 Today it's a delight to introduce you to Dr. Bob Beach, who is one of the foundational people in the field of medical ethics. When I was brought to the Hastings Center as a young pup by Bill May in the fall of 1975, Bob had been there for how many years, Bob? Five years, and had been the executive staff director of the Center in really its critical formative years. I was introduced to the death and dying group by Bill May, and Bob had been running that group for the five years that he had been there. It's really that there are very few people, I think, in American bioethics who have contributed so broadly to discussions in the field. Bob's professor of medical ethics at the Kennedy Institute, professor in the philosophy department at Georgetown, has been the senior editor of the Kennedy Institute of Ethics Journal for many years. His research interests are wide-ranging as you'll learn in a moment when I just recount a number of his important books, but they've included issues in death and dying, transplantation, ethics, consent, doctor-patient relationship, and many other areas. Some of Bob's many books, and I can't give you all of them, include death, dying, and the biological revolution, a theory of medical ethics, another book called The Foundations of Justice, a book on the patient as partner, a book on transplantation ethics, one entitled Disrupted Dialogue, Medical Ethics, and the Collapse of Physician-Humanist Connection. One of the most recent books is entitled Patient, Heal Thyself, How the New Medicine Puts the Patient in Charge. You can tell from some of those more recent titles, this focus in Bob's work, at least this inclusion in Bob's work, of aspects of the doctor-patient relationship as medicine changes and evolves. So for someone with many years, more than 30 years of contributions in the field, it's a delight to welcome Bob, who will speak today on probing professionalism, why professionalism is controversial. Bob Beach. Thanks very much, Mark, and thank you for the hospitality. It's really nice to be at the McLean Center, meet several people who are old friends, some of whom I haven't seen for a long time, and to make some new friends, or make some new enemies, as the case may be. We tend to think of being a professional as uncontroversially positive, something towards which every medical student or physician ought to strive. So you've got basically a whole year's worth of lectures in a series built primarily on the premise that professionalism is a positive experience. This one hour is going to gently raise some questions about professionalism. It's obvious that professionalism conveys something that is generally seen as a plus, but let me open with two quick historical anecdotes that suggest the problematic nature of what we're talking about. If you read ancient Confucian medicine, you'll discover that the ancient ideal was that every extended family should have a member designated to be the medical caregiver. The virtue was actually referred to as filial piety, done out of a kind of family loyalty. But the Chinese commentator Ho Chi-Pin tells us that his medicine became too complex. We began having to use specialists outside the family who did their work for money. And the tone of his remarks includes the idea that unfortunately in modern times, patients have to make do with a mere professional. So that's the kind of edge that I want to look at this morning. At a slightly later date, George Bernard Shaw in The Doctor's Dilemma is known to be commenting generally on professionals saying they are all conspiracies against the laity. He targets, for the most part, physicians who fail to live up to professional ideals. People like that are going to exist in any profession. I want to address something more subtle. The problems that exist with those who fulfill professional standards. In order to get started, let me turn to the sociologists who describe some characteristics of professions, and I think this will orient us to some of the issues I want to raise. People according to sociologists works with specialized knowledge and skill, normally works within a professional association, has a moral norm of altruism which separates professionals from mere business people, generally involves a self-generated code of ethics and self-regulation and discipline. Let me open the conversation by focusing first on specialized knowledge and skill. Turns out there are really two kinds of professional knowledge and skill. The first might be described as technical knowledge of medical facts and theories, diagnosis, prognosis, knowledge of pharmacology and the like. The second kind of knowledge, however, I think is quite different, knowledge of evaluation, ethical norms, or more generally the question of what's best for the patient. There's absolutely no doubt that expertise exists with regard to the first kind of knowledge. Patient who tries self-diagnosis or self-therapy is really a fool, and lay people claiming that they know the facts of medical therapy are going to be destined, I suspect, for short lives. On the other hand, I would suggest to you that there is no evidence that members of a profession have expertise of the second kind, expertise in establishing ethical norms or even the thesis of my patient-heal-thyself book, even knowing what's the best therapy for a patient. The mistake of collapsing these two kinds of knowledge, I, many years ago, referred to as the generalization of expertise. The idea that claiming expertise on facts and theories of a professional domain also leads to expertise in ethical and other evaluations. Assuming expertise about the facts of the professional