than they are in mississippi. I mean you've got to take account of that's part of life Knowing all of that's going on that you are you can't escape your background And you had how do you get people to understand that while working with very specific cases? but bring it such you know And there you need to be widely read and think about things and get fuss distressed by things and Nothing else suffices Am I answering your question I am describing education, that's right you know And how do you educate people to do this sort of thing? Well, and that's where I just believe You give them lots of lots of different things ways Cases to think about you give them lots of different ways of comparing different theories about all of this You let them engage in argumentation back and forth and that's why you know That's that's the way it's done. It seems to me Hi, um, I'm one of the students in the master's program and I I read your book and I liked it very much um And you one of the arguments you make a lot in the book and in your talk today is that to be a good bioethicist You should probably read a lot of literature How much science do you think you need to be a good bioethicist? You know, what would what would you recommend in terms of well, I've had to deal with this Let me this is a little self-advertisement. I've had to uh I've just finished writing a book has which on the face. There's nothing to do with bioethics at all But it's just it's a study of Global warming food shortages around the world water shortages obesity and chronic illness I picked them because all of them there are five areas. I call them the five horses. They're all getting worse not better Each one has a very important scientific component I my question is why why are all the things happening? Why are these five so impenetrable? They just don't seem to admit a solutions after 30 40 years of millions of dollars, but and uh, the uh And I suppose I'm sorry. I lost the thread here. Um How much science how much science yeah in each case I had to learn a lot of science to do it And it seems to me what you And I had I used to say people say how do you how do you deal with the science? Well, I can't deal with the science What I have to do is is read just read a lot of it try to understand sort of the bottom I don't understand a lot of bed global warming science How in the world you you did decide on? projections in the future of what the Level of carbon dioxide is going to be I don't it's very complicated. You have to be very good But you need to sort of be understand the bottom line That the trust what people you think are trustworthy that you understand where they're coming from That that that you get a good sense of whether they are well grounded what they're saying And you do that based on the consensus of other the agreement they've seen a mother scientist and But that's probably the that's the best you could do you can't you can't compete in their own Arena that's I wouldn't dare argue with a given scientist about Any any issue in global warming because they spend it's whole careers on it Uh So what I I said what you do biothics well is you have a most of us will have a one Professional discipline and then we become very good amateurs in other disciplines we work on I've written three or four books and things I knew nothing about I mean literally no, I mean I said most people I mean this is I the way I had fun in my career was I looked for issues Nobody else was particularly writing about A because then there was nothing to read you'd have to read a lot of stuff and secondly Just because it was just funded Inside wrote a book on medicine the market some years ago. Nobody really tried to look at that would I'd like whole question the whole research enterprise and how we spend money and why we spend money on research A variety of things that had not been written about before in each case. I had to make use of the science but But you sort of muddle through and then you get other people to read that I write something I've sent it to the side and says There's this past movie Could I write this and get away with it? I said When I wrote this recent book, I was in I was dealing with At least seven different disciplines in each case. I just would write out of the blue I was called I was looking for good Samaritans. I would write to somebody He was a big food expert in London and said you're so sorry really really liked your book in London Would you please read my manuscript and and nine out of ten would say yes, there's some that didn't bother answering But because I would hate that people asked me would you mind reading manuscripts, you know, does anybody really loves that particular Chore but but they didn't that helped uh, so after a while you cover yourself so to speak And I must say I'm sort of there's a kind of a cheating part of to all I think of this she Namely, but the lot of scientific stuff you read the praise see The abstract and you read the conclusion And then you say okay, this is what this person thinks and use that Though you don't understand anything in between to understand the methodology But if it's in a peer review journal you could probably get away with it because I can't understand the science And I'm not going to go back to get a degree in it to understand it It's boring anyway, so Thank you a lot for coming over and I'm also in the master's class and read the book and it was great um, and one of the questions that we had in our in our class was Similar to what amy mentioned You are a man of you know, you have your Multiple feet in multiple disciplines And are the father by with this quote-unquote, but do you think uh It is as easy to be a renaissance man Uh or a person who has expertise even minimally so in a vast array of disciplines enough to Have credibility in those different arenas are now in an era. Is this era more specialized and I have this struggle with people younger people in bioethics these days who have sort of Bought the notes that you've got a bit you've got to specialize And I say you don't have to specialize Partly because I've made a career of not specializing and I and I figured it how not to specialize And and how to keep up with with keep up with things and uh That that you can you can learn and take on new things and and it's it's death and it's and again It's it's that they keep doing the same old stuff a lot of people make an old career Writing of the same article almost or book I think that's the way to have a tedious kind of life and uh, who cares after a while anyway So at least for your own career, you want to keep moving around So that that you it keeps yourself simulated to find new territory and I think it's easy I said look if you can read and you learn how to do the kind of cheating I suggest you can get away You can get away if they're awful lot of stuff People are going to call me up reporters if my book is excessive on global war I said oh my god, they're gonna start Because I think I'm an expert. Well, you know, I've managed. I've probably managed to fake it pretty well Sorry, this doesn't sound very ethical, but Hello, it's not if it's bad ethics is ain't the worst