 Okay, so first of all, I want to welcome everybody back from vacation. And I'm really happy that everybody's back at the second half of our interdisciplinary McClain series lecture. I'm Mindy Schwartz, as all of you know, and it's my great pleasure to introduce our speaker, the host of the series, and a man who needs no introduction, but as is our custom of embarrassing speakers before they speak. I will give a little introduction with just the brief summary of his CV in a perfect position actually to speak to us. So this is Dr. Mark Siegler, Clinical Medical Ethics, Its History, Origins, and Contributions to American Medicine. Mark Siegler, MD, Master of the American College of Physicians, is the Lindy Bergman Distinguished Service Professor of Medicine and Surgery. He is the Director of the McClain Center for Clinical Medical Ethics, the Executive Director of the Bucksbaum Institute for Clinical Excellence. He is a respected physician specializing in general internal medicine. Dr. Siegler is internationally known for his work in the field of clinical medical ethics, a field he created and named in 1972. In 1984, the University of Chicago established the McClain Center for Clinical Medical Ethics, which quickly became and has remained the largest program in clinical ethics in the world. More than 600 physicians and assorted other health professionals have trained at the McClain Center, many who direct ethics programs in the United States, Canada, Europe, Africa, India, Australia, China, and South Korea. As an honorous graduate of Princeton University, Dr. Siegler received his medical degree in 1967, 55 years ago from the University of Chicago. Now that is your definition of a lifer. He was an intern resident and chief resident at the University of Chicago, followed by a year of advanced training at Hammersmith Royal Postgraduate Hospital in London, England. In 1972, he joined the nascent, the University of Chicago faculty, as the second faculty member in the newly created section of general internal medicine. In this capacity, he organized and directed one of the earliest medical intensive care units in Chicago for five years. Dr. Siegler has practiced internal medicine at the university for 52 years. His seminal 1981 paper, A Proposal for a Model of the Doctor Patient Encounter, has been cited extensively by the 1982 Presidential Commission as a basis for recommending a shared decision-making approach for doctors and patients. An approach which now has become the standard model for the doctor-patient relationship in the US. Dr. Siegler, whose research interests include ethics of the doctor-patient relationship, living organ donor transplantation, end of life care, ethics consultation, and medical decision-making, has published an astonishing 230 journal articles, 70 book chapters, and six books. His textbook Clinical Ethics, A Practical Approach to Ethical Decisions in Clinical Medicine co-authored by William Winslade and Elate Albert Johnson is now in its ninth edition as of December of 2021 and has been translated into 11 languages and is widely used by physicians and other health professionals around the world as the leading book in medical ethics. Another recent book co-edited by Dr. Siegler and Dr. Laura Roberts, Clinical Medical Ethics Landmark Works of Mark Siegler, was published in spring of 2017. Dr. Siegler is a master of the American College of Physicians and an elected fellow of the Association of American Physicians and the Hastings Center. Dr. Siegler's lecture is entitled Clinical Medical Ethics, Its Origins, Its History Origins and Contribution to American Medicine. But before we go, I just want to make, I want to highlight two things as a person who is fascinated by history. Number one is take note of the fact that at the beginning it was the generalist who gets spun off into the medical intensive care unit. The way medicine evolves is not obvious and it's not linear. And the second important thing is, and this is one of the reasons I was so hot to join Mark and to work on this seminar series is that among the many, many, many things that Mark Siegler has done, he has created a virtual community that is durable, palpable and extremely productive. And it is his personality, maybe more than personality, I'm going to say it's character, the way you not only, and we saw it just with the chit chat before the people, you not only help people professionally, but you never forget the person. And I'm sure that comes out of your fundamental primary MO of being a clinician first. So I'm going to stop and I'm going to let you teach us about the history of clinical medical ethics through your eyes. So thank you, Mark, and take it away. Mindy, I'm not sure I can go any further. Thank you very much for that extraordinary introduction. Welcome to all the people. We're resuming for the winter quarter, our fellowship program. And I really look forward to meeting with you. Let me try the paper. Lena, you can set up some of the slides. Look on your end. Also, thank you. I'm going to be talking about clinical medical ethics. It's history origins and contributions. Next slide, please. I'm going to begin with part one. What is clinical medical ethics? Next slide, please. In the 60s and 70s, the early development of biomedical ethics in the US was led mainly by a brilliant team of non-physician bioethicists, theologians, philosophers, humanists, legal scholars, social scientists, and more. Next slide, please. The problem was that physicians and other clinicians had minimal involvement in this development and even more disheartening was the fact that the impact of the new field of biomedical ethics was very limited with regard to physicians and nurses, to medical practice and medical education. There was little benefit offered to patients in that first five or 10 years of the bioethics evolvement. Next