domain with ethical expertise, I think raises very serious questions. There's just no reason to assume that members of the profession or indeed the professional association as a group have expertise on the ethical standards for the practice of their profession. Let me give you a very simple, easy to grasp example of this. If a patient comes to an oncologist with a mass in the abdomen, diagnosing it as metastatic cancer is surely a matter of professional expertise, but going on to choose between a referral to Sloan Kettering or whatever the appropriate hospital is here at the University of Chicago, on the one hand, or referral to a hospice is an entirely different kind of a question, and I believe there's no reason to think an oncologist is an expert on that second kind of question. In fact, it may even be worse. Maybe that oncologists, because of what led them into the specialty of oncology, have a particular built-in professional bias about what the proper referral might be. All of this, I suggest, has radical implication for the ethics of professional lay relationships, and that neither the professional nor the layperson can claim a special expertise in this domain of evaluation. The norms that is of the professional lay relationship cannot remain exclusively in the hands of one of these parties, or serious errors will result even by the most well-intentioned members of the profession. So it's not exactly George Bernard Shaw's problem I'm worrying about. It's a much more subtle problem. Now one of the domains that identify a profession is the ethics of altruism, and let me suggest that the working out of the meaning of altruism in a professional relationship is a bit more complicated than we've realized. If we define altruism as the working for the welfare and rights of another, this might be contrasted with self-interest, which is more the agenda of the typical business person. But I would suggest to you, even business people have limits on the pursuit of self-interest. For example, the ethical norm for business people is that they cannot intentionally lie in advertising. On the other hand, it's to me pretty clear that professionalism requires a deeper kind of altruism, where the core of the physician's role is self-sacrifice for the good of the patient. But that in turn poses a problem because altruism has many different ways of serving the other. The typical physician way of expressing altruism is what might be called patient-centered utility maximizing. Doing what's best for the patient, the Hippocratic tradition signals that kind of a commitment from a physician, but others would see altruism as social utility maximizing, or as respecting patients' rights, or in some religious traditions promoting social justice among patients. What I would like to do is give you three quick examples where I think there have been legitimate disputes between professional groups and lay groups over the norms for the professional lay interaction. And I've chosen these because I think they're legitimate questions. It's not obvious to me the lay group is right and the profession is wrong, but relying on the professional authority to express altruistically the good for the doctor-patient relationship seems to me to be open to real questions. The first of these is a kind of old example, but it comes from right here in Chicago and it really hits directly on the concern I have. In the 1970s there was a dispute between the AMA and the federal government over the prohibition in professional ethics of physician advertising. The AMA opposed physician advertising, the public expressing its views through the FTC, viewed the AMA position opposed advertising as a conspiracy in restraint of free trade. The AMA gave a traditional and well-reasoned defense of its view, but also insisted that the profession is responsible for creating the norms. The speaker of the House of the AMA House of Delegates at the time was a fellow named Russell Roth, and Russell Roth argued that the profession creates the norm and let me simply illustrate with his statement on the subject. Roth says the profession has imposed upon itself certain prescriptions which are often poorly understood by the public, such as the avoidance of any semblance of professional advertising which is alright for almost everyone else except physicians. Now I suggest that that's a position that can plausibly be argued for, but it's not obvious that it's the right answer. Physicians have self-interested reasons for opposing advertising, but they more importantly may simply evaluate the ethics differently from lay people. In their public role as licensed health professionals, physicians cannot claim authority to invent, as Roth says, to impose upon themselves a set of rules for interacting with the public. I'm suggesting the public can't automatically claim that authority either. There has to be some joint negotiating. Example number two a little bit later in the history of medical ethics. This is a woman named Teri-Lynn Mitchell. In 1981 in California, Miss Mitchell was raped, murdered, hit over the head with a hammer, stabbed the chest and killed. Michael Morales was arrested, tried, convicted, sentenced to death. The facts of the case aren't terribly relevant. There was a totally unbelievable, bizarre love triangle. Basically, Morales killed her as a favor to a relative of his who had been jilted by Miss Mitchell. Don't try to make sense of it. The bottom line is the woman was dead and Mr. Morales was on death row. There were countless appeals. Finally, Mr. Morales was scheduled for execution by lethal injection on February 21st of 2006. It turns out that the