kind. Okay Yes My name is Juan Carmon. I'm also in the master's program And I just wanted to return to the topic of biomedical research specifically I'm a molecular scientist by training But I'm curious to hear your thoughts about personalized genetic medicine because it's something that's really You know being said a lot. There's a lot of hype and a lot of expectation But in light of the Criticisms and things that you've raised. What do you think is reasonable to expect and what what do you think? Might be also abuses and things that we should be looking out for Thank you. Well, actually, I think that personalized medicine precision medicine they're sometimes going at these days I I think it's one of the most interesting and menacing parts of medical research Partly because you've had an awful lot of all sorts of new developments and ways to genetic ways of prenatally diagnosing people But but we've never really asked We don't have a good way of asking for it to say prenatal diagnosis So it seems to be a fundamental question that one needs to look into but nobody looks into is Well, what does it mean to be a parent? What kind of a child? What do you want to kind of a child do you want to be? People are worried they want to have healthy children and so forth. Well, the problem is there are a lot of people who have Healthy children who get screwed up in life from all other things That you'll have no control of what your children I think it was John F. Kennedy said children are hostages to fortune If you have children by God, you can start it with the healthiest kids and smartest kids in the world And they can really ruin your life by messing up their own life So I and and what's happening now is you're finding ways to project What's going to happen years decades later in people's lives? There's no no good way to decide how to use that information Or or to have people worried for the next 40 years that they may get, you know Alzheimer's at 85 for God's sakes. Uh, what's the what's the benefit there? And of course the difficulty is you've got a lot of researchers eager to find keep working on it to find more and more ways to Make these projections and predictions And you've got a lot of people going to make a lot of money off of it And that's the then you've got the worst possible combination But what if you what if you had to imagine a situation where nobody could make any money off of personalized medicine that would really cool things down a lot I think Oh Dan really is a utopian I'm alan brandt I'm a historian of medicine teacher former former Intern at the Hastings Center my god I met dan when I was 25 years old I guess you know, I was thinking a little bit about what you said about being the father of the field And I'm prepared to make the argument that you are and just how sort of What how how many progeny you produced? Because you know when I first met you in the mid 1970s You know the whether bioethics is a discipline and certainly wasn't yet a field There's just no question now that it's a thriving crucial Global field. It's in every academic institution. There are many people who are professors of bioethics those positions You know in terms of the history of the academy didn't exist 40 years ago and now we've watched its institutionalization We've watched the development of major credentials in our institutions both academic and hospitals As you pointed out specialization professionalization of the field and You know, it's just it's sort of a remarkable story You know that started at Hastings on Hudson in many ways, you know now You know since the late 1960s So in one sense one of my questions is I want you to sort of reflect on sort of the evolution of the field We often don't get to You know control or determine how our children do So that that's one question then the second question really focuses on what are you really saying about what our principles should be If you want to work on these questions And it seems to me and I you know, hope you'll agree with this is that We have to continue to work on the most important pressing and difficult issues of our time And there are many different strategies for doing that and some will involve intensive specialization to some degree But whenever we do that we have to continue to relate that specialized work to fundamental crucial and often Irreducible and irresolvable at least in the short term problems. And I just want to say, you know for me That's what's characterized your career Well, I think that's let me take two or three things. So I I think For those of us who got first interested in the field We were interested because it did ask very fundamental questions about the nature of the human good and what health is and so forth and so on Uh, and we saw it forcing people to ask the deepest of human questions Uh, and that's the way it got started. That's what a lot of the early scientists wanted And we did it But then we came in but then as this time went on particularly it's not because of the philosophers, but it was at least coincidental Uh, the pressure was entire Move away from the big issues to very Concrete practical up-to-date policy issues and of course the foundations Don't pay for you to sit around talk about the good life Maybe they like they want to see what's the outcome and what value you have in that And that sort of I think changed the nature of the field and made it easier to be be more specialized And that's where you got the money and and still if you want to get money from NIH you have to do that do that sort of stuff And I I think the trouble is how do you so we felt you always had to sneak in the big issues Along with the practical stuff, but you have to force yourself to keep pushing back on some of the deeper issues so Now as the field has moved along what struck me during the 1970s I I have an old chapter in my memoir about The reactions of the big public reaction of the public and of the academic intellectual world During our first decade. We got a huge amount of media attention. We were the new kid on the block the issues were hot We were in every possible magazine interviewed on tv and then and then and during that during the 1970s we went from practically no medical schools with courses on medical ethics. So by the end of the 70s almost every school and it was a Very fast movement and then then it began plateauing off after a while when we got settled And I think it began taking on the Trappings of a sort of an academic sub discipline Now we have urban studies women's studies black study. You name it. There are a whole bunch of things on the periphery of academia Which are also interdisciplinary and And I got particularly interested in in what what was our intellectual status? And what I measured major one of my measures was saying well How often did we get reviewed our books get reviewed the new york times or the new york review of books or In some of the broader intellect or the new republic or the nation And at first we get an awful lot I was reviewed three times in the new york times over the years There has not been a bioethics book review in 25 years of the new york time since then Yeah, thanks