slide, please. In 1972, the McLean Center helped change the practice of American medicine by working to transform the theoretical, nonclinical work of the bioethicists in the 1960s into an applied clinical and ethical approach, something that we called clinical medical ethics that has been used in essentially every routine encounter between patients and clinicians from the early 70s to the present. And each year, mind you, there are more than 1.5 billion, this is in the U.S. alone, more than 1.5 billion clinical ethical encounters with inpatients and outpatients. I mean, the vast majority are without patients. I'll give you some of the numbers in a little while. Next slide, please. While very few U.S. physicians today are formally trained as clinical medical ethicists, essentially all physicians and clinicians regularly and routinely apply clinical medical ethics approaches, things like telling the truth to patients, getting patients informed consent, maintaining patient privacy and confidentiality, working towards shared decision-making, occasionally dealing with pain control, all of these things are routinely done by clinicians. Next slide, please. I'm going to begin part one with what is clinical medical ethics and do these five sections. Let me start with a definition of clinical medical ethics. Next slide. It's a new medical field that I helped to name and start in 1972, one that works with patients and families, with physicians, nurses, and other clinicians to reach good clinical decisions by taking into account not only the medical details of the situation, but also the ethical issues, things such as the patient's personal preferences and values, and to that matter, the patient's vulnerabilities. Clinical medical ethics examines practical, not so much theoretical but practical ethical concerns that arise routinely. In fact, every day in ordinary encounters among patients, families, health professionals, healthcare institutions, these daily issues rarely require an ethics consultation, but they do require a clinical ethics approach. Next slide, please. This is an essay that I wrote in the spring of 2019 in the Journal of Clinical Ethics, which has quite a lot of what I'll be talking about today, the history and contributions of clinical ethics to American medicine. Next slide, please. The definition of clinical medical ethics that I started in 1972 is that it is an intrinsic part of medicine, rather than a branch of bioethics or philosophical ethics or legal ethics. Clinical medical ethics has to be practiced and applied, not so much by philosophers or bioethicists, but rather by licensed clinicians who deal with patients on a regular basis, physicians and nurses, other healthcare providers in our routine daily encounters with both inpatients and outpatients. Next slide, please. Second, is clinical medical ethics the same as performing ethics consults? This is a bit controversial, but let me go on now. Next slide, please. There are some ethicists, especially non-clinician ethicists, who claim that the core, the heart of clinical ethics is performing ethics consults. Although ethics consults are surely a small part of clinical medical ethics, I strongly disagree with this view and consider it to be somewhat narrow and mistaken understanding of what clinical medical ethics is. Next slide, please. Let me give you some of the numbers. While ethics consults remain a component of the larger field of clinical medical ethics, they're a pretty tiny component. In fact, less than 0.1% of inpatient clinical encounters and very close to 0% of outpatient encounters are based on ethics consultations. That is a very small number. Next slide, please. For example, cardiology practice and cardiology consults. The practice of cards is more than merely performing consultations. Clearly, cardiology consultations do not constitute the central body of clinical or research practice in cardiology. And similarly, the field of clinical medical ethics is much larger and more relevant in day-to-day care than the relatively infrequent 0.1% of inpatient ethics consults and the almost 0% of outpatient consults. Next slide, please. Here are some of the numbers. There are annually about 45 million inpatient admissions in the US and for that matter, over 1.5 billion outpatient encounters. In a 2021 paper written by Dr. Ellen Fox, who is a former McClean Center Ethics fellow here at the university, she indicated that the volume of consults had gone up between 2007 where it had been about 16,000 consults a year to about 68,000 by 2020. This was a paper that Ellen wrote in 2021. So 68,000 ethics consults a year and almost none of those consults were being done for outpatients. The vast, vast majority were being done for inpatients. The point that I'm trying to make here is that clinical medical ethics issues arise routinely in almost every encounter between clinicians and patients, between doctors and patients, nurses and patients, other clinicians, and that ethics consults occur very infrequently, as I say, at the level of 0.1% of inpatient encounters and close to 0% of outpatient encounters. Next slide, please. So I go on to part C. How is clinical medical ethics different from bioethics and philosophical ethics? Next slide, please. First of all, it's not very theoretical or arm share as an exercise. It has to be practiced and applied clinical medical ethics, essentially with all patients, inpatients and outpatients, not so much by humanists and philosophers who often do ethics consultations, but rather by clinicians in their routine daily activities, essentially with all of their patients. As I mentioned earlier, clinical medical ethics, in my view, is a branch of medicine more than it is a branch of philosophy or theology or law. Next slide, please. My central point is that physicians routinely encounter a huge number of ethical issues