U.S. court had ordered that a physician be present in the death chamber. For example, to avoid cruelty if the drug cocktail were to fail and leave Mr. Morales short of being dead. Two anesthesiologists were hired for this role. Their identities never made public. Things were going along well until the California Medical Association and the American Medical Association both objected. The medical organizations were critical of the doctors who had agreed to be present at the execution. And the AMA cited its official policy. A physician as a member of a profession dedicated to preserving life when there is hope of doing so should not be a participant in a legally authorized execution. The state's position was diametrically opposed. They said it's crucial that physicians be present in order to avoid cruelty. That physicians are licensed agents of the state. And for these activities, they are not subject to professional limits. The result was tragic any way you look at it. The physicians withdrew from their role under pressure from the various professional groups and left the scene two hours before the execution was scheduled. The result was the execution was suspended and is still suspended to this day until this complex problem of professional public responsibility is sorted out. There's an even more bizarre sequel to the story. A legislator then introduced a bill in the California legislature to protect physicians from professional discipline if they were to be present at the execution. Implying that the legislature has custody of this difficult professional question. It turns out that the state senator who introduced the bill was himself an anesthesiologist. So there's not unanimity within the profession that the prohibition is justified. At the same time, another legislator introduced a bill that would prohibit physician participation. And this happened to be by a member of the state assembly who was an eye surgeon. So two members of the profession in their public role as legislators are trying to shape the relationship between the profession and the broader society. It's not clear to me what the proper answer is to these questions. Should all physicians, no matter what their religious or philosophical commitment, be expected to adopt the same position on a morally controversial public policy question like physician participation and executions? And why should an association of members of a profession have custody over determining what is the correct moral answer? I'm particularly troubled by this because I'm inclined to think that the answer has to be worked out jointly between the citizens of the state of California and the members of the profession. But I'm quite convinced that the profession has the right answer on this particular example in part because I'm deeply suspicious about the ethics of execution in the first place. Let me move on to a third and final quick example. I do a lot of work in organ transplant. Laney Ross and I have spent the morning plotting out some revisions to a book we're doing together on the subject. Here's a rather simple example from our not too distant political past. The question arises, should livers for transplant be allocated locally or regionally? Sounds like a kind of technical question till you look at the arguments for one side or the other. Physicians have advocated local allocation, meaning that if a liver is obtained in Chicago it would be used in the Chicago metropolitan area rather than being transported to some other locality where there may be a longer waiting list. The argument for keeping it locally that came from the physicians is, first of all, the obvious one shorter ischemia time which means better preservation of livers. Second argument was if local people in Chicago understand that livers donated in Chicago are used locally that would encourage more organ donation. And third, this is a little bit tricky. If organs are kept locally in spite of the fact that they're longer waiting lists and people with a greater need in some other area, you'll actually get the organs to healthier people who will turn out to do better if the organ is transplanted to them. Therefore, you get more years of life out of the liver. From my point of view, all three of these arguments are designed to maximize the good that you get out of the liver. Now, this view was challenged by the federal government and many ethicists who were critical of local allocation, arguing that if we allocate regionally, that is over one of the 15 regions that exist throughout the United States, we'll be able to provide more equal access, we'll give organs to sicker people who have a stronger moral claim for them. And both of these reasons for allocating regionally are grounded not in maximizing the benefit but in promoting equity or fairness. Now, I would suggest there is once again no reason why the professional group, you know, dominated by medical professionals, should be the one that picks the goal of maximizing benefit at the expense of promoting equity. It's a question that all of us have a stake in and it not ought, it should not be resolved through professional channels. Now, when we talk about professional norms for ethics of a profession, in medicine, most lay people and in fact most physicians will think almost automatically of the Hippocratic Oath. And I want to say a word about the Hippocratic Oath, first suggesting that if you've ever read it, it is a weird document. And if more physicians would read it, they would probably be somewhat more careful and automatically assuming that the Hippocratic Oath is the founding of this core ethic that symbolizes the profession