so much. I was hoping that you would flesh out a little bit Your your thoughts about the the overall goals of medicine and I have one particular question about that which is I guess my My naive intuition would be that you know extending life Certainly not the be all and end all of in terms of the goals of medicine but I guess it seems like a really important and really commendable goal something that you know we as medical Professionals and as humans should be really proud of and should Look to continue in the future not to say that We don't overdo it at times and that there aren't other goals and that perhaps You know right now we're in a very unbalanced State between our ability to preserve life and preserve function and quality of life, but It doesn't mean that preserving life is not a a central goal of medicine. Well, I I think you have to make A lot of distinctions here saving life of young people. Yes, obviously saving life of middle middle aged adults Who are responsible for running the society and raising families? My question arises how far Do you want to go in saving life of the elderly? That's been a issue preoccupied me for years and it seems to me that We don't need an indefinitely long life to have a good life. We can't afford an indefinitely long life our progress to date in Many of you remember the idea of compression of morbidity a concept was floating around being in the 1980s What the medicine would find a way to have a longer A long life which with people die very rapidly very little illness and die rapidly Well interesting studies reason show this it just is not happening. In fact, it's just the opposite way People are living longer with morbidities than they used to in the past So it seems to me we're up against some biological barriers here and the question is it gets more and more Complicated to deal with those barriers. Yes, we can keep people alive A lot of people live to be a hundred and they're still Cruising around most aren't cruising around there are nursing homes at a hundred and they don't look too great when you see the pictures And at that point it seems to me if you get people that far you've done enough You don't have to keep pushing on the question is where do you stop and put more resources and Money that will help younger people rather than older people now. There's there's a big Complication there namely most of things that help really old people or things develop often for young people Advice they've worked very well to keep very old people alive, too That's one of the downsides of trying to set some limits and boundaries, but but Instead of thinking you're going to deal with end of life from just by counseling people about when to stop their treatment Whereas the researchers are finding ways more and more ways to Keep pushing off that time of decision. I would say that's not helpful to make it harder and harder And right I think what's happened now is Either it's getting harder to make these end of life decisions because the technology is constantly advancing the physician could always say well You know, we really got something new it's probably worth trying and We're not sure it works, but you know And the families as always hope that's that's I think that's the real tale of seduction there So the question is do you believe people are finite beings? Or do you think they just want to be able to live forever if they want to that's All right, well, why don't I take the moderators prerogative here and ask the last question. Um It's a little bit specific, but I think it gets to to some of the broader themes of your career as well So I know that the abortion issue was one where you really kind of cut your teeth on a lot of this and I've had some interesting disagreements with your wife over the years And I'm sure lots of great conversations at the dinner table Um Well as I as I take your position your your pro choice, but it's not it's not worshiping choice for the sake of choice Because there's there's good choices and there's bad choices And this is a little bit of a follow-up to Juan's question about the impact of genomics in our in our world because You know increasingly we are able to know more and more about uh the fetus before before birth One of the dramatic Advances has been on the prenatal diagnosis of Down syndrome and uh, you know increasingly available and accessible to most women and We know that about at least that the estimates are that about 90 percent of prenatal diagnoses of Down syndrome result in termination of pregnancy So As somebody who is generally pro-choice, but thinks there's better choices than others How do you view this this movement? Is it a Is it a good thing that people are able to select against certain types of severe disability? um, or is it a bad thing and Should we be offering these tests or not? well I guess the question is how do you uh, I don't think you can stop people off that researchers are going to come along Like it or not and they're going to they're going to do it You're not going to stop the research and once you the research goes on the research is going to get public The public will hear about them and they'll want it. Some people will want it And then I think the question is How do you begin educating parents to make these decisions and what should they think about and that's where my reference To the fact that you may have perfectly healthy children who get later in life get messed up Being a parent itself is a tricky business and just getting When I The era I grew up and I knew lots of people everybody had a lot of people had down Now they tended to be sort of stigmatized They hid them But they people functioned well enough and they took them and they loved them and they dealt with them The kennedy family had a very disturbed one of their one of their children So I know it's not the end of life to have it I mean it certainly can be a disaster in a way, but people manage to transcend their disasters So I think the question is what what kind of a parent do you want to be and how willing are you to put up with Your your child turning out not as you like once they're born If you don't like one a certain type of child Are you going to carry this all the way as they keep growing up? Are you going to hover over them and make sure by god they get into Harvard and you know It's part of the same continuum I think I'm forcing myself all right, well You've been wonderful I think the question what to do with things you can't stop is one of the and you can't stop the researchers and that's One of this is a side issue How do you how do you how do you deal with situations where things are in the pipeline of research? But but are still not out there in order to decide whether you want the research to go forward Do you want to get make more and more things? the one out of a thousand Things that could happen to your child make sure that but it's dealt with too well So how we direct the kind of research towards the kind of research that would actually Just gives us more choices, right, right, yep You've been great hour and a half up here Lots of questions. Thank you so much Thanks to everyone for for coming