in their ordinary daily practice, and addressing these clinical ethical issues is an intrinsic part of reaching clinical decisions and providing reasonable and good clinical care to patients. Next slide, please. The Lancet in 1997 came up with a view that we had sort of begun to develop in 1972, 25 years earlier, when they said in an editorial that ethics needs to be rooted in clinical practice and not in armchair moral philosophy. Debate on ethical matters is as much an integral part of everyday doctoring as choosing the best treatment for patients. Departments of ethics that are divorced from the medical profession, wallowing in theory and speculation are quaintly redundant. Very powerful editorial in 1997 in the English Journal of the Lancet. Next slide, please. At the McLean Center, we had not only been working, been making that same argument, as I say since the early 70s, but we had also insisted that clinical medical ethics be applied routinely to most, if not all, standard clinical practice cases. Next slide, please. And the goals of clinical medical ethics are next slide. As Dr. Ed Pellegrino and Dr. Peter Singer, who's now the second in charge of the World Health Organization, and I observed about 30 years ago, the central goal of clinical medical ethics is to improve the quality of patient care by identifying, analyzing and contributing to the resolution of ethical problems that arise in the routine practice of clinical medicine. So this is our view of clinical medical ethics by the late Ed Pellegrino and still by Singer and myself. Next slide, please. The goals are to improve patient care and outcomes to help physicians in their routine practice identify and respond to ethical issues that affect their patients and that occur routinely in the ordinary practice of medicine and to encourage all clinicians, doctors, nurses, and other health care providers to meet the legal and professional standard of care in the U.S. by practicing clinical medical ethics in the basic everyday encounters with their patients. Finally, next slide, please. The methods to achieve the goals and range of clinical medical ethics, I'll be very quick on this, please. Next slide by incorporating ethical considerations into everyday ordinary medical decisions relating to the care of patients by emphasizing the ethical obligations of physicians, nurses and other clinicians, including clinical competence, honesty, compassion, empathy and respect for our patients and by working to sustain and strengthen the patient clinician relationship. Next slide, please. I now want to go on to part two, the origins of clinical medical ethics and of the McLean Center here at the University of Chicago. Next slide, please. The McLean Center for Clinical Medical Ethics was started in late 83, early 1984 and is regarded as the primary supporter and expander of the field of clinical medical ethics. In fact, it's called the McLean Center for Clinical Medical Ethics, the field that we had sort of begun in the early 1970s. Next slide, please. In Chicago, we came to realize by the early 70s that the US bioethics movement that has started in the 1960s, largely at Yale, under the direction of Professor James Gustafson, a great theologian at Yale, who then moved to the University of Chicago in 1971, we came to realize that this field of clinical medical ethics was theoretical, not practical, was dominated in the 60s by non-clinicians, as I've said, brilliant philosophers, theologians, legal scholars and like, involved very few physicians, nurses or other health professionals and had very little or no relationship to clinicians and their routine clinical practice, or for that matter, to patients. It was a great theoretical area that was eager to be applied to clinicians and to patients. Next slide, please. The first uses of the name clinical medical ethics, I think I told you, 72, we started it here at the University of Chicago. In 1974, with Jim Gustafson having come up from Yale to Chicago in 71, and legal scholar and Dudley Goldblatt, the three of us wrote a grant to the US Department of HEW, Health Education and Welfare, that was a forerunner of HHS. And the grant was entitled clinical ethics in human values. The grant was awarded to us for three years and was one of the earliest US federal grants in the field of medical ethics and the first federal grant in the field of clinical medical ethics. Next slide, please. Some of the first uses of the term clinical ethics and clinical medical ethics was this JAMA article that I wrote in 1978 called Teaching Clinical Ethics at the bedside. And then in 1979, next slide, the AMA allowed me to organize a section in their archives of internal medicine called Clinical Ethics and Clinical Medicine. And that section went on for about four or five years in the archives of internal medicine. Next slide. And in 1982, Al Johnson, Bill Winslade and I published our first book on clinical ethics, that first edition, small enough to fit into a lab coat pocket, which is what we all wanted it to do. Next slide, please. And since then, the eighth edition came out in 2015 and the ninth edition was finally released by McGraw Hill on December 17 of 2021, less than a month ago. And this is the color of the ninth edition. Sadly, Al Johnson died after we had turned the paper, the book in, in late 2020. And we wrote a note about Al Johnson at the first pages of this ninth edition. Next slide, please. In 1983, the McLean Center for Clinical Medical Ethics received generous gifts from both Dorothy Jean McLean and from her McLean family. And in 1985, we received the 10-year grant from the Andrew Mellon Foundation in New York City. Next slide, please. In between 86 and 92, the Center received a six year grant from the Pew Charitable Trusts in Philadelphia and the Henry J. Kaiser Family Foundation in California to develop a national