of medicine. I would suggest not only is it a weird document, and I'll illustrate that in just a minute, but I would also suggest that in fact physicians or medical students in, as a matter of actuality, never take the Hippocratic Oath and don't subscribe to it. More generally, I want to suggest that professional oath taking as an enterprise and a kind of symbol of initiation into the profession and the commitment to the professionalism that this series is talking about, that that oath taking itself is morally suspect, in fact, indefensible. So, for those of you who have already given up on the Hippocratic Oath, you can tune out for just about five minutes or so where I'll try to support my claim about how weird the document is. It's divided into two sections, an initiation section and a code of conduct. Let me say just a word about the initiation section. It starts out after swearing by Apollo, Hygia, Pantasy, and all the gods and goddesses, which incidentally many physicians don't believe in anymore. It has the medical student or the initiate swear to treat the teacher as, the teacher's offspring as brothers in male lineage. It's obviously a kind of an apparent initiation or adoption ritual that brings the medical student into a kind of society or if you look at the, or the actual Hippocratic group, into a cult really, a religious medical scientific cult. It's a, and I'll emphasize this and come back to it at the end of my remarks. Symbolic of removing the initiate from normal society, setting apart the student with a new identity and for my purposes critically an identity not shared with patients. It goes on to hold the teacher as equal to one's parents. And then Dr. Siegler absolutely insisted that I make this next point. It's really important, he says. If your teachers are ever to come in financial need, it is the obligation of the teacher's student to come to his aid. So Dr. Siegler, I've done my duty. I'm sure you're going to be well taken care of. We will pass the hat around. There's more importantly a code of conduct in the Hippocratic Oath that covers several critical areas. There is a prohibition on giving deadly drugs, possibly a prohibition on murder, just conspiring with somebody to kill your patient. But more likely it's interpreted as a prohibition on mercy killing. But then only by giving drugs any other forms of participation in mercy killing. If you read the oath, literally aren't spoken to. This gives comfort to the Kvorkians of the world who insist that they don't give drugs. They just set up the equipment so the patient can do it himself. On the other hand, it is sometimes interpreted by conservatives on euthanasia as not being forceful enough. Likewise, there's a prohibition on abortive remedies, but the best literal translation is only refers to giving pessories to produce an abortion. And once again, liberals on abortion are critical of this line because it seems to oppose abortion. But conservatives say why only pessories? What about all the modern methods? There are virtues cited, not the virtue of filial piety that we see in Confucian medicine, but not the modern virtues either, not humanness, compassion, charity and the like. The virtues of the Hippocratic Oath are purity and holiness. Both of them, it turns out, religiously loaded virtues that many physicians may be puzzled by today. Most dramatically, there's a flat-out prohibition on Hippocratic physicians practicing surgery. This is not a general prohibition, but only if you're Hippocratic. The most plausible explanation I've been able to come up with is that, remember, Hippocratic physicians are a member of this quasi-religious group. They're almost as if they were priests. And in many ancient traditions, priests are to be kept pure, the virtue of purity. And you become impure with contact with body fluids and blood. So the Hippocratic Oath is quite clear. It's all right for others to practice surgery. It was not a fear of infection from surgery. But something going on that Hippocratic physicians could not practice. There's a prohibition on sexual relations with patients, but it extends not only to patients and their family members, but also slaves in the household that may not have much meaning in modern times. There is an odd and ambiguous confidentiality clause in the Hippocratic Oath that appears to permit some breaches of confidentiality, particularly paternalistic breaches to benefit patients, even without the permission of the patient. But modern confidentiality language, such as the AMA's own language, has rejected the Hippocratic language in favor of a requirement that physicians cooperate in some non-paternalistic breaches to protect the interests of third parties. This Hippocratic Oath comes from a Hippocratic school, one in many schools of medicine in ancient Greek, probably around the fourth century BC, probably Pythagorean, probably from, as I've suggested, a kind of specialized cult with Pythagorean leanings. There's disputes about that in modern scholarship, but I think more or less that's the proper account. So the question is, why in the world would rational secular 21st century American physicians make a pagan Pythagorean mystery religion the basis of the ethics of their professional group? Why should that be the centerpiece of professional morality, the cornerstone of a graduation ritual? Well, it turns out that it really is no longer the cornerstone of professional ethics. If you look at the studies that have been done over the last century of the oath-taking in medical school graduation ceremonies, the Hippocratic Oath has essentially disappeared. In 1958, the first study I will mention, seven out of 96 schools used the actual Hippocratic Oath, 14 used the modernized version, usually dropping the Greek deities in favor of reference to God or something of that sort, but others used the Declaration of Geneva and a substantial number, some other kind of code. In 1977, a similar pattern, six using the classical Hippocratic Oath, 45 some modified oath, some more using the Declaration of Geneva, some Jewish schools, and at least one secular school in the Chicago area using the prayer of Maimonides, slightly secularized, that's the code that was used for many years at the University of Illinois, and some use some other codes. By the 1990s, the pattern of diversification of code-taking, continues, one school uses the classical Hippocratic Oath, a number used the modified oath, a number using other kinds of oath, the one school that was using it in 1993 was the State University of New York at Syracuse, and I'm told by a colleague there they no longer use it. Now this raises some interesting problems if you're going to identify professionalism with a core self-generated ethic. In fact, we don't have one ethic. We've got a list of ethical codes that differ significantly among themselves. I happen to teach all the medical ethics at St. George's University School of Medicine in Grenada. Most of the students there are from the United States or at least want to practice medicine in the United States, and I thought it would be interesting to ask them, as they come into the school, the naive question, what code of ethics would you turn to based on what you know today if you faced an ethical question in the practice of your profession? This is kind of a busy slide. I apologize for it, and I can't use my pointer very well, but you'll see here that the responses are all over the place. About half the students said the AMA, thinking that they would practice medicine in the U.S. 19 percent were still picking the Hippocratic Oath, 6 percent the Declaration of Geneva, but then there's a whole string of other choices, various religious codifications, various secular codifications that are not related to any professional organization such as the UNESCO Universal Declaration. It raises questions about whether there is any such thing as a commonly agreed upon code of ethics for a profession. If we look at the choices the students were making at the time they came into medical school, it seems clear that any single code will be incompatible with at least half the physicians in the St. George's class and probably if we were to ask the questions carefully incompatible with the ethics of most physicians. Any single code, moreover, will simply ignore the patient-moral commitments in the doctor-patient relationship. If I'm correct that professional groups can claim expertise on the theories of their profession, but not on the evaluations that go into choices within their profession, then professional groups can't even claim authority in code writing in the first place and it's my conclusion that it's time for professional groups to get out of the code writing business. Now what are the problems with this oath-taking pattern that I've described? I've demonstrated that students start out with different ethical codes. I suggest that this raises an enormous problem for the faculty of a medical school. What is it the job of the St. George's University faculty of medicine to evangelize the students and convert them to the St. George's academic oath? If we were to go back to that slide you would have seen that five out of something like 250 students chose the St. George's academic oath at the beginning every one of those students who successfully negotiates four years of medical school will be handed a piece of paper and asked to recite the St. George's oath at the end of their medical education. If we're going to have students believing in the St. George's oath, that means teaching it and doing something so that students will actually believe the content of that oath even in those places where it deviates from their religious and secular commitments that they brought to medical school. Suppose by some miracle we successfully convert every student so that they accept the oath they swear to on graduation day. We might do that by asking the class to write its own oath. Some schools are doing that these days and they probably get at least majority support of the students but surely not unanimous support and even if there were unanimous support the next thing that will happen to medical students is they'll go on to residencies in various hospitals throughout the land and they will meet up with other recent graduates from other medical schools who've made different moral commitments and they'll be expected to meld together and practice medicine together having just taken conflicting solemn oaths that they will abide by the norms that happen to have been legitimated by their particular school. Most critically at no place in this process has the lay half of the doctor-patient relationship been represented in the oath taking process. Patients have been excluded. Now I would suggest to you that one alternative would be to turn to human rights theory or more general philosophical theory to at least attempt to identify a kind of core minimum of ethics for a profession. You might get that starting with the UN Declaration on Human Rights, the Council of Europe's Convention on Human Rights and most relevantly UNESCO's Declaration on Bioethics and Human Rights that was produced in 2005 with both lay and professional cooperation. It is a document based on the UN Universal Declaration. It's an international document. Both