faculty training program in clinical medical ethics. This was funded by Pew and Kaiser. Next slide, please. One of the goals of that program was to train 12 outstanding faculty for two years to become scholars and leaders of national programs in clinical medical ethics. In this way, clinical ethics expanded beyond the McLean Center at the University of Chicago and included at least some of these, all of these 12 institutions. Peter Singer at Toronto and Susan Tolle at Oregon, Marion Secundi, the late Marion Secundi at Howard University, late Doug Kinsella at Calgary in Canada, Ken Iserson at Arizona, Bruce White then at Albany, J. Jacobson at Utah, the late Ron Miller at UC Irvine, Woody Moss at West Virginia, Chris McHenry at Cincinnati, Bob Walker at South Florida University and Eugene Barreza at University of Montreal. It was a great team and we worked together for two years in the program and in the training. Next slide please. In 1990, I was invited along with Peter Singer and later at Pellegrino to introduce the new field of clinical ethics by writing and publishing five papers about the field in the opening volume of a new journal. The name of the new journal was the Journal of Clinical Ethics. Let me say one more thing about that in the next slide. The publisher of that journal, Norman Quist and the editor-in-chief from the beginning to now, the beginning in 1989-1990, Dr. Randy Howe, Edmund Howe, now plan to move their journal to the University of Chicago Press and to make the McLean Center the program in charge of this new publication at UChicago Press. It can be very exciting and will probably take place over the next year or two. Moving the journal from Baltimore and Maryland to to Chicago. Next slide please. I now turn to the third and final part of my discussion, the contributions of the McLean Center that started in 83-84 to clinical medical ethics and to medicine. Next slide please. This is my list of things and some of them will be short and some will be somewhat longer. But I hope to get through these well in advance of one o'clock so that we can have questions that will begin, I hope, under Mindy Schwartz's guidance. So part three, the contributions of the McLean Center to clinical medical ethics and to medicine. Part A, created and developed the field. Next slide please. The McLean Center is seen, as I've said, is sort of the birthplace of clinical medical ethics. The first program in the world to study and apply this new medical field in the care of patients and in the work of clinicians. The McLean Center is seen as the leading program in clinical medical ethics in the world. One of the probably the earliest program and next slide please. By 2013, the ASBH, the American Society of Biorethics and Humanities, which is the leading bioethics organization in the world, had given its Cornerstone Award to only three other institutions. To the Hasting Center in 69, to the Kennedy Institute of Ethics in 71, and to the Institute for Medical Humanities at Galveston in 1973. In October of 2013, the ASBH was kind enough to recognize the McLean Center and give them the the Cornerstone Award. And the McLean Center was selected for quote, outstanding contributions from an institution that has helped shape the direction of the field of medical ethics. That I think was our work over the years in clinical medical ethics. Next slide please. In November 2016, the Johns Hopkins Institute of Biorethics selected me and the more importantly the McLean Center as the 26th awardee of the prestigious Harvey M. Meyerhoff Leadership Award. The award letter from Meyerhoff and the Hopkins stated, quote, the training programs established by the McLean Center have had a greater impact than any other clinical ethics training program in the world. Through generations of scholars, you have populated the field of clinical ethics in perpetuity. That was part of a much longer letter that Hopkins sent to the McLean Center in recognition of its 2016 award. Next slide please. Currently, the McLean Center associate directors are Peter Angelos, the surgeon, Marshall Chin and Monica Peak from the Department of Medicine and also in both experts in health care disparities. And Laney Ross, great expert in pediatrics and pediatric health care. Next slide please. In addition to the associate directors, we have 10 outstanding assistant directors, Julie Korn, Obigaine, Sarah Hone and Tracy Kugler in pediatrics who run our ethics consultation service. Dan Brudney from the Department of Philosophy, who's been with us for about 15 years. Valerie Cook, our law and ethics expert whose Valerie has been with us for seven or eight years. Emily Landon, our expert, of course, at the moment in COVID-19, but previously in many aspects of clinical ethics. Will Parker, pulmonary doctor, Micah Prochaska, health physician, Selwyn Rogers, the head of trauma surgery, and Laurie Zoloth, the former head of the school of health care here at the university. It's a wonderful collection of people and I'm so honored to be working with them. Next slide please. And more than 50 members, essentially many from the biological sciences, but also from the social sciences, humanities, the law school, the boot school of business, the vinegar school, and the school of social science administration are part of our current McLean faculty, which you won't be able to see, but here's the list. Next slide please. This is a list of 55 of our current faculty members. Next slide please. And very briefly, part B, we emphasize the importance of the doctor-patient relationship and the four box model of clinical and ethical decision making. Next slide please. The four box model, of course, is represented in the book that I showed you, clinical ethics. Each of the four chapters represents one of these four in order. Medical indications is chapter one, patient preferences is chapter