professionals and lay people have jointly shared in the writing and it is generally consistent with contemporary philosophical theory. On the other hand, they get agreement across the world by fudging on all of the controversial issues. They don't take a stand on the ethics of intentional mercy killing by physicians. They avoid even the issue that business people can agree on, the issue of whether it's immoral to tell a lie. It's still a lively debate internationally as whether physicians can benevolently lie to their patients. There's no consensus on what it means to be dead. There's no agreement on whether Terry Shiveau's nutrition can be withheld. If any of these topics were taken up, we'd face a much more serious dispute about an international code. One final defense, and with this I will close, in some ways I think it's the most important but the most complex and subtle issue I will raise with you. Maybe it's the case that doesn't matter what the oath says, that it's simply a symbolic ritual, a dramatic outward and visible sign. That references to being called into a profession. That's the language of the description of the sacraments in the church. I'm suggesting oath taking may be a sacrament of the medical profession whereby a professional is separated from ordinary citizens. If that's the case, let me suggest two problems. First, very briefly let me say that it is odd to claim that a solemn oath should be discounted as a mere symbolic act that really doesn't matter what you pledge. It is, after all, one probably one of the two more solemn oaths one will take in a lifetime, the other being the marriage vow. And it seems odd to write it off as something that's a mere symbol. More critically, I think it's troublesome to think of physicians as separated from their cultural roots. Fracturing of a bond critical for the doctor-patient relationship. I would suggest the successful doctor-patient relationship requires mutually shared cultural vision. And there's really no need to force all physicians to share a common understanding of their identity. Something that symbolizes that they've been set apart, isolated from the patient, given a new identity that patients in principle cannot share. In a pluralistic world physicians probably should end up subscribing to various cultural ethics. One would hope that they would line up with patients who share that worldview. And if it turns out that there are some norms that are so fundamental they should be shared by everybody in the physician's role, then those norms should be articulated by patients and physicians working together as a community, not by physicians alone claiming to be set apart from the patient. So my conclusions, medical school oath is not a mere symbol. It's potentially much more dangerous than that. And professionalism is not an uncontroversial good. It's much more problematic. Let me stop at that point. Dr. Siegler, do we have some time for some questions? Sure, we do absolutely. Thank you so much. Thank you. Professor Beech's talk is open for questions and comments. It's a very provocative thesis, Bob, that this combination of three features, the limitation on generalizing expertise from the technical realm to the moral realm is one of the fundamental issues that you have brought up for the last 35 years. Secondly, that there are areas in which professional views conflict with the state views on matters. And it is, in fact, the state that licenses and sanctions the profession as such or the professions to function as a kind of monopolistic practice within the state. And that creates real tensions and you gave three wonderful examples. And then the third point about the difficulty of finding in a secular world and a heterogeneous world finding a common set of professional values that people can agree to, subscribe to, pledge to in the ritual of the oath, adds a third dimension to what I think you fairly call, in your title, why professionalism is controversial. I mean, all of these combine. It's a very illuminating thesis, open for comments. It seems to me you've you've you've effectively identified the limits of anything, any kind of substance that would give shape and direction to the profession of medicine that. But my, the examples advertising the death penalty allocating livers seem to me at pretty far removed from the everyday kinds of core activities that doctors and patients are about, in which the notion and we can go back to the first example you brought up of a patient diagnosed with cancer or an ab mass in their abdomen. The notion that the doctor has no expertise, I think you put it whatsoever about what the patient ought to do. The only expertise about what is possible and what's technically feasible and how to achieve it and so on seems to me really to run up against in a dramatic way the experiences of clinicians and patients going on every, you know, all the time. And the idea that a patient is going to look to their physician and just say all I want here is just a list of technical possibilities and recommendations about who can technically bring about one of the many ends I might seek. It seems to me a caricature of what actually happens and I wonder if you could comment on that more common interaction between sick people and their doctors. I've devoted the book Patient Heal Thyself to looking at this particular problem and moving from the, what I would take more obvious examples that an oncologist can't tell you whether aggressive experimental protocol or hospice is the better choice for a malignancy, a gynecologist can't tell you whether abortion is the right choice for a pregnant woman, but moving from those