two, quality of life chapter three, and external considerations, many different considerations in chapter four. Next slide please. The question is, what is the central focus of clinical medical ethics? And based on the four box model, the central focus is the doctor-patient relationship and how to help patients reach medical decisions that come out as their own choice and are the right decisions for them. This is the key reason why clinicians, perhaps more so than philosophers or theologians, have to be centrally involved in this field of clinical medical ethics. Clinicians, as I say, physicians and nurses and other clinical caregivers. Next slide please. We turn out to the third portion of clinical medical ethics, and that is shared decision making. Next slide. In the four box model, shared decision making is usually agreement in the top two categories, medical indications as they occur to the clinicians and patient preferences as they occur to the patients themselves. And when those two come together, as they do in a very large percent of cases, as I'll show you in a moment, they can result in shared decision making. Next slide please. Shared decision making was somehow evolved from a talk that I gave at the New York Academy of Medicine in 1979 that they asked me to publish in their journal in 1981. I called it searching for moral certainty in medicine, a proposal for a new model of the doctor patient encounter. And it talked about something called doctor patient accommodation. Next slide. The President's Commission, which was started in 1979-1980 and went on to 1982-83. They invited me in 1982 to present the results of that talk that I had given on shared decision making to them. And they liked the talk very much and they liked the paper very much. And they used it for about 15 or so references in their journal, the journal that I show you here, Making Health Care Decisions, a report on the ethical and legal implications of informed consent. Next slide please. They had one section on shared decision making in which they said at each point, the patient and physician will arrive at a joint decision in which the physician agrees to care for the patient and the patient agrees to be treated by the physician. The resiliency of the relationship will depend importantly on the extent of trust and confidence exchanged between patient and professional. And they referenced the article that I showed you. Next slide please. This is the last of the references that I'll show you. But the President's commission cited me repeatedly and said the commission's view recognizes that clinical participants move toward doctor-patient accommodation through the process of shared decision making. And then they referenced that paper that I showed you. Next slide please. The McLean Center held pioneer ethics consultations. Next slide please. They were modeled after medical consultations. Ethics consultants with knowledge and training were available to patients and staff to review cases, to offer informed and practical suggestions, to assist in resolving conflicts. Importantly, the final decisions were not made by the ethics consultants, but were rather made by the primary participants. The patients, their families, the medical team, that's how the ultimate decisions would be reached. Next slide please. We started ethics consults at the University of Chicago even before the McLean Center was started in 83, 84, in 75. And the University of Chicago was among the first hospitals in the U.S. to have ethics consultations. We helped develop the model for ethics consultations. We wrote many of the original papers about ethics consults. Two of our fellows, Drs. John Lapuma and Dr. David Cheathemeyer, wrote the first book about ethics consults. Our former fellow from 1991, Dr. Ellen Fox, studied the field published in 2007 and has recently released a series of six papers in 2020 and 2021 about ethics consultations. I'll show you some of this quickly in the next few slides. Next slide, please. Here was one of the early papers on ethics consultations written by John Lapuma in the Western Journal of Medicine in May of 87. Next slide. Here was a slide paper by Lapuma, Carol Stocking, Mark Silverstein, Andrea DiVartini and me printed in JAMA in 1988 in Ethics Consultation Service in a teaching hospital talking about the ethics consultation service. Next slide, please. Here was a paper by doctors Bernie Helixer, David Meltzer and myself on the effect of clinical medical ethics consultations on health care costs. I think this was 91 or 92. Next slide, please. This was the first book on ethics consultations written by doctors John Lapuma and David Sheetamire published in 1994 in its first edition. Next slide, please. This was Ellen Fox's early paper in 2007 on ethics consultations in US hospitals, a national survey that she did with Sarah Myers and Bob Perlman and published in 2007 in the American Journal of Bioethics. Next slide, please. And this is a recent one of Ellen Fox's recent papers in 2021, ethics consultations in US hospitals, a national follow up study in 2021 to her original study in 2007. And in this one, she finds that compared with 2000, the estimated number of case consultations performed annually is now above 68,000. So it had been much lower in much lower 20 years earlier in 2000. But it was 68,000 by 2020. Next slide, please. We at the University of Chicago have now seen more than 3,000 ethics consult cases in the past 40 years. Despite the complexity and conflicts that often lead to ethics consultations, it's been quite amazing that no lawsuits or legal challenges have resulted as best we could tell from any of these 3,000 ethics consult cases. Quite amazing that none of them have proceeded to go on to legal cases. Next slide, please. We launched the empirical turn in in bioethics research. Next slide, please. Prior to 1980s, bioethics research had not relied on clinical data. Rather, it had used analytic scholarship that was done, as I've said earlier, primarily by philosophers, theologians and legal scholars. But in the 1980s, the McLean Center played a key role in the empirical turn in bioethics scholarship, which was scholarship based on clinical data. Empirical data uses the techniques of clinical epidemiology, health services research, decisional science to study ethical matters and clinical practice. That's all I'm going to say about this. Next slide, please. We developed the field of surgical ethics. Let me quickly show you that next slide. It builds on the McLean Center's successful clinical ethics fellowship program. The goal of the program is to prepare surgeons, the academic careers that combine clinical surgery with scholarly studies in surgical ethics, and fellows receive training. Next slide, please. The McLean Center has advanced the field in close cooperation with Dr. Peter Angelo and the American College of Surgeons. The surgical ethics program at the McLean Center has now become the leading national program in the field. Next slide. And the leader has always been Dr. Peter Angelo's, who moved back from Northwestern to join us in 2006 and became the director and leader in surgical ethics. Next slide and has written many papers about surgical ethics. This one appeared in the Journal of the American College of Surgeons in 1999. Next slide, please. Since Peter Angelo's arrived in 2006, he's helped train more than a hundred surgeons in the field of surgical ethics. And I list on here some, not all, but some of the medical schools that have been represented by surgical ethicists who have trained with us over the years, both in the US and at the end I talk about the UK and Spain and Switzerland, China, South Korea, Nigeria, and other international and national countries. Next slide, please. The impact of the program in surgical ethics is that editors, Alberto Ferreris, a former fellow of ours, Peter Angelo's, one of our faculty, and Eric Singer, a member of the American College of Surgeons, published The American College of Surgeons, Ethical Issues in Surgical Care. The 21 chapters in the book were written by experts in surgical ethics. And interestingly enough, 15 of the 21 chapters were written in part by our former surgical ethics, those hundred surgical ethics fellows that I have mentioned before. Next slide, please. And a new book that's coming out any day now is written by three of our former fellows and two of our former fellows, and Peter Angelo's, who actually was a former fellow, called Difficult Decisions in Surgical Ethics, Vasalaknea, Peggy Kelly, and Peter Angelo's are the co-editors, and that book will be published any week now, I expect. Next slide, please. This is a note from the chair of surgery, Chef Matthews, in 2019, to Peter Angelo's, saying, I'm pleased to announce that you will be appointed in the Department of Surgery as the Vice Chairman for Ethics, Professional Development and Wellness. And so Peter was appointed as the Vice Chair of Surgical Ethics in 2019 by Jeff Matthews, and he's remained in that role since then. Next slide, please. I come up now with founding the Clinical Ethics Fellowship Training Program. I'll be quick about this next slide. This program started in 1981. The McLean Center Fellowship Program is the oldest, largest, most successful clinical ethics fellowship program in the world. And since 81, we've trained more than 625 fellows, including 500 physicians, 100 surgeons, and 75 nurses. Next slide, please. This is a list of all the fellows. Next slide, please. I think I've told you more than 625 fellows, more than 500 physicians, more than 50 university ethics programs have been directed, US programs. More than 30 of our former fellows have held endowed university professorships. More than 200 books have been written by our fellows. Next slide, please. The McLean Center has emerged as a world leader in research and clinical medical ethics, with the 200 books written in thousands of peer-reviewed journal publications. Next slide, please. We've directed programs in all seven continents, North America, South America, Europe, Africa, Asia, in China and South Korea, Australia, and Antarctica. Next slide, Ken Kaisersen. Next slide, was the only ethics fellow in Antarctica in 2016 at the McMurdo base. Next slide, please. And let me just conclude by the Reclaim Center has helped improve medicine and medical practice in the US. Next slide. It changed the practice of American medicine by transforming the theoretical non-clinical work that the bioethicists started brilliantly in the 1960s into the applied clinical approach that's used in everyday practice now from the early 70s to the present. Next slide. In contrast to the 70s, almost every medical organization now has an ethics committee and a code of ethics. This is the American Medical Association's major revision of their code in 2017. I was fortunate enough to write forward to this AMA code. Next slide. There is, as I say, this Journal of Clinical Ethics. As I mentioned earlier, we're hoping that the journal will be moved to the University of Chicago Press in the next year or two. Next slide, please. In the past 60 years, clinical medical ethics has become one of the major components of the American bioethics movement itself. Next slide. Almost every large hospital is required by law to have an ethics committee or an ethics consultation service to help resolve clinical ethical problems. Next slide. Clinical medical ethics care is provided to every inpatient and outpatient and inpatient discussions have become a part of the everyday clinical conversations that occur in outpatient to inpatient clinical settings across the US. Next slide. In the US in 2021, clinical medical ethics is a central component of clinical practice. It's