obvious examples where value judgment shape what is in the patient's best interest. I've moved from that to much more mundane examples where choices get made I claim in literally every clinical decision that require some value choices. Now if I were a naive liberal, I would advocate as you described that the physician just give a list of the treatment options and what the effects of those treatment options would be. I'm utterly convinced that that is naive and unacceptable, that for one thing the account of the treatment options will get shaped by the clinician's world view so that the patient will end up making a choice that looks like the physician's choice anyway. So it's a much more complex problem than that and I end up, one reason I'm so concerned about a pluralism of codes of ethics among practitioners is I end up concluding that probably the best we can do in a highly pluralistic society is to choose your primary caregivers in a way that you get clinicians who share your world view. That means you will get value loaded accounts of what your treatment options are, but if you're lucky they're loaded in the way you would want them loaded. When I began this work I began with a simple empirical study of the relationship of obstetricians and patients in a community in the state of Connecticut which happens to be richly pluralistic in its religious views. And what I found was devout conservative Catholic women picking the local abortionist in town as their gynecologist and that just seems to me a disaster waiting to happen. And incidentally I found exactly the opposite occurring. The leaders of the local feminist health collective choosing the doctor who not only is religiously opposed to all abortion, he's also religiously opposed to all birth control. Those interactions between doctor and patient I believe are destined for disaster. It may turn out that for many maybe even most decisions in medicine we can get by okay if there's not a value meeting of the minds between doctors and patients. That means it makes sense for me when I'm a stranger in Chicago to go to the local ER and be cared for by a stranger doctor if I'm having a massive heart attack at the time. There is enough value consensus that we can jointly articulate, hence I endorse the UNESCO approach, that will structure those necessarily stranger based relationships. But the bottom line conclusion I reach is even though it's not the standard model of doctor-patient relationships, literally every clinical choice involves value choices. Choices about which set of side effects are preferable, what dose level is worth risking. Choices of that sort where different doctors with different values will make a case where you know your competent colleague would treat the patient somewhat differently. That I think is to be attributed in part to the value differences among competent professional clinicians and I'm interested in bringing out those value disputes. And the main way I know of going about it is making sure you're more or less on the same page in terms of an ethical world view with the clinicians you choose if you're a patient. Thanks Bob. It had been quite a few years since I'd heard that strong repudiation of the generalization of expertise and of all oath taking so I appreciate hearing it again. But in some ways, and maybe it follows a little on even what you said about in response to FAR, I'm reminded because you do such a good job of your argument of the interview that Jerry Rubin from the old weatherman had when he was asked what are you going to do now that you've destroyed civilization as we know it. And he said well I don't know man kind of groove on the rubble. There's a sense in which you're very good at sort of picking out what some of the problems might be, but I wonder what the medical educators around the table here who are charged with teaching professionalism are supposed to do for their medical students. Well that's one reason I included my remarks about oath taking. I think that's a practical problem that once you realize the students in a typical class like the University of Chicago's class have widely disparate ethical positions on some crucial issues in medicine. Once you realize that, and if you accept my claim that it is ethically suspect to turn oath taking into a mere ritual that the student is supposed to ignore after he gets out of the graduation exercise, you've got to do something about that problem. If there is a core ethic for all those in the profession, it's not reflected in any of the oaths that are used in any medical school graduation exercises, and I'm frankly not sure that there could be such a document. That's why I've reluctantly come to the conclusion that we ought to stop oath taking in medical schools. That would be one very practical area for medical educators to begin thinking about the implications of what I've said. I acknowledge that there will, in the complex world in which we live, always have to be stranger medicine. The medical care you get when you have an emergency and you're away from your primary caregiver. UNESCO I think is as close as we have come to a core meaningful set of moral commitments that were produced jointly by lay people and professionals. It's far superior to anything else I can identify as the sort of minimalist default core ethic that the entire profession worldwide might share, but I acknowledge they get there by fudging on all the controversial stuff. My guess is that what the profession has to say is, as members of the profession we don't agree on a long list of things, and it may be okay that the members of the profession don't agree on a long list