so widely integrated into practice and into the doctor-patient relationship. Doctors often don't even realize they're doing clinical ethics when they tell patients the truth when they get informed consent for a procedure or when they make decisions based on shared decision making or when they reach decisions with surrogate decision makers in cases where the patient may lack capacity. Next slide, please. To finalize my talk, clinical medical ethics practice standards like truth-telling informed consent, shared decision making, end-of-life care have become over the years legal and professional standard of care here in the United States. Thank you so much for listening. I look forward to your questions and comments. Thank you. I'm going to turn it over to Professor Mindy Schwartz. Thank you. Okay. I'll get to you in one second, Josh. I just want to respond because that was my definition of masterclass, okay? Not only is that an unbelievable force of kind of the scope of, you know, clinical medical ethics, but it shows how it shows how one, you know, that aphorism about one person can change the world. You can definitely change the world, but you have to create a community and you have to disseminate what you do and, you know, get really good people to buy into your vision, which is such a good example of how Mark's passion from way back when he was intern and early trainee has just really bloomed into a literal paradigm shift in medicine. And I love the way you ended the talk where he said people don't even realize they're doing ethics. That's how you know it's so powerful because it's part of who we are and the way we behave and it's become the normative way we behave and that was articulated and largely formed by you. So I'm going to let our old friend and buddy Josh ouzer take the floor as we continue in comments. Josh. Hey Mark, Mindy you're very kind. I can attest to Mark's clinical acumen because a bunch of years ago I don't want to say how many I used to cover his beeper. So your point, Mindy, of Mark being a clinical first. But my name is Josh Houser. I'm a palliative care physician now at Northwestern and the Jesse Brown VA. Mark, I want to ask you a little bit more about this topic of ethics being so much part of the fabric of clinical medicine about being every day and quite frankly unexceptional and ask you to speculate or not to speculate, talk about how we teach that and how we come to impart that on our colleagues, on our students, on our trainees. So if again, if the observation is that it is every day and integrated into everything we do and that's an observation I think you made very powerfully, how do we come to teach that to others? I think it's a great question Josh and it's done differently in different institutions. I think that's for sure. Part of it is done in the preclinical years in the medical universities through bioethics courses or ethics courses or occasionally clinical ethics courses. But I think I think a substantial amount is done in the in the clinical teaching of our students and our residents and our fellows in our universities around the country. And that is through the practice itself, the practice that often originates these days even before the third year when when medical students are being introduced to patients and are seeing patients often in their first and second years even before they begin their clinical training. Does any of this I'm sure it reinforces the work that you've done at Northwestern and that Northwestern is done over the years. Thank you, I appreciate it. I really appreciate your question. Thank you so much. We have another request from somebody who's labeled a Zoom user. So I'm not sure who that person is, but they had their hand up. So before I have Tarek Malik talk. Zoom user, did you want to make a comment? You're on Zoom. Maybe I'll have Tarek Malik talk. Thanks. My question would be, I mean, as you said, we have a lot of codes and a lot of rules. But they are just laws. And if they're not implemented, they don't make sense. So my question would be, how can you basically experience? How can you set a bar or quantify the effectiveness of the practice of bioethics? And as you showed some data that some hospitals use it more often, other hospitals use less often. So is there any difference of lawsuit, patient satisfaction, better morbidity and mortality when people practice better bioethics? That's it. Thanks. It's a very complicated question that you're asking, Dr. Malik. I strongly believe, as I've tried to say in my talk, that that that ethics has emerged as as a very routine, regular portion of clinical encounters with the vast majority of our patients. It's evolved. It's evolved over the last 30 or 40 years so that things like telling truth to the patients and and and obtaining patient approval and consent for for treatment programs or even investigative programs, diagnostic programs are part of the core of clinical care and that they happen that they happen both in the inpatient setting, which as I pointed out earlier involves 40 to 50 million people a year in the US by itself and in the outpatient setting, which is a billion and a half or more people annually of that billion and a half, I should tell you eight hundred and fifty million take place in university outpatient settings and the other six or seven hundred million take place in private practices around the country. But but I think that all of those are important elements that that that go into the evolution of ethics and bioethics into the care of our of our patients in private practice and in university practice. I'm not sure I've totally answered the question you raised, Dr. Malik, but it was a complex question. Thank you. OK, Allison, Kastin, you want to take it away. Good morning, Dr. Siegler. I I just wanted to zoom in and congratulate you. I as a undergraduate in the college, I was hired into Dr. Siegler's office in 1984 and was part of this very exciting time with Dr. Gustafson and our Kaplan. And I was actually the copy girl in those times when you had a room of machines and I would have all these papers. And of course, being a U Chicago alum or U Chicago student, you know, you would chug chug chug chug chug and you would literally I would literally be sitting and reading all these papers. And it was an incredible opportunity. And I would ask Dr. Siegler, this is crazy talk. How can you possibly think that there will be something a category called the old old that there would be our technology would outpace our quality of life. That the phrase is the patient and accurate historian. So I just wanted to congratulate you on the the growth of the McLean Center is just so important, so much a part of the conversation. And I'm just honored that I got to kind of be a part. Well, obviously not the beginning as I just learned, but definitely part of of this this this phenomenal work and gift that you've given to all of us. Thank you. Alison, you you were an amazing part of the work, and you were very close to the beginning of the McLean Center, which which had sort of made its way in December of 83, but but really started in 84, which was the year that that you came over from the university to join us and to work with us. It's been quite extraordinary. Now, I've stayed on. Interestingly enough, as the director of the McLean Center through from 83, 84 to to the beginning of 2022. But I will not be surprised if my replacement, which has been offered or suggested to me since 2019 may come this year. And so that's a real possibility. And I I would look forward to joining that person and meeting the person and working with them and helping them become the the new director of the McLean Center. So I'm very, very excited about what may be coming up this year coming out. Well, congratulations again on your alumni, distinguished alumni award. I'm looking for celebrating that as well. So this was just a wonderful lecture. And again, thank you. Thank you for for for at all. I'm so glad you were with us. Thanks so much. I'll turn it back to Mindy. We may be able to to break for 15 minutes, you know, before the 130 meeting. Is that possible? Yeah, there's just one last person who wants to talk. I think Williams has a question. The Zoom user. Can you hear me? I can. So I I've always wondered how the Lowell T. Kagelshaw fellowships, the three of us ended up at the University of Chicago. I of course fondly remember being there with Marion Grace Cundey, with Eugene Berreza, with Ken Iserson, with Annette Dula. And of course, the production of the book, it just ain't fair coming out of that group. Steven Thuleman and really that was a seminal period of time in my subsequent 25 years of practice and the way I approached practice. But I never knew how that came into being, how all of us got together, how you chose us to come. Oh, it's it's well, it's a very it's a very complicated question that that you're asking September. In in in 83, 84, actually going back to 81, we had started to have an occasional fellow join us over over that first decade from 81 to 91. Or actually first seven or eight years. Among those who joined us in that early period were Greg Rammel-Spocker, Joel Howell, Jay Jacobson, Dr. Kinsella, John Lantos, John Lapuma, Laura Roberts, Dr. Sanchez Gonzalez from Spain, David Sheetamire, Dr. Shapiro, Mark Sheldon from from Northwestern, Dr. Simpson, Peter Singer, Susan Toll, Robert Walker, and Dr. Zugar from New York. But then but then beginning in 89 and 90 and your group 1991, we stopped doing one or two people a year and we went to larger groups and your group was extraordinary with Dr. Barreza, Dr. Annette Dula, Ken Iserson, Dr. Primo, Marilyn Secundi, Dr. White and you. September Williams. It was a fabulous group and we started with groups then and have continued with groups since then. I won't tell you that this year we're on Zoom as we were last year with 72 fellows and last year with 34 on Zoom. But in person fellows, we were between 20 and 25 fellows the last seven or eight years up until the pandemic two years ago. So it's a fascinating question that you raise and that group that you were in was the what was the second group of people who were together with us and there was a fabulous team and September it's so wonderful to hear you and see you and know what you're doing in California and warmest wishes to you and your family. Thank you so much. And to you Mark in the center, extraordinary work in history. Thank you, Mindy. Thanks so much for your help. So this was great and I just want to wrap it up since you're going to be talking again in about 15 minutes and just take a break. But this was really terrific Mark, I think everybody who heard it was not just really impressed, but you know, it's it's really a tour to force. So I just want to thank you and give you a little time to have some downtime and I'm sure you're going to reconvene with your 72 ethics fellows in about 15 minutes. Thank you. Next week, I just want to give you a heads up. Yes, I have. I think next week is Julie Fairman who is a who is a PhD nurse historian and is the director of the Barbara Bates Center. For those of you who don't know, this is just a little tidbit for next week. Barbara Bates was a faculty, I think at the University of Pennsylvania, who had the brilliant idea of teaching physical diagnosis to nursing students and medical students at the same time. I think it's really a fascinating thing. So next week, we're going to talk a little bit about nursing and the advanced practice nurse and nurse practitioners and the whole issue of professionalization of nursing and the whole nurse panoply out there. So enjoy your week. We'll see you later. And thanks again, Mark. It was great. Thank you.