of things, so that some practitioners will behave one way and some behave another. I've sort of turned to Dean Holly Humphrey, who is the Dean of Medical Students here for many years, and who bears the responsibility of crafting a pedagogical approach to training students who go out into the world to be effective, competent, caring doctors. Just to see if Holly might not say a few words about some of these core values that you refer to as sort of underlying what a proper code might look like. Holly. I have never before had the chance to hear you speak live, but I am familiar with your written work and certainly have been illuminated on more than one occasion, having read many of your pieces. I also very much appreciate the clarity with which you presented your argument, and in these few moments that I'm trying to take that all in, I must say that for the most part I strongly disagree with your point of view. I disagree with it because I believe in rituals and I believe in the profession and all that the profession can do on behalf of patients and the public, and I certainly fully understand that we have had many missteps, and that we are not always our best selves and we are not always our best profession. But I for one am not ready to give up on the fact that this is complex and it's complicated, and we live in, as you say, a pluralistic society. And for me that's a challenge and one that I aspire to try to meet, not by doing away with rituals and with attempting to put into words that with which we believe and that to which we aspire. So maybe we don't have it right yet, but as I said I do believe that there are some very fundamental values that even in a pluralistic society we can agree on. And during my years when I've found myself taking care of very complex, difficult patients whose values are clearly different than my own, the things that have gotten me through those kinds of difficult interactions have very often been the touchstone of the very core elements and values of the profession. So I need to think more deeply about what you shared today, and I always learn from our students and our residents and our faculty colleagues, but I to this point continue to be encouraged that those entering this profession enter this profession for all of the right reasons, seeking to do good and to advance society, not to become distracted by the complexity of it. Yeah, I appreciate what you've said. I'm certainly not disparaging rituals, I'm a believer in rituals. I think the core take home message from what I said today with regard to rituals is there's something really mistaken if the student as happens in some medical schools. I have no idea if it happens here. But what bothers me is the student is handed the piece of paper the morning of graduation day and said here's your oath recited in the next 20 minutes without having studied it in detail. What we've done at St. George's, much to the consternation of some of my faculty colleagues, is spend our medical ethics time dissecting the content of the St. George's oath to see the extent to which it is found acceptable. Well, I know of no written codification today, certainly no modified Hippocratic oath, that legitimately could be sworn to with seriousness by an entire medical school class. I think that's a real problem that we've not taken seriously. If the ritual can identify what you describe as core values, values that literally every member of the profession ought to be able to commit to, and if that can be formulated in a pledge or codified way, I wouldn't have a problem with that. I still raise the question of whether oath taking and professionalism generally doesn't have as an unintended side effect the symbolic removal of the individual from the broader society and in Hippocratic language commitment into a new group, a group that by definition patients can't share in. I think that that's a real problem with many traditional comment, many traditional views about professionalism. Yeah, I agree that that is a fair critique. And again, I use that as an example for us to aspire to push past that, to overcome that, to build the bridge with the patient and their family to not erect a wall between the doctor and the patient and the family. Most people, when they look at all carefully at the Hippocratic oath and see the oddities in it, they finally get to the sentence that said, well, at least this week and all accept the physician will work for the benefit of the patient according to his ability and judgment. His masculine pronoun, but you can fix that if you like. That still raises some serious problems in a complex notion of a profession. Much of what a physician does is not working for the benefit of the patient. It may be respecting the rights of the patient, even when you think the patient isn't going to benefit. It may be working for the benefit of others. If you do any research on human subjects, you're not benefiting the patient, you're benefiting, you're contributing to the pursuit of generalizable knowledge. So even that simple, what seems like a sentence we could all agree on, work for the benefit of the patient, turns out to be controversial, and I'm pretty sure it's wrong. You don't work for the benefit of the patient if you allocate livers regionally, but it turns out to be the choice of what the people seem to have wanted. They purposely sacrifice benefit to the patient in order to get a more equitable system. Well, I want to thank Bob Beach so much for coming, and we look forward to your next visit. This is the one hour in the professionalism series, so you've got a whole year to counteract what I've said. We'll try. Thank you.